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Introduction: Adolescence is a critical time for mental health promotion and prevention and establishing healthy behaviours. Implementing universal, school-based psychosocial interventions can improve short- and long-term health trajectories for adolescents. While these interventions may offer important opportunities for fostering skills and relationships, few school-based interventions have been developed for and tested in low- and middle-income countries (LMICs) where adolescent mental health needs may be significant and under-served. This manuscript details the development of a multi-component, universal school-based intervention, Health Action in ScHools for a Thriving Adolescent Generation (HASHTAG), for adolescents aged 12–15 years in Nepal and South Africa. Methods and results: We describe HASHTAG's development over four phases, combining methods and results as each phase was iteratively conducted between 2018 and 2021. Phase 1 included a systematic review and components analysis, building from WHO guidelines for adolescent mental health. Seven components were strongly supported by the evidence: emotional regulation, stress management, mindfulness, problem-solving, interpersonal skills, assertiveness training, and alcohol and drug education. Phase 2 encompassed site selection, theory of change development, and formative research engagements; research teams in each site engaged adolescents and key adult stakeholders to identify priorities for intervention. Stakeholders voiced preferences for external facilitators and key content and delivery for intervention sessions. These findings informed Phase 3, a draft manual of HASHTAG, including a whole-school component, called Thriving Environment in Schools, and a classroom-based, six-session component, Thrive Together. In Phase 4, participants engaged in consultative workshops to review and contextualise content by country, preparing HASHTAG for implementation in a feasibility trial. Minor adaptations were made in Nepal, including using school nurses and adjusting take-home materials; both country's workshops identified practical considerations for implementing activities. Conclusions: HASHTAG was designed around core evidence-based components to increase translatability across LMICs, while enabling country-specific tailoring to enhance feasibility. Future research will test whether this multi-component, whole-school approach can improve adolescent mental health.

Abstract Introduction Adolescent girls and young women (AGYW) living with HIV experience poor HIV outcomes and high rates of unintended pregnancy. Little is known about which healthcare provisions can optimize their HIV‐related outcomes, particularly among AGYW mothers. Methods Eligible 12‐ to 24‐year‐old AGYW living with HIV from 61 health facilities in a South African district completed a survey in 2018–2019 (90% recruited). Analysing surveys and medical records from n = 774 participants, we investigated associations of multiple HIV‐related outcomes (past‐week adherence, consistent clinic attendance, uninterrupted treatment, no tuberculosis [TB] and viral suppression) with seven healthcare provisions: no antiretroviral therapy (ART) stockouts, kind and respectful providers, support groups, short travel time, short waiting time, confidentiality, and safe and affordable facilities. Further, we compared HIV‐related outcomes and healthcare provisions between mothers (n = 336) and nulliparous participants (n = 438). Analyses used multivariable regression models, accounting for multiple outcomes. Results HIV‐related outcomes were poor, especially among mothers. In multivariable analyses, two healthcare provisions were “accelerators,” associated with multiple improved outcomes, with similar results among mothers. Safe and affordable facilities, and kind and respectful staff were associated with higher predicted probabilities of HIV‐related outcomes (p

AbstractRates of adolescent pregnancy within sub-Saharan Africa are increasing. Adolescent mothers ages 10–19 years face a distinct set of risks to their own and their children’s health, compounded by many economic, social, and epidemiological challenges, such as living with HIV. In navigating this complex developmental period, many adolescent mothers face structural barriers impeding safe transitions to adulthood and motherhood. Drawing on existing literature and emerging data, we outline three normative, legal, and policy issues – violence and gender inequity, access to sexual and reproductive health services, and access to social and structural supports – which affect the health, wellbeing and development of adolescent mothers and their children. We also highlight emergent evidence about programming and policy changes that can better support adolescent mothers and their children. These key proposed responses include removing barriers to SRH and HIV service integration; ensuring implementation of return-to-school policies; and extending social protection systems to cater for adolescent mothers. Despite ongoing global crises and shifts in funding priorities, these normative, legal, and policy considerations remain critical to safeguard the health and wellbeing of adolescent mothers and their children.

Childhood and adolescence are key developmental periods in the life course for addressing mental health, and there is ample evidence to support significant, increased investment in mental health promotion for this group. However, there are gaps in evidence to inform how best to implement mental health promotion interventions at scale. In this review, we examined psychosocial interventions implemented with children (aged 5–10 years) and adolescents (aged 10–19 years), drawing on evidence from WHO guidelines. Most psychosocial interventions promoting mental health have been implemented in school settings, with some in family and community settings, by a range of delivery personnel. Mental health promotion interventions for younger ages have prioritised key social and emotional skills development, including self-regulation and coping; for older ages, additional skills include problem-solving and interpersonal skills. Overall, fewer interventions have been implemented in low- and middle-income countries. We identify cross-cutting areas affecting child and adolescent mental health promotion: understanding the problem scope; understanding which components work; understanding how and for whom interventions work in practice; and ensuring supportive infrastructure and political will. Additional evidence, including from participatory approaches, is required to tailor mental health promotive interventions to diverse groups’ needs and support healthy life course trajectories for children and adolescents everywhere.

Background: In South Africa, health and care service providers (SPs) face many interconnected challenges at work, including inadequate training and supervision and high levels of burnout. Nyamekela4Care (N4C) was developed as an integrated intervention for SP teams, to support their ability to provide high-quality care through providing a structure for operating regular team meetings that includes training, empathic skills development, administration, case sharing and self-care. We aimed to determine the feasibility, acceptability, and preliminary effectiveness of the N4C intervention as a support package for SPs in resource-constrained settings. Methods: This study utilized a mixed-methods, repeated measures design. Purposive sampling was used to recruit 42 SPs from two healthcare service settings in South Africa where teams of primary care clinic staff work together with home-visiting community health workers from community-based organisations. Data were collected across three timepoints. Self-report data were collected directly from participants at all timepoints, alongside qualitative interviews, investigating participants’ wellbeing, work satisfaction, work-related knowledge, and acceptability of N4C. A repeated measures ANOVA was applied to the data to test the preliminary effectiveness of N4C. Qualitative interview data were analysed using a thematic analysis approach to identify pertinent themes in the data. Results: The N4C intervention was found to be acceptable, with low uptake of the intervention at one site limiting interpretation of its feasibility. Qualitative data demonstrated that the intervention resulted in improved collaboration between organisations; improved capacity to practice self-care in certain cases; and improved work-related knowledge. Quantitative data identified a significant increase in work-related knowledge, but no significant differences for any other outcomes. The success of implementation may have been impeded by contextual factors such as uncertainty regarding contractual agreements for staff, staff attrition, lack of commitment and skill of some of the operational leadership and the small number of N4C meetings held. Conclusion: While participants noted improvements in work-related knowledge, self-care and intersectoral collaboration as benefits of the intervention, the implementation of N4C, particularly at one site, limited our ability to assess its feasibility and impact. Further areas for quality of care intervention research are discussed.

Abstract Background Community health worker (CHW) programs have been positioned as a way to meet the needs of those who experience marginalization and inequitable access to health care, and current global health narratives also emphasize their adaptable nature to meet growing health burdens in low-income settings. However, as CHW programs adopt more technical roles, the value of CHWs in building relationships with clients tends to be overlooked. More importantly, these programs are often reframed and redeployed without attending to the interests and needs of program clients themselves. We set out to gather perspectives of program and CHW engagement from clients of a maternal and child health program in rural South Africa. Methods We conducted 26 interviews with pregnant or recently-delivered clients of the Enable Mentor Mother program between February–March 2018. After obtaining informed consent, a trained research assistant conducted all interviews in the clients’ home language, isiXhosa. Interviews, translated and transcribed into English, were organized and coded using ATLAS.ti software and thematically analyzed. Results We found that clients’ home-based interactions with Mentor Mothers were generally positive, and that these engagements were characterized by two core themes, instructive roles and supportive relationships.. Instructive roles facilitated the transfer of knowledge and uptake of new information for behavior change. Relationships were developed within the home visit setting, but also extended beyond routine visits, especially when clients required further instrumental support. Clients further discussed a sense of agency gained through these interactions, even in cases where they chose not to, or were unable to, heed their Mentor Mother’s advice. Conclusions These findings highlight the important roles that CHWs can assume in providing both instructive and supportive care to clients; as deepening relationships may be key for encouraging behavior change, these findings pinpoint the need to bolster training and support for CHWs in similar programs. They also emphasize the importance of integrating more channels for client feedback into existing programs, to ensure that clients’ voices are heard and accounted for in shaping ongoing engagement within the communities in which these programs operate.

Abstract Background Pregnancy and parenthood are known to be high-risk times for mental health. However, less is known about the mental health of pregnant adolescents or adolescent parents. Despite the substantial literature on the risks associated with adolescent pregnancy, there is limited evidence on best practices for preventing poor mental health in this vulnerable group. This systematic review therefore aimed to identify whether psychosocial interventions can effectively promote positive mental health and prevent mental health conditions in pregnant and parenting adolescents. Methods We used the standardized systematic review methodology based on the process outlined in the World Health Organization’s Handbook for Guidelines Development. This review focused on randomized controlled trials of preventive psychosocial interventions to promote the mental health of pregnant and parenting adolescents, as compared to treatment as usual. We searched PubMed/Medline, PsycINFO, ERIC, EMBASE and ASSIA databases, as well as reference lists of relevant articles, grey literature, and consultation with experts in the field. GRADE was used to assess the quality of evidence. Results We included 17 eligible studies (n = 3245 participants). Interventions had small to moderate, beneficial effects on positive mental health (SMD = 0.35, very low quality evidence), and moderate beneficial effects on school attendance (SMD = 0.64, high quality evidence). There was limited evidence for the effectiveness of psychosocial interventions on mental health disorders including depression and anxiety, substance use, risky sexual and reproductive health behaviors, adherence to antenatal and postnatal care, and parenting skills. There were no available data for outcomes on self-harm and suicide; aggressive, disruptive, and oppositional behaviors; or exposure to intimate partner violence. Only two studies included adolescent fathers. No studies were based in low- or middle-income countries. Conclusion Despite the encouraging findings in terms of effects on positive mental health and school attendance outcomes, there is a critical evidence gap related to the effectiveness of psychosocial interventions for improving mental health, preventing disorders, self-harm, and other risk behaviors among pregnant and parenting adolescents. There is an urgent need to adapt and design new psychosocial interventions that can be pilot-tested and scaled with pregnant adolescents and adolescent parents and their extended networks, particularly in low-income settings.

Background: Research shows that caregiver mental health problems have direct, significant effects on child behaviour. While these risks are amplified in low-resource settings, limited evidence exists from these places, especially sub-Saharan Africa. Objective: We measured associations between caregiver mental health and child behaviour in a rural Kenyan sample, hypothesizing that higher rates of caregiver mental health would be associated with increased child behavioural problems. We also sought to provide an overview of caregiver mental health symptoms in our sample. Method: Cross-sectional data were collected from caregivers of children ages 4–5 years old enrolled in a community-based early child development programme in western Kenya. 465 caregivers were recruited and assessed at baseline, and answered questions about child behaviour, mental health symptoms (depression, anxiety, stress), and help-seeking. A multivariate linear regression model was used to assess significance of each mental health factor. Results: Caregiver anxiety (p = 0.01) and parenting stress (p

Vaccination, and particularly childhood vaccination, is widely acknowledged as one of the greatest public health interventions in history. Nevertheless, challenges exist that threaten the progress of childhood vaccination in many parts of the world. We investigated challenges to vaccination experienced by point-of-care vaccinators in the Cape Town Metropolitan District (Cape Metro), and reported on their current and proposed efforts to combat these challenges. Semi-structured interviews were conducted with 19 vaccinators in 16 purposively selected healthcare facilities in the Cape Metro from September to November 2019. Interviews were transcribed and analysed using thematic and narrative analysis methods. Challenges of both the demand and the supply side of routine vaccination were reported by the study participants, as were contextual challenges such as community safety issues. Defaulting was the most common challenge encountered, reported by 16 of the 19 participants. The use of computerized appointment systems, the enlistment of community health workers to track down defaulters, and the use of certificates to incentivize caregivers are part of the creative ways of mitigating some of the challenges encountered by these vaccinators. Their insightful recommendations can positively influence the landscape of childhood vaccination uptake in the Cape Metro and beyond if adapted and applied.

Introduction Globally, no person has been untouched by the COVID-19 pandemic. Yet, little attention has been given to children and adolescents in policy, provision and services. Moreover, there is a dearth of knowledge regarding the impact of COVID-19-associated orphanhood and caregiver loss on children. This study aims to provide early insights into the mental health and well-being of children and adolescents experiencing orphanhood or caregiver loss in South Africa.Methods and analysis Data will be drawn from a quantitative longitudinal study in Cape Town, South Africa. A sample of children and adolescents between the ages of 9 and 18 years, experiencing parental or caregiver loss from COVID-19, will be recruited together with a comparison group of children in similar environments who did not experience loss. The study aims to recruit 500 children in both groups. Mental health and well-being among children will be explored through the use of validated and study-specific measures. Participants will be interviewed at two time points, with follow-up data being collected 12–18 months after baseline. A combination of analytical techniques (including descriptive statistics, regression modelling and structural equation modelling) will be used to understand the experience and inform future policy and service provision.Ethics and dissemination This study received ethical approval from the Health Research Ethics Committee at Stellenbosch University (N 22/04/040). Results will be disseminated via academic and policy publications, as well as national and international presentations including high-level meetings with technical experts. Findings will also be disseminated at a community level via various platforms.