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Maternal responses to infant facial expressions were examined in two socioeconomically diverse samples of South African mothers (Study I, N = 111; and Study II, N = 214; age: 17-44 years) using pupil and gaze tracking. Study I showed increased pupil response to infant distress expressions in groups recruited from private as compared to public maternity clinics, possibly reflecting underlying differences in socioeconomic status (SES) across the groups. Study II, sampling uniformly low-SES neighborhoods, found increased pupil dilation and faster orientation to expressions of infant distress, but only in the highest income group. These results are consistent with maternal physiological and attentional sensitivity to infant distress cues but challenge the universality of this sensitivity across socioeconomic diversity.

Little is known about the economic impact of disability grants for people living with schizophrenia in low- and middle- income countries. In this brief report, we show that receipt of disability benefits is significantly associated (β = 0.105, p < 0.0001) with increased household and personal wealth in large sample of people living with schizophrenia in South Africa (n = 1154). This study provides further support for the use of disability grants as a mechanism to protect people living with schizophrenia and their families against the economic costs associated with schizophrenia. [ABSTRACT FROM AUTHOR]

Central nervous system involvement in HIV infection leads to neurobehavioural sequelae. Although apathy is a well-recognised symptom in adults living with HIV linked to alterations in brain structure, there is scarce research examining motivation in children living with HIV (CLWH). We used the Children's Motivation Scale (CMS; normative mean = 50, SD = 10) to assess motivation levels in 76 CLWH aged 6–16 years (63 on antiretroviral therapy [ART]; 13 ART-naïve slow progressors) in South Africa. Overall, CLWH scored low on the CMS (mean = 35.70 [SD = 5.87]). Motivation levels were significantly reduced in children taking ART compared to ART-naïve slow progressors (p = 0.02), but were not correlated with markers of HIV disease (CD4 + cell count or viral load), or neurocognitive function (p > 0.05). CMS scores were correlated with diffusion tensor imaging metrics of white matter microstructure in specific frontostriatal brain regions (p < 0.05). On multiple regression, associations with the anterior limb of the internal capsule, a subcortical white matter region, remained significant after adjusting for potential confounders. These findings suggest that reduced motivation may be an important neurobehavioural symptom in CLWH and may reflect changes in white matter microstructure of frontostriatal brain regions. [ABSTRACT FROM AUTHOR]

Background: Mental health problems are common and impairing among university students, yet only a minority of students with psychological disorders access treatment. Understanding barriers to treatment is integral to planning services, especially in resource constrained settings like South Africa (SA). Methods: Data collected across 17 institutions in the online SA National Student Mental Health Survey were used to: (1) estimate 12-month prevalence of common mental health problems and self-harm; (2) estimate the proportion of students receiving treatments for the various mental health problems; (3) explore barriers to treatment; and (4) investigate sociodemographic predictors of treatment mediated through the various barriers endorsed by students with mental health problems. Prevalence analyses were carried out using cross-tabulations and prediction analyses using modified Poisson regression models. Results: Prevalence of clinically significant mental health problems is high relative to international comparisons, with the prevalence of severe, mild and moderate symptoms of any disorder and/or self-harm of 24.8% (SD = 0.3), 18.8% (SD = 0.3) and 27.6% (SD = 0.4) respectively. Treatment rates were 35.2% (S.E. = 0.6) among students with mental health problems who perceived need for treatment and 21.3% (S.E. = 0.4) irrespective of perceived need. Treatment rates were highest for mood disorders (29.9%, S.E. = 0.6) and lowest for externalising disorders (23.8%, S.E. = 0.5). Treatment rates were much less variable across disorder types among students with perceived need than irrespective of perceived need, indicating that perceived need mediated the associations of disorder types with received treatment. Adjusting for disorder profile, probability of obtaining treatment was significantly and positively associated with older age, female gender, study beyond the first year, traditional sexual orientation, and diverse indicators of social advantage (full-time study, high parent education, and attending Historically White Institutions). Among students with mental health problems, numerous barriers to treatment were reported adjusting for disorder profile, including lack of perceived need (39.5%, S.E. = 0.5) and, conditional on perceived need, psychological (54.4%, S.E. = 1.0), practical (77.3%, S.E. = 1.1), and other (79.1%, S.E. = 1.1) barriers. Typically, students reported multiple barriers to treatment. Differences in perceived need explained the gender difference in treatment, whereas practical barriers were most important in accounting for the other predictors of treatment. Conclusion: Mental health problems are highly prevalent but seldom treated among SA university students. Although many barriers were reported, practical barriers were especially important in accounting for the associations of social disadvantage with low rates of treatment. Many of these practical barriers are however addressable. [ABSTRACT FROM AUTHOR]

Background: The Mini International Neuropsychiatric Inventory 7.0.2 (MINI-7) is a widely used tool and known to have sound psychometric properties; but very little is known about its use in low and middle-income countries (LMICs). This study aimed to examine the psychometric properties of the MINI-7 psychosis items in a sample of 8609 participants across four countries in Sub-Saharan Africa. Methods: We examined the latent factor structure and the item difficulty of the MINI-7 psychosis items in the full sample and across four countries. Results: Multiple group confirmatory factor analyses (CFAs) revealed an adequate fitting unidimensional model for the full sample; however, single group CFAs at the country level revealed that the underlying latent structure of psychosis was not invariant. Specifically, although the unidimensional structure was an adequate model fit for Ethiopia, Kenya, and South Africa, it was a poor fit for Uganda. Instead, a 2-factor latent structure of the MINI-7 psychosis items provided the optimal fit for Uganda. Examination of item difficulties revealed that MINI-7 item K7, measuring visual hallucinations, had the lowest difficulty across the four countries. In contrast, the items with the highest difficulty were different across the four countries, suggesting that MINI-7 items that are the most predictive of being high on the latent factor of psychosis are different for each country. Conclusions: The present study is the first to provide evidence that the factor structure and item functioning of the MINI-7 psychosis vary across different settings and populations in Africa. [ABSTRACT FROM AUTHOR]

Background Transcriptomic profiling of adults with tuberculosis (TB) has become increasingly common, predominantly for diagnostic and risk prediction purposes. However, few studies have evaluated signatures in children, particularly in identifying those at risk for developing TB disease. We investigated the relationship between gene expression obtained from umbilical cord blood and both tuberculin skin test conversion and incident TB disease through the first 5 years of life. Methods We conducted a nested case-control study in the Drakenstein Child Health Study, a longitudinal, population-based birth cohort in South Africa. We applied transcriptome-wide screens to umbilical cord blood samples from neonates born to a subset of selected mothers (N = 131). Signatures identifying tuberculin conversion and risk of subsequent TB disease were identified from genome-wide analysis of RNA expression. Results Gene expression signatures revealed clear differences predictive of tuberculin conversion (n = 26) and TB disease (n = 10); 114 genes were associated with tuberculin conversion and 30 genes were associated with the progression to TB disease among children with early infection. Coexpression network analysis revealed 6 modules associated with risk of TB infection or disease, including a module associated with neutrophil activation in immune response (P <.0001) and defense response to bacterium (P <.0001). Conclusions These findings suggest multiple detectable differences in gene expression at birth that were associated with risk of TB infection or disease throughout early childhood. Such measures may provide novel insights into TB pathogenesis and susceptibility. [ABSTRACT FROM AUTHOR]

We examined oral PrEP interest among adolescents and its association with perceived parental support and PrEP stigma. Cross-sectional data were collected during baseline procedures of the "Our Family Our Future" intervention trial in South Africa. Adolescents (14–16 years) at elevated risk for acquiring HIV and their parents or caregivers were dyadically enrolled from 2018 to 2021. There were 879 complete adolescent-parent dyads. Among adolescents, 27% had heard about PrEP, 67% reported they would want to use PrEP, and 58% thought their parent would want them to use PrEP. Among parents, 33% had heard about PrEP and 85% reported they would want their adolescent to use PrEP. Adolescents who thought their parent would want them to use PrEP were more likely to be interested in PrEP than adolescents who thought their parent would not want them to use PrEP (adjusted prevalence ratio (aPR) = 2.11, 95% CI 1.82, 2.44). Further, adolescents with higher average PrEP stigma scores above the adolescent sample median were less likely to be interested in PrEP than adolescents with lower average PrEP stigma scores (aPR = 0.81, 95% CI 0.72, 0.91). In conclusion, parents were more supportive of their adolescent taking PrEP than adolescents perceived they would be, and perceptions of low parental support and greater PrEP stigma were associated with reduced PrEP interest among adolescents. Interventions should aim to improve adolescent-parent communication around sexual health and effective HIV prevention tools. [ABSTRACT FROM AUTHOR]

Mental health problems often begin in early childhood. However, the associations of various individual and contextual risk factors with mental health in the preschool period are incompletely understood, particularly in low- to middle-income countries (LMICs) where multiple risk factors co-exist. To address this gap, we prospectively followed 981 children in a South African birth cohort, the Drakenstein Child Health Study, assessing pre-and postnatal exposures and risk factors. The predictive value of these factors for child mental health (assessed by the Child Behavior Checklist) was modeled using structural equation modeling. We identified two key pathways to greater externalizing behavior: (1) prenatal exposure to substances (alcohol and smoking) directly predicted increased externalizing behavior (β = 0.24, p < 0.001); this relationship was partially mediated by an aspect of infant temperament (negative emotionality; β = 0.05, p = 0.016); (2) lower socioeconomic status and associated maternal prenatal depression predicted more coercive parenting, which in turn predicted increased externalizing behavior (β = 0.18, p = 0.001). Findings in this high-risk LMIC cohort cohere with research from higher income contexts, and indicate the need to introduce integrated screening and intervention strategies for maternal prenatal substance use and depression, and promoting positive parenting across the preschool period. [ABSTRACT FROM AUTHOR]

Despite a high prevalence of intimate partner violence in South Africa, few epidemiological studies have assessed individual risk factors and differential vulnerability by gender. This study seeks to analyze gender differences in risk for intimate partner violence victimization and perpetration according to childhood and adult risk factors in a national sample of South African men and women. Using data from the cross-sectional, nationally representative South Africa Stress and Health Study, the authors examine data from 1,715 currently married or cohabiting adults on reporting of intimate partner violence. Our analysis include (a) demographic factors, (b) early life risk factors (including exposure to childhood physical abuse, witnessing parental violence, parental closeness, and early onset "DSM-IV" disorders), and (c) adult risk factors (including experiencing the death of a child and episodes of "DSM-IV" disorders after age 20). Although prevalence rates of intimate partner violence are high among both genders, women are significantly more likely than men to report being victimized (29.3% vs. 20.9%). Rates of perpetrating violence are similar for women and men (25.2% and 26.5%, respectively). Men are more likely to report predictive factors for perpetration, whereas women are more likely to report predictors for victimization. Common risk factors among men and women reporting perpetration include exposure to childhood physical abuse, witnessing parental violence, and adult onset alcohol abuse/dependence. However, risk factors in male perpetrators are more likely to include cohabitation, low income, and early and adult-onset mood disorders, whereas risk factors in female perpetrators include low educational attainment and early onset alcohol abuse/dependence. The single common risk factor for male and female victims of partner violence is witnessing parental violence. Additional risk factors for male victims are low income and lack of closeness to a primary female caregiver, whereas additional risk factors for female victims are low educational attainment, childhood physical abuse, and adult onset alcohol abuse/dependence and intermittent explosive disorder. Intimate partner violence is a significant public health issue in South Africa, strongly linked to intergenerational cycling of violence and risk exposure across the life course. These findings indicate that gender differences in risk and common predictive factors, such as alcohol abuse and exposure to childhood violence, should inform the design of future violence-prevention programs and policies. (Contains 4 tables.)

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Background: Neuroimaging studies have emphasized the impact of prenatal alcohol exposure (PAE) on brain development, traditionally in heavily exposed participants. However, less is known about how naturally occurring community patterns of PAE (including light to moderate exposure) affect brain development, particularly in consideration of commonly occurring concurrent impacts of prenatal tobacco exposure (PTE). Methods: Three hundred thirty‐two children (ages 8 to 12) living in South Africa's Cape Flats townships underwent structural magnetic resonance imaging. During pregnancy, their mothers reported alcohol and tobacco use, which was used to evaluate PAE and PTE effects on their children's brain structure. Analyses involved the main effects of PAE and PTE (and their interaction) and the effects of PAE and PTE quantity on cortical thickness, surface area, and volume. Results: After false‐discovery rate (FDR) correction, PAE was associated with thinner left parahippocampal cortices, while PTE was associated with smaller cortical surface area in the bilateral pericalcarine, left lateral orbitofrontal, right posterior cingulate, right rostral anterior cingulate, left caudal middle frontal, and right caudal anterior cingulate gyri. There were no PAE × PTE interactions nor any associations of PAE and PTE exposure on volumetrics that survived FDR correction. Conclusion: PAE was associated with reduction in the structure of the medial temporal lobe, a brain region critical for learning and memory. PTE had stronger and broader associations, including with regions associated with executive function, reward processing, and emotional regulation, potentially reflecting continued postnatal exposure to tobacco (i.e., second‐hand smoke exposure). These differential effects are discussed with respect to reduced PAE quantity in our exposed group versus prior studies within this geographical location, the deep poverty in which participants live, and the consequences of apartheid and racially and economically driven payment practices that contributed to heavy drinking in the region. Longer‐term follow‐up is needed to determine potential environmental and other moderators of the brain findings here and assess the extent to which they endure over time. [ABSTRACT FROM AUTHOR]

Aim: This study aimed to contribute to the paucity of literature on disability in youth with OCD, particularly in low‐ and middle‐income countries (LMICs). Methods: In South Africa (a LMIC), data was collected from 26 children and adolescents with OCD (12 girls, 14 boys; age range 6–18 years), and their parents, on an outpatient basis. Clinical measures aimed at assessing functional impairment due to OCD were administered. Results: Key findings were 1) that children with OCD reported being most significantly affected by their OC symptomatology within the school domain whereas parents placed emphasis on the impairment within the social domain; 2) scores on the Child Obsessive–Compulsive Impact Scale – Revised and the Children's Global Assessment Scale, were consistent, and 3) clinician‐rated symptom severity was positively associated with parental reports on children's impairment due to OCD. Findings show similarities with data from similar studies in a high‐income country (HIC) context. Conclusions: Children with OCD and their parents do not necessarily agree on the ways in which OCD impacts their lives. A comprehensive view of functional impairment in children with OCD, that is, from the viewpoints of the patient, parents, and clinicians, is critical when treatment is planned. Such information may assist with selection of relevant treatment targets, and ultimately improve the quality of life of all affected. [ABSTRACT FROM AUTHOR]

Introduction: Mothers who have experienced childhood trauma may be at increased risk for disruptions in caregiving behavior, with potential consequences for early child development. However, assessments of caregiving behavior tend to be self-reported, which may bias results, and have been limited in lower-resource settings. Methods: In an overall sample of 256 South African mothers followed across the perinatal period, this longitudinal study used structural equation modeling to test pathways of association between maternal childhood trauma and depressive symptoms on observed mother–infant interactions at 3.5 months and subsequent child growth outcomes at 1 year. Results: On average, mothers with childhood trauma histories tended to show lower rated overall interactions with their infants (B = − 0.16, p =.013), which in turn was associated with reduced child growth at 1 year (B = 0.17, p =.046). When this model was adjusted for maternal age and relative socioeconomic status (SES), maternal SES strongly explained child growth (B = 0.31, p <.001) such that the direct effect of mother–infant interactions was no longer significant. Discussion: For child growth in a lower-resource setting, quality of mother–infant interactions could be a relevant predictor but more strongly explained by maternal SES factors, suggesting a need for broader approaches that not only improve dyadic relationships but also address maternal ecological resources. [ABSTRACT FROM AUTHOR]

Background: The Kessler Psychological Distress Scale (K-10) is a short screening tool developed to identify, with good sensitivity, non-specific psychological distress in the general population. Sensitivity and specificity of the K-10 have been examined in various clinical populations in South Africa; however, other psychometric properties, such as construct validity and factor structure, have not been evaluated. We present evidence of the prevalence and severity of psychological distress in an outpatient setting in South Africa and evaluate the internal reliability, construct validity, and factor structure of the K-10 in this population. Methods: We explored prevalence estimates of psychological distress using previously established cutoffs and assessed the reliability (consistency) of the K-10 by calculating Cronbach's alpha, item-total correlations and omega total and hierarchical coefficients. Construct validity and factor structure of the K-10 were examined through split-sample exploratory factor analysis (EFA) followed by confirmatory factor analysis (CFA), comparing several theoretical models and the EFA. Results: Overall, there was low prevalence of psychological distress in our sample of 2591 adults, the majority of whom were between the ages of 18–44 (77.7%). The K-10 showed good construct validity and reliability, with a Cronbach's alpha of 0.84 and omega total of 0.88. EFA yielded a four-factor solution with likely measurement artifacts. CFA showed that the four-factor model from EFA displayed the best comparative fit indices, but was likely overfitted. The unidimensional model with correlated errors was deemed the best fitting model based on fit indices, prior theory, and previous studies. Conclusion: The K-10 displays adequate psychometric properties, good internal reliability, and good fit with a unidimensional-factor structure with correlated errors. Further work is required to determine appropriate cutoff values in different populations and clinical subgroups within South Africa to aid in determining the K-10's clinical utility. [ABSTRACT FROM AUTHOR]

This study aimed to assess the association of childhood trauma, stressful life events and HIV stigma with mental health in South African adolescents from the Cape Town Adolescent Antiretroviral Cohort (CTAAC). The Childhood Trauma Questionnaire, Life Events Questionnaire and the HIV Stigma Scale for South African Adolescents Living with HIV was used to assess childhood trauma, stressful life events and stigma in adolescents living with perinatally acquired HIV and healthy controls enrolled in the CTAAC. These measures were associated with mental health outcomes including the Beck-Youth Inventories, Child Behaviour Checklist, Columbian Impairment Scale, Childrens Motivation Scale, Conners Scale for Attention Deficit Hyperactivity Disorder using Pearson correlations and self-reported alcohol use, using Spearman-rank correlation. 63.7% of adolescents reported at least one childhood trauma on the CTQ. Significant associations were reported between CTQ measures and Beck-Youth Inventories. Emotional abuse was associated with anxiety, anger, depression and disruptive behaviour. Emotional neglect was associated with poor self-concept and disruptive behaviour. LEQ total score was significantly associated with Beck-Youth Inventories including anxiety, depression, anger and disruptive behaviour scales. HIV stigma was significantly associated with Beck-Youth Inventories including depression, anger and disruptive behaviour. Childhood trauma, stressful life events and HIV stigma in South African adolescents are associated with anxiety, depression, anger, disruptive-behaviour and poor self-concept. This study highlights the importance of enquiring about exposure to a variety of traumas, particularly those commonly experienced by South African adolescents. In addition, it is important to understand the impact of trauma exposure on each individuals mental health and functioning. [ABSTRACT FROM AUTHOR]

Supplemental data for this article can be accessed on the publisher's website. We used a cross-sectional web-based survey and discrete-time survival analysis with person-year as unit of analysis and retrospective age-of-onset reports to estimate prevalence and predictors of suicidal ideation, plan, and attempt, and transitions from ideation to plan and attempt among South African university students (n = 1402). The lifetime prevalence of ideation, plan, and attempt were 46.4% (n = 650), 26.5% (n = 372), and 8.6% (n = 120), respectively. Multiple temporally primary mental disorders predicted subsequent onset of suicidality and transitions from ideation to plan and attempt. Results highlight the need for campus-based suicide prevention in South Africa, vulnerability of historically disadvantaged students, and the importance of promoting mental health in suicide prevention. [ABSTRACT FROM AUTHOR]

The article discusses ten game-changers for mental health in South Africa. It highlights the need for a whole-of-society approach, including the inclusion of mental health in the national health framework and addressing early trauma as a risk factor. The article also emphasizes the importance of providing independence and resources to monitoring bodies and institutions involved in mental health governance. Additionally, it calls for increased human resourcing, sharpening the focus on key indicators, and improving the delivery of evidence-based care by health professionals. The article concludes by emphasizing the need for funding and implementation of the National Mental Health Policy Framework to improve mental health services in the country. [Extracted from the article]

The effect of chronic HIV-infection on psychological adjustment, including the impact of HIV-related stigma in perinatally HIV-infected (PHIV+) youth across Africa is largely unknown. This study examined psychological adjustment and HIV-related stigma using the Strengths and Difficulties Questionnaire (SDQ) and a 10-item stigma questionnaire in a cohort of PHIV+ youth in Cape Town, South Africa. The relationships between SDQ scores, elevated viral load, and suboptimal antiretroviral therapy (ART) adherence were also explored. Among 473 PHIV+ youth (aged 9–14 years, on ART > 6 months at enrollment), higher perceived HIV-related stigma was associated with higher scores across all adolescent and caregiver-reported SDQ difficulty subscales. Higher socioeconomic status (SES) was associated with lower scores on adolescent self- and caregiver-reported hyperactivity subscales. Higher adolescent-reported prosocial scores were associated with lower odds of self-reported suboptimal ART adherence, and higher caregiver-reported conduct scores were associated with higher odds of elevated viral load. No associations were observed between perceived HIV-related stigma and treatment outcomes. These findings highlight the potentially detrimental impact of perceived stigma on psychological adjustment in PHIV+ youth. The use of psychosocial metrics and interventions aimed at reducing illness related stigma in PHIV+ youth is also considered. [ABSTRACT FROM AUTHOR]

Mother–infant dyads in low- and middle-income countries (LMICs) may be exposed to a range of factors associated with suboptimal development. Optimal infant development is likely supported by synchronicity in the early mother–infant relationship, but limited corroborative research is available in LMICs. The Drakenstein Child Health Study (DCHS) provided an opportunity to study this synchronicity and its associations in South Africa. A South African birth cohort study investigating early-life determinants of child health in a LMIC context provided participants. The Shared Pleasure (SP) paradigm helped assess early mother–infant synchronicity in videos of a sub-set of 291 mother–infant dyads at their 14-week well baby visit. General linear regression models investigated the relationship between selected maternal and infant characteristics and the presence of Shared Pleasure moments. Out of a possible 291 dyads, 82% (n = 239) yielded Shared Pleasure moments. The mean age of mothers was 27 years, while infant sex distribution comprised 54% females and 46% males. The shortest single Shared Pleasure moment lasted at least 0.5 s and the longest 28 s. Shared Pleasure moments were associated with higher gestation age at delivery (p = 0.008) and higher infant birth weight (p = 0.006), but were not related to mother's mental health and infant health outcomes at 14 weeks. The high frequency of positive Shared Pleasure moments in reciprocal dyadic interactions in this sample suggests that significant disruption in shared pleasure may be present only in extreme cases (e.g. mothers with severe mental disorders). Further work is needed to investigate the mechanisms underlying the associations between early mother–infant synchronicity and better outcomes noted here, and to assess whether SP may serve as a culturally appropriate screen for assessing connectedness. [ABSTRACT FROM AUTHOR]

Intimate partner violence (IPV) has been linked to poor fetal and infant growth. However, factors underlying this relationship are not well understood, particularly in the postnatal time period. In a South African cohort, we investigated (1) associations between IPV in pregnancy and growth at birth as well as postnatal IPV and child growth at 12 months and (2) whether maternal depression, tobacco or alcohol use or infant hospitalizations mediated IPV‐growth relationships. Mothers were enrolled in pregnancy. Maternal IPV was measured during pregnancy and 10 weeks postpartum; depression, alcohol and tobacco use were measured during pregnancy and at 6 months postpartum. Child weight and length were measured at birth and 12 months and converted to z‐scores for analysis. Linear regression and structural equation models investigated interrelationships between IPV and potential mediators of IPV‐growth relationships. At birth, among 1,111 mother–infant pairs, maternal emotional and physical IPV were associated with reduced weight‐for‐age z‐scores (WFAZ). Only physical IPV was associated with length‐for‐age z‐scores (LFAZ) at birth. Antenatal maternal alcohol and tobacco use mediated IPV‐growth relationships at birth. Postnatally, among 783 mother–infant pairs, emotional and physical IPV were associated with reduced WFAZ at 12 months. Only emotional IPV was associated with LFAZ at 12 months. Maternal tobacco use was a mediator postnatally. Findings highlight the role of physical and emotional IPV as risk factors for compromised fetal and infant growth. Findings underscore the importance of programmes to address interrelated risk factors for compromised infant growth, specifically IPV and substance use, which are prevalent in high‐risk settings. [ABSTRACT FROM AUTHOR]

Introduction: There is a growing population of children who are HIV‐exposed and uninfected (HEU) with the successful expansion of antiretroviral therapy (ART) use in pregnancy. Children who are HEU are at risk of delayed neurodevelopment; however, there is limited research on early brain growth and maturation. We aimed to investigate the effects of in utero exposure to HIV/ART on brain structure of infants who are HEU compared to HIV‐unexposed (HU). Methods: Magnetic resonance imaging using a T2‐weighted sequence was undertaken in a subgroup of infants aged 2–6 weeks enrolled in the Drakenstein Child Health Study birth cohort, South Africa, between 2012 and 2015. Mother–child pairs received antenatal and postnatal HIV testing and ART per local guidelines. We compared subcortical and total grey matter volumes between HEU and HU groups using multivariable linear regression adjusting for infant age, sex, intracranial volume and socio‐economic variables. We further assessed associations between brain volumes with maternal CD4 cell count and ART exposure. Results: One hundred forty‐six infants (40 HEU; 106 HU) with high‐resolution images were included in this analysis (mean age 3 weeks; 50.7% male). All infants who were HEU were exposed to ART (88% maternal triple ART). Infants who were HEU had smaller caudate volumes bilaterally (5.4% reduction, p < 0.05) compared to HU infants. There were no group differences in other subcortical volumes (all p > 0.2). Total grey matter volume was also reduced in infants who were HEU (2.1% reduction, p < 0.05). Exploratory analyses showed that low maternal CD4 cell count (<350 cells/mm3) was associated with decreased infant grey matter volumes. There was no relationship between timing of ART exposure and grey matter volumes. Conclusions: Lower caudate and total grey matter volumes were found in infants who were HEU compared to HU in the first weeks of life, and maternal immunosuppression was associated with reduced volumes. These findings suggest that antenatal HIV exposure may impact early structural brain development and improved antenatal HIV management may have the potential to optimize neurodevelopmental outcomes of children who are HEU. [ABSTRACT FROM AUTHOR]

Background: The ENhancing Assessment of Common Therapeutic factors (ENACT) tool measures a set of therapeutic competencies required for the effective psychological intervention, including delivery by non-specialists. This paper describes the systematic adaptation of the ENACT for the South African (SA) context and presents the tool's initial psychometric properties. Methods: We employed a four-step process: (1) Item generation: 204 therapeutic factors were generated by SA psychologists and drawn from the original ENACT as potential items; (2) Item relevance: SA therapists identified 96 items that were thematically coded according to their relationship to one another and were assigned to six domains; (3) Item utility: The ENACT-SA scale was piloted by rating recordings of psychological therapy sessions and stakeholder input; and (4) Psychometric properties: Internal consistency and inter-rater reliability of the final 12-item ENACT-SA were explored using Cronbach's alpha and intraclass correlation co-efficient (ICC) for both clinical psychologists and registered counsellors. Results: Although the original ENACT provided a framework for developing a tool for use in SA, several modifications were made to improve the applicability of the tool for the SA context, and optimise its adaptability other contexts. The adapted 12-item tool's internal consistency was good, while the inter-rater reliability was acceptable for both clinical psychologists and registered counsellors. Conclusion: The ENACT-SA is a reliable tool to assess common factors in psychological treatments. It is recommended that the tool be used in conjunction with assessment protocols and treatment-specific competency measures to fully assess implementation fidelity and potential mechanisms of therapeutic change. [ABSTRACT FROM AUTHOR]

Suicidal ideation and behaviour (SIB) in the perinatal period is prevalent in low- and middle-income countries (LMICs). Past work has been limited by reliance on self-rated scales, and there are few data on SIB severity in such settings. We collected cross-sectional data on SIB using a clinician-administered scale and explored risk factors associated with the presence of SIB and SIB severity. Data were collected from the Drakenstein Child Health Study cohort antenatally and at 6 months postpartum. SIB was measured using the Mini International Neuropsychiatric Interview, and potential sociodemographic, psychosocial, and psychiatric risk factors were assessed. Multivariable analysis determined cross-sectional risk factors. Multinomial regressions determined predictors of SIB risk categories. Among 748 women, the antenatal SIB prevalence was 19.9% and postpartum 22.6%. SIB was associated with younger age (antepartum), PTSD (postpartum), and depression (ante- and postpartum). Depression and PTSD predicted belonging to the high-risk SIB group. The medium-risk group was more likely to have depression, alcohol use during pregnancy, and substance abuse. Depression, PTSD, food insecurity, recent intimate partner violence (IPV), and childhood trauma were associated with the low-risk group versus the no-risk group. Screening is needed for perinatal SIB. Associations of perinatal SIB with younger age and major depression are consistent with previous work. The association with PTSD is novel, and underscores the importance of assessment of trauma exposure and outcomes in this population. Different risk categories of SIB may have different causal pathways and require different interventions. [ABSTRACT FROM AUTHOR]

Introduction: Many individuals with obsessive-compulsive disorder (OCD) delay seeking help, leading to greater illness severity, additional comorbidity, and increased functional impairment. Patterns of help-seeking for OCD have however not yet been described in South Africa, a low-and middle-income country with many health service challenges. Using the health belief model as a conceptual framework, study aims were to identify predictors of and barriers to help-seeking among South Africans with OCD. Methods: Fifty adults with OCD completed an online survey to assess (1) socio-demographic characteristics, (2) OCD symptom severity, (3) treatment barriers, (4) perceived treatment benefits, (5) self-efficacy, and (6) help-seeking intention. Multiple linear regression analysis was used to establish predictors of help-seeking intention. Descriptive statistics were used to determine the most endorsed help-seeking barriers. Results: 42.6% of the variance in help-seeking intention was explained by the investigated constructs (R 2 = 0.426, F = 4.45 and p < 0.01). Perceived treatment benefits were the only significant predictor of help-seeking intention (B = 1.37, t = 5.16, and p < 0.01). More than a third (36%) of the sample endorsed wanting to handle the problem independently as a significant barrier, followed by treatment concerns (26%), affordability (22%), and shame (20%). Conclusion: An innovative analysis of help-seeking patterns suggested that perceived treatment benefits were the only significant predictor of help-seeking intention among South African adults with OCD. Psychoeducation and mental health literacy programmes may be useful in increasing public appreciation of the benefits of OCD treatment, and in mitigating key help-seeking barriers. [ABSTRACT FROM AUTHOR]

Purpose: Childhood maltreatment elevates risk for common mental disorders (CMDs) during late adolescence and adulthood. Although CMDs are highly prevalent among university students, few studies have examined the relationship between childhood maltreatment and 12 month CMDs in a low- to middle-income countries. This paper describes the prevalence of maltreatment and the relationship between type, number and patterns of maltreatment exposure and 12 month CMDs among first-year university students in South Africa. Methods: Maltreatment and CMD data were collected via well-validated self-report scales (corresponding with DSM-IV diagnoses) in a web-based survey of first-year students from two large urban universities (n = 1290) in South Africa. Various multivariate modelling approaches (additive, restrictive interactive and latent class) were used to examine the relationship between maltreatment and CMDs. Results: Overall, 48.4% of participants reported childhood maltreatment, the most common type being emotional abuse (26.7%). Regardless of the modelling approach used, emotional abuse was the only type of maltreatment independently associated with 12-month diagnoses of major depressive disorder (MDD), generalised anxiety disorder (GAD) or drug use disorder (DUD) even after adjusting for types and number of types of maltreatment. Similarly, students in the latent class reflecting histories of emotional abuse (either alone or combined with physical abuse) were more likely to meet criteria for 12-month MDD, GAD or DUD. Conclusion: Findings confirm the high prevalence of childhood maltreatment among South African students. As this exposure elevates risk for MDD, GAD and DUD, interventions aimed at preventing and treating CMDs among first-year students should address experiences of childhood maltreatment. [ABSTRACT FROM AUTHOR]

Objective: To explore health care providers' views on the acceptability and feasibility of two models for integrating facility-based counsellor delivered mental health counselling into chronic disease care, and how such an approach could be improved in South Africa. Methods: Fourteen focus group discussions and 25 in-depth individual interviews were conducted with 109 health care workers and facility managers from 24 primary health clinics in the Western Cape, South Africa. Results: Findings suggested that despite recent efforts to integrate mental health counselling into chronic disease services for common mental disorders, there remains limited availability of psychosocial and psychological counselling. Feedback on the two models of integration suggested equipoise and the potential of a hybrid approach where these approaches may be tailored to the specific needs and available resources of each facility. Participants identified constraints within the health system and broader social context that require consideration for integrating mental health counselling into chronic disease care. Conclusion: Although study participants unanimously agreed that counselling for common mental disorders should be integrated into chronic disease services, they had differing views on the type of model that should be adopted. There is a need for further testing of the two models and aspects of the health service that may require strengthening to implement any such model. [ABSTRACT FROM AUTHOR]

Violence against women remains a significant public health problem globally. The majority of longitudinal studies documenting the negative impact of intimate partner violence (IPV) on the mental health of women come from high-income countries. The aim of this study was to investigate the longitudinal association between emotional, physical, or sexual IPV and depression symptoms among South African women in a prospective cohort study. Participants were 981 South African women enrolled in the Drakenstein Child Health Study—a cohort study investigating the early life determinants of child health. Interview data from four time-points (antenatal care visit, 6 months, 12 months, and 18 months postpartum) were included. The primary independent variable was self-reported emotional, physical, and sexual IPV in the past 12 months. Depressive symptoms were assessed at each time-point with the Edinburgh Postnatal Depression Scale (EPDS); a cutoff score of ⩾13 was used to define significant depression symptoms. We used pooled-multivariable logistic regression models to determine associations between the three different forms of IPV and significant depression symptoms while adjusting for time-fixed and time-updated covariates. The mean age of the sample at antenatal care visit was 27 years (standard deviation = 6.0). In the adjusted model including all forms of IPV and adjusting for sociodemographic and clinical characteristics, substance use, and childhood trauma, emotional (adjusted odds ratio [aOR] =1.55, 95% confidence interval (CI): [1.02, 2.34]; p =.039)] and sexual (aOR = 2.02, 95% CI: [1.10, 3.72]; p <.001) IPV were significantly associated with significant depression symptoms. The relationship between physical IPV and significant depression symptoms was not statistically significant (aOR = 0.68, 95% CI: [0.44, 1.05]; p =.485). Our study confirms findings from high-income countries of the association between IPV and depressive symptoms among women in South Africa. Routine screening for IPV, including emotional IPV and intervention programs for IPV among women, is needed in South Africa. [ABSTRACT FROM AUTHOR]

Background: South Africa is marked by high rates of both HIV and alcohol use, and there is a detrimental synergistic relationship between these two epidemics. The Institute of Medicine recommends integrated care for alcohol use treatment and HIV, but implementation of integrated services remains a challenge in South Africa. This protocol describes a study designed to evaluate trainer, provider-, and patient encounter-level outcomes relating to the national rollout of a cascade train-the-trainer model of task-sharing to build capacity of the HIV workforce to deliver Screening, Brief Intervention, and Referral to Treatment (SBIRT) to address risky alcohol use. Methods: This 5 year protocol consists of two phases. First, we will finalize development of a robust SBIRT train-the-trainer model, which will include an SBIRT Trainer Manual, Provider Resource Guide, fidelity observational coding system, case vignettes, and a curriculum for ongoing consultation sessions. Materials will be designed to build the capacity of novice trainers to train lay workers to deliver SBIRT with fidelity. Second, we will recruit 24–36 trainers and 900 providers in order to evaluate the effects of the SBIRT train-the-trainer model on trainer- (e.g., fidelity, knowledge), provider- (e.g., SBIRT attitudes, confidence, acceptability), and patient encounter- (e.g., proportion receiving screening, brief intervention, referral to treatment) level variables. Data on patient encounters will be tracked by providers on programmed tablets or scannable paper forms in real-time. Providers will report on SBIRT delivery on an ongoing basis over a 6-months period. Additionally, we will test the hypothesis that trainer-level factors will account for a substantial proportion of variability in provider-level factors which will, in turn, account for a substantial proportion of variability in patient encounter-level outcomes. Discussion: This protocol will allow us to take advantage of a unique national training initiative to gather comprehensive data on multi-level factors associated with the implementation of SBIRT in HIV service settings. In the long-term, this research can help to advance the implementation of integrated alcohol-HIV services, providing lessons that can extend to other low-and-middle income countries confronting dual epidemics. [ABSTRACT FROM AUTHOR]

Purpose: To determine the prevalence of substance use disorders (SUDs) in patients with schizophrenia in a sample from South Africa and compare the clinical and demographic correlates in those with and without co-occurring SUDs.Methods: Patients with schizophrenia were interviewed using the Xhosa version SCID-I for DSM-IV. We used logistic regression to determine the predictors of SUDs.Results: In the total sample of 1420 participants, SUDs occurred in 47.8%, with the most prevalent SUD being cannabis use disorders (39.6%), followed by alcohol (20.5%), methaqualone (6.2%), methamphetamine (4.8%) and other SUDs (cocaine, ecstasy, opioids, 0.6%). Polydrug use occurred in 40%, abuse occurred in 13.5%, and 39.6% had at least one substance dependence diagnosis. Significant predictors of any SUD were younger age (41-55 vs. 21-30: OR = 0.7, 95% CI = 0.5-0.9), male sex (OR = 8.6, 95% CI = 5.1-14.6), inpatient status (OR = 1.7, 95% CI = 1.3-2.1), post-traumatic stress symptoms (OR = 4.6, 95% CI = 1.6-13.3), legal (OR = 3.4, 95% CI = 2.0-5.5) and economic problems (OR = 1.4, 95% CI = 1.0-2.0). Methamphetamine use disorders occurred significantly less often in the Eastern compared to the Western Cape provinces. Inpatient status and higher levels of prior admissions were significantly associated with cannabis and methamphetamine use disorders. Post-traumatic stress symptoms were significantly associated with alcohol use disorders. Anxiety disorders were associated with other SUDs.Conclusion: SUDs occurred in almost half of the sample. It is important for clinicians to identify the presence of SUDs as their presence is associated with characteristics, such as male sex, younger age, inpatient status, more prior hospitalisations, legal and economic problems, PTSD symptoms and anxiety. [ABSTRACT FROM AUTHOR]

Campus-based suicide prevention is an important priority for universities. One approach could be to identify and treat common mental disorders, but it is unclear what potential reduction in suicide might be achieved by such an approach. Our aim was to quantify this potential effect on prevalence of nonfatal suicidal behaviour among first-year students. Data were collected from students at two South African universities (N = 633) via an online survey. We assessed prevalence of nonfatal suicidal behaviour and six common mental disorders and used logistic regression models to identify all main and interaction associations of sociodemographic variables and common mental disorders as predictors of nonfatal suicidal behaviour. Population attributable risk analysis was used to quantify the potential reduction in nonfatal suicidal behaviour achieved by effectively treating common mental disorders, based on the simplifying assumption that the logistic regression coefficients of the common mental disorders represented causal effects on nonfatal suicidal behaviour. Twelve-month prevalence of suicidal ideation, plan, and attempt were 40.9%, 22.3%, and 3.9%, respectively. Increased risk was associated with identifying as Black, female and reporting an atypical sexual orientation. Of the six common mental disorders, major depressive disorder and generalised anxiety disorder were associated with all dimensions of nonfatal suicidal behaviour, bipolar spectrum disorder with increased risk of ideation and plan, attention-deficit/hyperactivity disorder with ideation, and alcohol use disorder with suicide plan. Population attributable risk analysis suggests that treating common mental disorders could yield absolute reductions in suicide ideation, plan, and attempt of 17.0%, 55.0% and 73.8%, respectively. Pragmatic trials are needed to evaluate the effects on nonfatal suicidal behaviour of identifying and treating students with a prior history of common mental disorder early in their university careers. [ABSTRACT FROM AUTHOR]

Background: Over the past three decades, a range of international stakeholders have highlighted the possibility that genomic research may impact stigma associated with psychiatric disorders. Limited research has been conducted in Africa to investigate this relation. Method: In the present study, using focus group discussions, we explored the relation between genetic attribution and stigma among 36 Xhosa people with schizophrenia. We addressed three main questions: (1) What causal beliefs do Xhosa people with schizophrenia use to explain their illness and to what extent do genetic explanations play a role in these beliefs? (2) What are the internalised stigma experiences of Xhosa people with schizophrenia? (3) How do genetic explanations relate to stigma experiences, if at all? Results: Most participants were able to define genetics and some linked genetics to disease causation. Despite adequate knowledge of genetics and an emphasis on genetic explanations of schizophrenia in the study, most participants held a multitude of causal explanations including: psychosocial, environmental, and cultural. Moreover, participants rarely mentioned disease cause when describing their stigma experiences. Discussion: For this population group, there was no straight-forward relation between a genetic attribution and stigma. Therefore, we did not find evidence that genetic attribution may significantly increase stigma. Although North American and European literature provides conflicting evidence regarding this relation, there is increased consensus that biomedical explanations for psychiatric disorders may reduce blame. This study found evidence supporting that consensus. This study provides an empirical foundation to inform ongoing work on the psychosocial implications of psychiatric genomics research in non-Western contexts. [ABSTRACT FROM AUTHOR]

Diversion of antiretroviral therapy (ART) for recreational use is concerning for countries with high HIV prevalence. This paper presents reports of recreational use of ART among adolescents from two HIV prevention studies in South Africa: (1) a cross-sectional survey of N = 200 adolescents and (2) a qualitative study of pre-exposure prophylaxis with N = 57 adolescents and N = 25 clinicians. Among adolescents, 3% used and 14% knew someone who used non-prescribed ART for recreational purposes. Administration included smoking (71%), snorting (15%), injecting (15%), ingesting (15%), and inserting (3%). Participants predicted increased crime as recreational use of ART increased. Future studies should investigate prevalence, composition, and diversion of ART from HIV prevention and treatment. [ABSTRACT FROM AUTHOR]

Background: Substance use disorders (SUDs) occur frequently in patients with psychotic disorders and have been associated with various demographic and clinical correlates. There is an absence of research on the prevalence and clinical correlates of SUDs in psychotic disorders in low-and-middle-income countries (LMICs). Aim: We aimed to determine the prevalence and correlates of SUDs in psychotic disorders. Setting: Patients attending a large secondary-level psychiatric hospital in Cape Town South Africa. Results: In total sample (N = 248), 55.6% of participants had any SUD, 34.3% had cannabis use disorders, 30.6% alcohol use disorders, 27.4% methamphetamine use disorders, 10.4% methaqualone use disorders and 4.8% had other SUDs. There were significant associations with male sex for most SUDs, with younger age and Coloured ethnicity for methamphetamine use disorders, and with lower educational attainment for cannabis use disorders. Anxiety symptoms and suicide attempts were significantly associated with alcohol use disorders; a diagnosis of a substance induced psychosis with cannabis and methamphetamine use disorders. Across most SUDs legal problems and criminal involvement were significantly increased. Conclusion: This study found a high prevalence and wide distribution of SUDs in patients with psychotic disorders, consistent with previous work from high income countries. Given clinical correlates, in individuals with psychotic disorders and SUDs it is important to assess anxiety symptoms, suicidality and criminal involvement. [ABSTRACT FROM AUTHOR]

Background: Evidence from high-income countries suggests that childhood trauma is associated with schizophrenia. Studies of childhood trauma and schizophrenia in low and middle income (LMIC) countries are limited. This study examined the prevalence of childhood traumatic experiences among cases and controls and the relationship between specific and cumulative childhood traumatic experiences and schizophrenia in a sample in South Africa. Methods: Data were from the Genomics of Schizophrenia in the South African Xhosa people study. Cases with schizophrenia and matched controls were recruited from provincial hospitals and clinics in the Western and Eastern Cape regions in South Africa. Childhood traumatic experiences were measured using the Childhood Trauma Questionnaire (CTQ). Adjusted logistic regression models estimated associations between individual and cumulative childhood traumatic experiences and schizophrenia. Results: Traumatic experiences were more prevalent among cases than controls. The odds of schizophrenia were 2.44 times higher among those who experienced any trauma than those who reported no traumatic experiences (95% CI 1.77–3.37). The odds of schizophrenia were elevated among those who experienced physical/emotional abuse (OR 1.59, CI 1.28–1.97), neglect (OR 1.39, CI 1.16–1.68), and sexual abuse (OR 1.22, CI 1.03–1.45) compared to those who did not. Cumulative physical/emotional abuse and neglect experiences increased the odds of schizophrenia as a dose–response relationship. Conclusion: Childhood trauma is common in this population. Among many other benefits, interventions to prevent childhood trauma may contribute to a decreasing occurrence of schizophrenia. [ABSTRACT FROM AUTHOR]

Introduction and Aims: As South Africa, especially the Western Cape Province, faces an epidemic of methamphetamine use disorder, therapeutic approaches suited to the South African context are needed. This secondary analysis assessed retention and methamphetamine abstinence outcomes in response to an 8-week pilot contingency management (CM) intervention trial of neural correlates of methamphetamine abstinence, exploring sociodemographic and clinical differences between responders and non-responders.Design and Methods: Research participants provided thrice-weekly monitored urine samples, which were analysed by qualitative radioimmunoassay. The primary outcome for this analysis was therapeutic response, defined as abstinence from methamphetamine (≥23 of 24 possible methamphetamine-negative urine samples).Results: Data from 30 adults living in Cape Town, South Africa (34 ± 6.1 years of age, mean age ± SD, 21 men) were included. Sixty-three percent (12 men) were responders. In bivariate comparisons, baseline measurements showed fewer responders reported monthly household income ≥25 000+ South African Rand (ZAR; ~USD $1880; vs. ZAR < 25 000) than non-responders (15.8% vs. 63.6%; P = 0.007). Furthermore, responders had higher median years of education (12 vs. 10; Kruskal-Wallis χ2 = 4.25, DF = 1, P = 0.039) and lower median body mass index than non-responders (19 vs. 24; Kruskal-Wallis χ2 = 6.84, P = 0.008).Discussion and Conclusions: Therapeutic response in this study were comparable to those obtained with CM for methamphetamine use disorder in North America and Europe. Our findings suggest that CM may be a useful component of treatment strategies to boost retention and continuous abstinence from methamphetamine in Cape Town, South Africa. Larger efficacy studies are needed in this setting. [ABSTRACT FROM AUTHOR]

Background: Obsessive-compulsive disorder (OCD) has a lifetime prevalence of 2–3% and is a leading cause of global disability. Brain circuit abnormalities in individuals with OCD have been identified, but important knowledge gaps remain. The goal of the new global initiative described in this paper is to identify robust and reproducible brain signatures of measurable behaviors and clinical symptoms that are common in individuals with OCD. A global approach was chosen to accelerate discovery, to increase rigor and transparency, and to ensure generalizability of results. Methods: We will study 250 medication-free adults with OCD, 100 unaffected adult siblings of individuals with OCD, and 250 healthy control subjects at five expert research sites across five countries (Brazil, India, Netherlands, South Africa, and the U.S.). All participants will receive clinical evaluation, neurocognitive assessment, and magnetic resonance imaging (MRI). The imaging will examine multiple brain circuits hypothesized to underlie OCD behaviors, focusing on morphometry (T1-weighted MRI), structural connectivity (Diffusion Tensor Imaging), and functional connectivity (resting-state fMRI). In addition to analyzing each imaging modality separately, we will also use multi-modal fusion with machine learning statistical methods in an attempt to derive imaging signatures that distinguish individuals with OCD from unaffected siblings and healthy controls (Aim #1). Then we will examine how these imaging signatures link to behavioral performance on neurocognitive tasks that probe these same circuits as well as to clinical profiles (Aim #2). Finally, we will explore how specific environmental features (childhood trauma, socioeconomic status, and religiosity) moderate these brain-behavior associations. Discussion: Using harmonized methods for data collection and analysis, we will conduct the largest neurocognitive and multimodal-imaging study in medication-free subjects with OCD to date. By recruiting a large, ethno-culturally diverse sample, we will test whether there are robust biosignatures of core OCD features that transcend countries and cultures. If so, future studies can use these brain signatures to reveal trans-diagnostic disease dimensions, chart when these signatures arise during development, and identify treatments that target these circuit abnormalities directly. The long-term goal of this research is to change not only how we conceptualize OCD but also how we diagnose and treat it. [ABSTRACT FROM AUTHOR]

We tested the acceptability, feasibility, and preliminary efficacy of Our Family Our Future, a resilience-oriented intervention engaging families in prevention of adolescent HIV and depression. South African adolescents, 13–15 years of age, with mild depressive symptoms, were randomized to intervention or wait-list using parallel assignment in a single-blind trial. HIV risk behavior and depression were evaluated at baseline, 1, and 3 months. We examined intervention satisfaction, fidelity, trial retention, and preliminary efficacy. One hundred-ninety-six adolescent-parent dyads completed eligibility screening and baseline, and n = 73 dyads were randomized. All families ranked intervention quality as good or excellent. Over 90% were satisfied with content. Facilitators were adherent to intervention protocol. All families were retained in post-intervention assessments. Intervention recipients reported diminished depressive symptoms, inconsistent condom use, and sexual activity, as well as increased HIV testing. Our Family Our Future is highly acceptable and feasible and should be tested in a future efficacy trial. [ABSTRACT FROM AUTHOR]

Background: Addressing inequalities in mental healthcare utilisation among university students is important for socio-political transformation, particularly in countries with a history of educational exclusion. Methods: As part of the WHO World Mental Health International College Student Initiative, we investigated inequalities in mental healthcare utilisation among first-year students at two historically "White" universities in South Africa. Data were collected via a web-based survey from first-year university students (n = 1402) to assess 12-month mental healthcare utilisation, common mental disorders, and suicidality. Multivariate logistic regression models were used to estimate associations between sociodemographic variables and mental healthcare utilisation, controlling for common mental disorders and suicidality. Results: A total of 18.1% of students utilised mental healthcare in the past 12 months, with only 28.9% of students with mental disorders receiving treatment (ranging from 28.1% for ADHD to 64.3% for bipolar spectrum disorder). Of those receiving treatment, 52.0% used psychotropic medication, 47.3% received psychotherapy, and 5.4% consulted a traditional healer. Treatment rates for suicidal ideation, plan and attempt were 25.4%, 41.6% and 52.9%, respectively. In multivariate regression models that control for the main effects of mental health variables and all possible joint effects of sociodemographic variables, the likelihood of treatment was lower among males (aOR = 0.57) and Black students (aOR = 0.52). An interaction was observed between sexual orientation and first generation status; among second-generation students, the odds of treatment were higher for students reporting an atypical sexual orientation (aOR = 1.55), while among students with atypical sexual orientations, the likelihood of mental healthcare utilisation was lower for first-generation students (aOR = 0.29). Odds of treatment were significantly elevated among students with major depressive disorder (aOR = 1.88), generalised anxiety disorder (aOR = 2.34), bipolar spectrum disorder (aOR = 4.07), drug use disorder (aOR = 3.45), suicidal ideation (without plan or attempt) (aOR = 2.00), suicide plan (without attempt) (aOR = 3.64) and suicide attempt (aOR = 4.57). Likelihood of treatment increased with level of suicidality, but not number of mental disorders. Conclusion: We found very low mental healthcare treatment utilisation among first-year university students in South Africa, with enduring disparities among historically marginalised groups. Campus-based interventions are needed to promote mental healthcare utilisation by first-year students in South Africa, especially among male and Black students and first-generation students with atypical sexual orientations. [ABSTRACT FROM AUTHOR]

Background: Peripartum common mental disorders (CMD) are highly prevalent in low- and middle-income countries (LMIC) such as South Africa. With limited public mental health resources, task sharing approaches to treatment are showing promise. However, little is known about the feasibility and acceptability of, as well as responses associated with problem-solving therapy (PST) for the treatment of prepartum CMD symptoms in South African public health settings. Aim: To investigate participants' preliminary responses to a task sharing PST intervention, and to evaluate the feasibility and acceptability of the intervention. Setting: A Midwife and Obstetrics Unit attached to a Community Health Centre in a Western Cape district. Methods: Using mixed methods, 38 participants' responses to a PST intervention, and their perceptions of its feasibility and acceptability, were explored. Primary outcomes included psychological distress (Self Reporting Questionnaire; SRQ-20) and depression symptoms (Edinborough Postnatal Depression Scale; EPDS). Semi-structured interviews were conducted three after the last session. Six stakeholders were also interviewed. Results: Significant reductions were seen on EPDS (Cohen's d = 0.61; Hedges g = 0.60) and SRQ-20 (Cohen's d = 0.68; Hedges g = 0.67) scores. The intervention's acceptability lay in the opportunity for confidential disclosure of problems; and in relieving staff of the burden of managing of patients' distress. Barriers included lack of transport and work commitments. Conclusion: Results support task sharing PST to Registered Counsellors to treat antenatal CMDs in perinatal primary health care settings. Research is needed on how such programmes might be integrated into public health settings, incorporating other non-specialists. [ABSTRACT FROM AUTHOR]

Literature indicates a high prevalence and burden of mental illness in youths world-wide, which may be even higher in low- and middle-income countries (LMIC), such as South Africa and Zambia. Additionally, there is a lack of knowledge regarding youth depression amongst many primary health care (PHC) practitioners. The principal goal of the MEGA project is to provide youth with better access to mental health services and appropriate care, by developing a mental health screening mobile application tool to be used in PHC settings in South Africa and Zambia. In this study, we will use a mixed methods multi-center study design. In phase one, we will investigate the mental health literacy of PHC practitioners to identify areas in need of development. Based on the needs identified, we will develop and test a mobile health application to screen for common youth mental health problems in phase two. In phase three, we will implement and evaluate a tiered education and training program in the use of the m-health application. In the final phase, we will evaluate the acceptability and feasibility of the m-health application in PHC centres across South Africa and Zambia. Evidence suggests that PHC practitioners should routinely consider mental illness when assessing youth. However, common psychiatric disorders remain largely undetected and untreated in PHC settings. By identifying limitations in PHC workers knowledge with regard to youth mental health, we aspire to improve the depression care provided to youth in Southern Africa and Zambia by developing and implementing a locally relevant m-health application. [ABSTRACT FROM AUTHOR]

Background: Maternal physical and mental health during pregnancy are key determinants of birth outcomes. There are relatively few prospective data that integrate physical and mental maternal health measures with birth outcomes in low- and middle-income country settings. We aimed to investigate maternal health during pregnancy and the impact on birth outcomes in an African birth cohort study, the Drakenstein Child Health Study. Methods: Pregnant women attending 2 public health clinics, Mbekweni (serving a predominantly black African population) and TC Newman (predominantly mixed ancestry) in a poor peri-urban area of South Africa were enrolled in their second trimester and followed through childbirth. All births occurred at a single public hospital. Maternal sociodemographic, physical and psychosocial characteristics were comprehensively assessed. Multivariable linear regression models were used to explore associations between maternal health and birth outcomes. Results: Over 3 years, 1137 women (median age 25.8 years; 21% HIV-infected) gave birth to 1143 live babies. Most pregnancies were uncomplicated but gestational diabetes (1%), anaemia (22%) or pre-eclampsia (2%) occurred in a minority. Most households (87%) had a monthly income of less than USD 350; only 27% of moms were employed and food insecurity was common (37%). Most babies (80%) were born by vaginal delivery at full term; 17% were preterm, predominantly late preterm. Only 74 (7%) of babies required hospitalisation immediately after birth and only 2 babies were HIV-infected. Food insecurity, socioeconomic status, pregnancy-associated hypertension, pre-eclampsia, gestational diabetes and mixed ancestry were associated with lower infant gestational age while maternal BMI at enrolment was associated with higher infant gestational age. Primigravida or alcohol use during pregnancy were negatively associated with infant birth weight and head circumference. Maternal BMI at enrolment was positively associated with birth weight and gestational diabetes was positively associated with birth weight and head circumference for gestational age. Smoking during pregnancy was associated with lower infant birth weight. Conclusion: Several modifiable risk factors including food insecurity, smoking, and alcohol consumption during pregnancy were identified as associated with negative birth outcomes, all of which are amenable to public health interventions. Interventions to address key exposures influencing birth outcomes are needed to improve maternal and child health in low-middle income country settings. [ABSTRACT FROM AUTHOR]

Objective: To examine the association of psychological distress with serum C-reactive protein (CRP) in a South African cohort. Methods: Data were analysed on individuals aged ≥15 years from the South African National Health and Nutrition Examination Survey (SANHANES) of 2012. Psychological distress was evaluated using the Kessler Psychological Distress Scale. Linear regression models assessed the association of psychological distress with serum CRP, adjusting for possible confounding factors. Results: The analytic sample comprised n = 3944 individuals (mean age = 40 and sex = 36% males). Psychological distress was significantly associated with increased serum CRP levels (B = 0.31 and p = 0.001). This association was no longer significant after adjusting for demographic variables, lifestyle factors, cardiac disease, diabetes, hypertension, trauma and anti-inflammatory medication use (B = 0.15 and p = 0.062). Conclusion: Psychological distress was associated with elevated levels of CRP among South African adults. However, the association was confounded by a range of factors, with demographic variables (age, sex and population group) having the largest confounding effect. These findings indicate that CRP is not a useful biomarker of psychological distress, and that additional work is needed on the underlying psychobiology of psychological distress. [ABSTRACT FROM AUTHOR]

Tobacco-attributable deaths in South Africa have increased since 1990, yet data are scanty from healthcare settings. Internationally, emergency centre (EC) visits are increasingly utilised as opportunities for health risk behaviour screening and intervention, but this is not the case in South Africa. Effective advocacy for these services requires data on the prevalence and correlates of tobacco use among South African EC patients. The study objectives were to investigate tobacco prevalence and associated factors in ECs. Demographics, hospital presentation and substance use data were collected as part of a screening and brief intervention programme for alcohol and drugs in three ECs. We conducted descriptive statistics and utilised logistic regression to examine the associations of demographics, presenting complaint and substance use with moderate–high risk-tobacco use as the dependent variable. Of 12,522 patients screened, 37.0% used tobacco and 35.7% showed moderate–high risk for tobacco-related harms. Factors associated with tobacco-related harms included male gender and moderate–high risk for other substances. Of the patients who met criteria and received an intervention for alcohol or drugs, 65.5% were at moderate–high risk for tobacco-related harms. Given the high prevalence of tobacco use among patients attending ECs, intervening on this platform has the potential to reduce risk for non-communicable disease. [ABSTRACT FROM AUTHOR]

Background: Approximately 250 million (43%) children under the age of 5 years in low- and middle-income countries (LMICs) are failing to meet their developmental potential. Risk factors are recognised to contribute to this loss of human potential. Expanding understanding of the risks that lead to poor outcomes and which protective factors contribute to resilience in children may be critical to improving disparities.Methods and Findings: The Drakenstein Child Health Study is a population-based birth cohort in the Western Cape, South Africa. Pregnant women were enrolled between 20 and 28 weeks' gestation from two community clinics from 2012 to 2015; sociodemographic and psychosocial data were collected antenatally. Mothers and children were followed through birth until 2 years of age. Developmental assessments were conducted by trained assessors blinded to background, using the Bayley-III Scales of Infant and Toddler Development (BSID-III), validated for use in South Africa, at 24 months of age. The study assessed all available children at 24 months; however, some children were not able to attend, because of loss to follow-up or unavailability of a caregiver or child at the correct age. Of 1,143 live births, 1,002 were in follow-up at 24 months, and a total of 734 children (73%) had developmental assessments, of which 354 (48.2%) were girls. This sample was characterised by low household employment (n = 183; 24.9%) and household income (n = 287; 39.1% earning 1 domain affected, and 75 (10.2%) had delay in all domains. Bivariate and multivariable analyses revealed several factors that were associated with developmental outcomes. These included protective factors (maternal education, higher birth weight, and socioeconomic status) and risk factors (maternal anaemia in pregnancy, depression or lifetime intimate partner violence, and maternal HIV infection). Boys consistently performed worse than girls (in cognition [β = -0.74; 95% CI -1.46 to -0.03, p = 0.042], receptive language [β = -1.10; 95% CI -1.70 to -0.49, p < 0.001], expressive language [β = -1.65; 95% CI -2.46 to -0.84, p < 0.001], and fine motor [β = -0.70; 95% CI -1.20 to -0.20, p = 0.006] scales). There was evidence that child sex interacted with risk and protective factors including birth weight, maternal anaemia in pregnancy, and socioeconomic factors. Important limitations of the study include attrition of sample from birth to assessment age and missing data in some exposure areas from those assessed.Conclusions: This study provides reliable developmental data from a sub-Saharan African setting in a well-characterised sample of mother-child dyads. Our findings highlight not only the important protective effects of maternal education, birth weight, and socioeconomic status for developmental outcomes but also sex differences in developmental outcomes and key risk and protective factors for each group. [ABSTRACT FROM AUTHOR]

Impulsivity is known to increase the likelihood of using stimulant drugs which in turn may increase impulsivity, leading to potentially hazardous use. However, little research has been conducted on impulsivity in methamphetamine (MA) users. In this case-control cross-sectional study, 54 adults with MA use disorder (MUD) were compared to 52 matched healthy control (HC) participants using the UPPS-P Impulsive Behavior Scale (UPPS-P). Demographic and clinical correlates and predictors of impulsivity in MUD participants were also investigated. Our findings indicate that the MUD cohort had significantly increased impulsivity (p < 0.01) compared to the HCs. In the MUD cohort, the UPPS-P total score was also positively correlated with the number of comorbid mental disorders (r = 0.29, p = 0.04), and degree of family impairment (r = 0.37, p < 0.01). Multiple linear regression analysis showed that the level of family impairment associated with MUD was significantly associated with impulsivity, explaining 16% of the variance (R2 =.16, F(2,51) = 4.88, p =.01). Understanding the clinical correlates and predictors of impulsivity in MUD may inform prevention, early identification, and intervention. [ABSTRACT FROM AUTHOR]

Accessible summary: What is already known about this topic?: Integrating mental health counselling into primary care services is a recommended strategy for reducing the mental health treatment gap in low‐ and middle‐income countries.To support this strategy, potential barriers to counselling integration must be identified and addressed.Organizational preparedness for implementation may influence the extent to which the introduction of counselling is successful.Features of primary care facilities associated with preparedness for the implementation of mental health counselling have not been explored. What the paper adds to existing knowledge?: This study uses a novel approach to explore variations in preparedness of primary care services to implement counselling and factors potentially associated with these variations.Findings suggest there is considerable variation in the preparedness of facilities to implement counselling.Organizational factors such as resource availability, management style and facility environment are potentially associated with capability for implementing mental health counselling. What are the implications for practice?: Health planners could use this method to identify poorly functioning services that may benefit from additional interventions to build preparedness for counselling implementation.Future research should examine whether differences in facility preparedness impact on the implementation and outcomes of this service. Introduction: Differences in primary care facilities' preparedness for implementing mental health counselling may affect the implementation process but have rarely been studied. Aim: To assess the feasibility of using a novel methodological approach to explore variations in capability for implementing mental health counselling and factors potentially associated with this variation among primary care services in the Western Cape, South Africa. Methods: Staff from 26 facilities participated in discussions about their facility's mental health implementation capability. Three researchers conducted observations of the facility's environment, staff–patient interactions and resources. We used qualitative comparative analysis to identify factors potentially associated with implementation capability. Results: Facilities appeared to vary in their capability for implementing counselling services. The availability of person‐centred health services, a therapeutic environment and sufficient human resources may be requirements for implementation preparedness. Other factors that seem to support preparedness include the availability of confidential space for counselling and an adequately managed facility. Discussion: This study identified several features of well‐functioning primary care facilities. Facilities with these features may be better prepared to implement a new counselling service. Implications for practice: This method may identify facilities that are poorly prepared for implementation that could benefit from preparedness‐building interventions. Whether differences in preparedness affect counselling outcomes is yet to be established. [ABSTRACT FROM AUTHOR]

Pregnancy represents a time of increased risk for intimate partner violence (IPV), and an HIV diagnosis further increases the vulnerability of this at-risk group. This study explores experiences of recent IPV using qualitative interviews with N = 12 HIV-positive pregnant women recruited from a clinical setting in South Africa, a location with a high global prevalence of IPV and HIV. Partner dynamics around IPV resulted in HIV shame and stigma and adversely affected engagement in HIV care and HIV treatment behaviors. The results highlight the challenges women face in navigating disclosure of both IPV and HIV, accessing necessary support, and engaging in both HIV-related and pregnancy-related care in the context of an abusive relationship. [ABSTRACT FROM AUTHOR]

Behavioural health risks, including substance use, early sexual debut, bullying and suicidality, are common during adolescence, but may be complicated among perinatally HIV-infected adolescents. However, there are few data exploring these behaviours in sub-Saharan Africa. We compared behavioural health risks (any self-report of substance use, sexual activity, bullying others or suicidality, or a positive urine toxicology screen) among perinatally-infected adolescents ages 9-14 years to that of an HIV-uninfected comparator group; and explored the effect of behavioural health risks on adolescent and caregiver report of adolescent suboptimal adherence (missed antiretroviral therapy dose(s) on ≥1 day during the preceding 30 days) and elevated HIV viral load (≥50 and ≥1000 copies/mL in sensitivity analyses) in multivariable logistic regression models. Among 506 HIV-infected and 110 HIV-uninfected adolescents (median age overall: 12 years), 15% and 25% reported any behavioural health risk (p = 0.018), respectively. Tobacco and other drug use was uncommon, while alcohol use was reported by 8% of HIVinfected versus 12% of HIV-uninfected adolescents (p = 0.185). One HIV-infected (0.2%) and 3 HIV-uninfected adolescents (3%) reported any sexual activity (p = 0.019). Among HIV-infected adolescents, report of any behavioural health risk was more common among male adolescents [adjusted odds ratio (aOR): 1.78; 95% confidence interval (CI): 1.08-.95] and was associated with adolescent report of suboptimal adherence (aOR: 1.66; 95% CI: 0.99-2.78) but not with caregiver report of suboptimal adherence or with elevated viral load. In this group of perinatally-infected youth entering early adolescence, the prevalence of behavioural health risks was lower than that among same-age, HIV-uninfected peers. Longitudinal data are needed to explore the reasons underlying these differences, for example the possibility of more protective caregiving and supportive family environments, or of emotional and physical immaturity, as well as the emergence of risk behaviours over time in this population. [ABSTRACT FROM AUTHOR]

Depression is prevalent among people living with HIV in South Africa and interferes with adherence to antiretroviral therapy. This study evaluated a nurse-delivered, cognitive behavioral therapy intervention for adherence and depression among antiretroviral therapy users with depression in South Africa (n = 14). Primary outcomes were depression, antiretroviral therapy adherence, feasibility, and acceptability. Findings support robust improvements in mood through a 3-month follow up. Antiretroviral therapy adherence was maintained during the intervention period. Participant retention supports acceptability; however, modest provider fidelity despite intensive supervision warrants additional attention to feasibility. Future effectiveness research is needed to evaluate this nurse-delivered cognitive behavioral therapy intervention for adherence and depression in this context. [ABSTRACT FROM AUTHOR]

This study examines the associations between symptoms of mental disorders and diabetes and hypertension in a nationally representative sample of South Africans. We examined unadjusted and adjusted associations of socio-demographic characteristics, alcohol use and psychological distress with diabetes and hypertension. Multivariate logistic regression revealed that hypertension is significantly associated with age, while diabetes is significantly associated with age, population group and psychological distress. The association between psychological distress and diabetes found here suggests the usefulness of additional research using more detailed measures of psychiatric disorders in local studies and reinforces clinical calls for attention to psychiatric screening in patients with diabetes. [ABSTRACT FROM AUTHOR]