Browsing by Subject "Psychiatry and Mental Health"
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- ItemOpen AccessA Clinical audit of the transgender unit at Groote Schuur hospital(2021) Wilson, Allanah Joan; Torline, John; Marais, AdeleBackground The Transgender Clinic at Groote Schuur Hospital (GSH) – a large government funded academic hospital in Cape Town, South Africa - assists with the mental health assessment of transgender individuals and facilitates access to other gender affirming services, such as hormone therapy, plastic and reconstructive surgery, psychosocial, and legal services. Objectives This clinical audit aimed to gain a clearer understanding of the service and areas within the service which could be improved. To this end the general compliance of the clinical services of the multidisciplinary team (MDT) as recommended by the World Professional Association for Transgender Health 7th Version of Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (WPATH SOC 7) was assessed. In addition, an analysis of the demographic and clinical characteristics of individuals attending the clinic and a review of waiting times and distance travelled to attend the clinic, was conducted. Methods The study was a clinical audit without a repeat data collection cycle. Participants included the MDT members working at GSH's Transgender Unit and individuals attending the Transgender Clinic from September 2018 to December 2019 (n = 50). All 11 MDT members were invited to participate in the study and were required to complete a data collection sheet related to their competency and experience. Data collection with respect to services provided, and waiting times for services, was captured from clinician administered standardized historytaking and assessment booklets and patient hospital folder reviews. Results All members of the MDT who participated met the WPATH SOC 7 competency requirements. The mean age of the individuals attending the GSH Transgender Clinic was 28 years. Forty-eight percent were employed, 36% unemployed and 16% full time scholars. The 7 mean waiting time for an initial appointment with mental health was 75 days, 73 days for endocrinology and 255 days for plastic surgery. Non- attendance at initial appointment was a factor across gender affirming services – 18% mental health service, 20.5% endocrinology and 27% plastic surgery. Forty-two percent of individuals screened positive for a co-occurring mental health condition with a third of these individuals having more than one mental health disorder. Mood and anxiety disorders co-occurred together most frequently. Seventy-five percent of individuals with an untreated or partially treated mental health concern were provided a therapeutic intervention at the time of initial assessment. The introduction of laboratory investigations being performed prior to the initial appointment with endocrinology resulted in a significant improvement in waiting time to the initiation of hormone therapy. Conclusion WPATH SOC 7 competency requirements were met by the GSH Transgender clinical team. Inconsistencies were found in the documentation of WPATH SOC 7 recommended clinician tasks within the mental health and endocrinology service. This is secondary to the layout of the standardized history taking and assessment booklet, and documentation of certain tasks being clinician dependent. Limited hospital resources and subsequent understaffing, long waiting times for appointments and gender-affirming surgery and lack of access to other services (e.g. fertility services) result in continued barriers to gender-affirming care.
- ItemOpen AccessA retrospective study of outcomes after referral to the early intervention in psychosis programme at Valkenberg Psychiatric Hospital(2023) Setjie, Sewela; ; ; Horn, Neil; Rodwell CatherineBackground. Psychotic Disorders affect more than 1% of the South African adult population and have a chronic course that is associated with high rates of morbidity and mortality. The implementation of early intervention strategies may reduce the severity of these disorders. Little is known about the effectiveness of these interventions in South Africa and few longerterm studies have been undertaken internationally. Aim. This study aimed to measure the effectiveness of an Early Intervention and Support (EISH) service at reducing readmission to hospital in patients with psychotic disorders. Setting. Valkenberg Psychiatric Hospital, Cape Town. The EISH Team is an outpatient service consisting of psychiatrists, a psychologist, an occupational therapist, psychiatric nurses and social workers. Methods. Retrospective cohort study. Hospitalisation during the two years after discharge from the index admission was measured in 100 subjects who attended EISH and 100 who had treatment as usual (TAU). Readmission rate, average length of stay (ALOS), and time to readmission to District Hospitals (DH) and Tertiary Psychiatric Hospitals (TPH) were calculated. Results. Readmission Rates were three times higher in TAU compared to EISH patients for both types of Hospital. For TAU subjects compared to EISH subjects: ALOS was longer (59 vs 13 days), and days to readmission were fewer (187 vs 320 days). All differences were statistically significant (ps < .05). Conclusion. EISH intervention at Valkenberg Hospital was useful in reducing readmission rate, ALOS, and time to readmission in patients with Psychotic disorders. Prospective controlled trials are required to confirm the efficacy of this intervention.
- ItemOpen AccessAn investigation of a neuro-inflammatory profile of HIV-associated neurocognitive disorders(2021) Williams, Monray Edward; Naude, Pieter; Joska, John; Stein, DanBackground HIV-associated neurocognitive disorder (HAND) is the consequence of the effects of HIV-1 within the central nervous system (CNS). HIV-associated neurocognitive impairment differs in severity with milder forms presenting in 50% of people living with HIV (PLWH), regardless of treatment status. Chronic immune dysregulation has been associated with HAND; in particular, it has been noted that inflammation persists despite the successful treatment with antiretroviral therapy (ART). However, the nature to which (neuro)inflammation influences cognitive performance and brain integrity remain unclear. Further, it is not clear how sequence variation in neurotoxic viral proteins, including Tat, affects inflammation in PLWH. This study aimed to 1) perform a systematic review of the existing literature to identify changes in peripheral immune markers that are associated with HAND in ART-experienced PLWH, 2) determine the association of blood peripheral immune markers with domain-based neurocognitive performance and structural brain changes in South African PLWH, and 3) lastly, to evaluate the possible influence of Tat sequence variation on a dysregulated immune profile in HIV-1C infection (i.e. Tat-C). Methods A systematic review of the published literature was performed to identify the most common markers associated with HAND in the ART-era. A panel of markers was measured in a treatment naïve South African cohort by enzyme-linked immunosorbent assays (ELISA). Cognitive performance was established using a battery of tests sensitive to HIV-associated neurocognitive impairment, with domain based scores utilized in analysis. Thickness and surface area of all cortical regions were derived using automated parcellation of T1-weighted images acquired at 3T. Markers were correlated with neurocognitive performance and cortical thickness and surface area. Further, a prospective review of the literature was performed to determine the association between Tat sequence variation and underlying mechanisms (and inflammation) of HAND. The HIV-1 was genotyped and the influence of Tat sequence variation on immune marker levels was evaluated in a subset of South African participants. Results A systematic review of the existing literature suggested that peripheral immune markers of monocyte activation (sCD14 and sCD163) and inflammation (IL-18 and IP10) were associated with HAND in the majority of studies. Evaluation of blood immune markers in a treatment naïve South African cohort showed that thymidine phosphorylase (TYMP) and neutrophil gelatinase-associated lipocalin (NGAL) levels were significantly higher, while matrix metalloproteinase (MMP)9 levels were significantly lower in PLWH. The results further showed that in PLWH, worse psychomotor processing speed was associated with higher TYMP and NGAL levels and worse motor function was associated with higher NGAL levels. Further, in imaging analysis, it was reported that higher NGAL levels were associated with the reduced thickness of the bilateral orbitofrontal cortex. The association of NGAL withworse motor function was mediated by the cortical thickness of the bilateral orbitofrontal cortex. The associations between higher NGAL and TYMP levels with cortical thickness were largely found in the regions of the frontal cortex. A review of the literature suggests that key protein signatures (C31S and R57S) present in the Tat protein from HIV-1 subtype C (Tat-C) infection may contribute to the lowered inflammation. Supporting this hypothesis, the results from this thesis showed that HIV-1C participants with the R57S mutation had lower peripheral TYMP levels. Conclusions Current literature supports the premise that chronic inflammation may be an important contributor to the development of the milder forms of HAND. For patients on ART, other strategies are required to address the ongoing peripheral inflammation, in addition to simply suppressing the viral load. In a South African context, TYMP and NGAL may be promising markers for their involvement in HAND. Patients were largely treatment-naïve; therefore, these markers may represent HIV related effects without the potential confounding effects of ART. Therefore, these findings may represent long-standing effects which might persist in treatment experienced participants. In HIV-1C infection, the level of certain inflammatory markers may be influenced by the R57S Tat protein signature. To our best knowledge, this is the first thesis to report the association of these markers with HAND. These immune markers need to be investigated for their potential role in the underlying mechanisms of HAND.
- ItemOpen AccessCaregiving experiences of South African mothers of adults with intellectual disability who display aggression: clinical case studies(2016) Coetzee, Jacobus (Ockert); Adnams, Colleen; Swartz, LeslieBackground: Adults who have an intellectual disability (ID) often continue to live with their parents long after their siblings have left home. While an increasing body of research has described positive parental experiences, research has also found that parents of adults who have ID and behavioural difficulties are more vulnerable to develop parental stress and depression. Aggression is one of the most difficult forms of problem behaviours to manage and could have a negative impact on the parent-child relationship, the child's social inclusivity and the psychological well-being of parents. Method: A case-based psychotherapy design was used to explore maternal experiences among mothers of adults with ID and aggression who access a specialised mental health service in Cape Town. Psychotherapy was used with six participants to attempt to reduce parental stress and other negative psychological states. In an area of research that has received scant attention in South Africa, the study extensively describes the psychotherapy process and the role of contextual factors in the lives of the participating mothers. The study used a mixed methods design which included psychometric measurements that were conducted at various intervals of intervention. Thematic analysis was used in all the case studies and interviews were scheduled before and after completing psychotherapy. External credibility was enhanced through the use of different qualitative strategies that included peer supervision and reflexivity. Findings: Besides elevated parental stress, the majority of participants presented with symptoms of depression and other mental health problems that varied according to their individual profiles. Although parental stress showed a discernible relationship with the child's behavioural difficulties, other significant life stressors contributed to maternal stress and depressive symptoms. Psychotherapy produced only modest improvement of parental stress among some of the participants. However, therapeutic input appeared to be more effective in reducing depressive symptoms among the majority of mothers. Critical reflection and discussion are centred on the clinical implications and meaning of findings on a psychological level.
- ItemOpen AccessDeveloping a ball mill model that incorporates grate and overflow discharge configurations(2023) Mwale, Owen; Abrahams, ZulfaThe purpose of this thesis was to investigate performance differences between the grate and overflow discharge type ball mills of the same size under similar operating conditions using platreef ore which is classified as rheologically complex. The results from this investigation were used to develop a ball mill model that incorporates discharge mechanism and variables that influence mill power draw and product size distribution. Discharge configuration effects and power draw being one of the most important factors in ball mill performance, this thesis was set out to include these in performance prediction and analysis. The pilot ball mill operated by Magotteaux installed at the Anglo Platinum plant in Rustenburg was used to collect performance and operational data for use in the modelling. Two discharge configuration types were tested. The grate at two set open areas of 9.5% and 3.4% were used as well as the overflow type. The 1.25 m diameter and 2.20 m length mill was operated at two ball-load set points and a feed rate range of 1.50 tph to 2.25 tph for each configuration. Results showed that the grate configured ball mill produced much finer product compared to the overflow when operated under similar conditions. Results further showed that the grate ball mill had relatively higher breakage and discharge rates when operated at same conditions as the overflow. It was also shown that the grate discharge ball mill will draw an average of 18% more power than the overflow ball mill of the same size under similar operating conditions. Using these results, a new ball mill model was developed. The model is based on the principle that breakage distribution of the ore is unique to its competence and specific energy. The model incorporates mill operating conditions and retains the use of the appearance function. The model further incorporates influences of design and operating variable on mill power draw to predict product size distribution. It was found that the model agrees well with the pilot ball mill performance data. The model was later sub-developed into two models each specific to the discharge configuration type, the grate and overflow. For each configuration type, the model was found to give good predictions in agreement with real data. Thus, a model that considers the unique properties of the ore and discharge configuration incorporating mill power draw was developed.
- ItemOpen AccessDeveloping antenatal maternal mental health services: Identifying depression in pregnant women attending antenatal care in Sodo district health centres, Ethiopia(2020) Bayouh, Fikirte Girma; Schneider, Marguerite; Hanlon, CharlotteBackground Major Depressive Disorder is a leading cause of disease burden for women of childbearing age. The prevalence of perinatal depression is significantly higher in women from low and middle income countries than from high income countries. Antenatal depression is associated with low birth weight and preterm delivery. There is also evidence that depression during pregnancy can alter the development of a woman's fetus and her child, with an increased risk for child emotional and behavioral problems. Detection of perinatal depression in primary health care (PHC) is very low. This research gathered evidence on the current practice of detection of pregnant women with moderate-severe depression in the Sodo district and explored potential solutions to the identified challenges. Methods A qualitative study was conducted in four health centres and a primary hospital, located in the Sodo district, Ethiopia. In-depth interviews were carried out with pregnant women diagnosed to have depression. Focus group discussions (FGDs) were conducted with antenatal care (ANC) PHC workers. A framework approach to qualitative data analysis was used. OpenCode computer software was used for data handling during the analysis. Results Nine pregnant women were interviewed in-depth and twelve ANC PHC workers participated in two FGDs. Identified themes were categorized under client, provider and system level barriers, and illness related influences. Women's reluctance to disclose symptoms and seek help and not thinking what they had was an illness and/or not thinking they would get help from ANC clinic were client-side barriers to identifying depression. ANC PHC workers not asking about depressive symptoms, their reluctance to disclose a diagnosis of depression to the affected women and not thinking women with mental health problems are in their clinics were the main provider level barriers. The setting not being conducive for depression assessment, inadequate mental health training and ANC assessment format not having a place for recording mental health assessment were system level barriers raised. Difficulty in differentiating clinical depression from normal emotional reaction emerged as the main illness related influence. ANC PHC workers proposed community awareness-raising, improving communication between women and PHC workers and making mental health assessment part of the routine ANC service, among others, as possible solutions to improve detection of antenatal depression in ANC clinics. Conclusion Multiple client, provider and system level barriers to detection of depression in pregnant women in ANC clinics were identified in the current study. The identified barriers call for interventions at different levels; awareness raising at a community level, training on communicating about emotional concerns and mental health care at a provider level and enabling the health care system to support integration of mental health care into maternal health services at a higher level. Follow-up studies are required to better understand the experiences of women and providers, to quantify the magnitude of the problem and to develop and evaluate contextually appropriate interventions to improve detection of depression in pregnant women.
- ItemOpen AccessDevelopment and scaling up of a psychological intervention for common mental disorders among people living with HIV in Zimbabwe(2016) Chibanda, Dickson; Lund, Crick; Cowan, Frances MCommon mental disorders (CMD) which primarily include depression, anxiety disorders and mixed anxiety depression are leading causes of disability in sub-Saharan Africa. They are particularly common in people living with HIV (PLWH) and may hasten HIV disease progression. This thesis consists of 5 articles which have been submitted for publication and provide evidence on the requirements for developing a psychological intervention to be delivered by lay health workers (LHW) and a strategy for scaling up this intervention to over 50 primary health care clinics in Harare, Zimbabwe. The thesis formed part of formative research leading to a cluster randomized controlled trial(RCT) of a psychological intervention and provides supplementary research to the RCT to support the scale up of the intervention. The first chapter describes the magnitude of the problem and the lack of resources to reduce the treatment gap for CMD. It highlights the growing evidence of using Lay Health Workers (LHW) to reduce this treatment gap.
- ItemOpen AccessDiagnostic conversion following admission for a first-episode substance induced psychosis: A four-year retrospective cohort study(2021) de Vaal, Sybrand Johannes; Temmingh, HendrikBackground: Substance-induced psychotic disorder (SIPD) is prevalent in South Africa, yet there is a paucity of research regarding its longitudinal course, with studies finding that diagnostic conversion occurs often, mostly to schizophrenia (SCZ). Aim: We examined the rate of, and factors associated with, diagnostic conversion in first-episode SIPD to primary, non-substance-related mental disorders. Setting: Adult inpatients with a diagnosis of first-episode SIPD discharged between 2012 to 2014 from Valkenberg psychiatric hospital, Cape Town. Methods: We conducted a retrospective cohort study of first-episode patients discharged from hospital, followed-up for a four-year period. We used survival analysis and Cox-proportional hazard regression to determine factors associated with diagnostic conversion to a primary mental disorder. Results: Of the sample of 225 patients, the majority were young, male and polysubstance users. Diagnostic conversion occurred in 26.2%, the majority within 3 years - 71.2% to SCZ-spectrum disorders and 28.8% to major affective disorders. In the adjusted analysis, diagnostic conversion remained significantly associated with male sex (HRadj=1.85, 95% CI=1.00– 3.42, p=0.045) and greater length of index admission (HRadj=1.02, 95% CI=1.01 – 1.04, p=0.006). Compared to nonconverters, significant associations with conversion to SCZ-spectrum disorders were male sex and length of index admission. Conversions to both SCZ-spectrum and major affective disorders were significantly associated with number of re-admissions during follow-up. Conclusion: Diagnostic conversion occurred in a substantial proportion of SIPD cases, often to SCZ. This warrants enhanced follow-up of high-risk cases, with attention to indicators such as sex and length of index hospitalisation.
- ItemOpen AccessA diffusion tensor imaging and neurocognitive study of ART-naïve and ART-treated children in Cape Town(2015) Hoare, Jacqueline; Stein, Dan JThere are still no diagnostic criteria for a spectrum of neurocognitive disorders (ND) secondary to HIV infection for children. The American Academy of Neurology (AAN) proposes guidelines for assessment of HIV associated neurocognitive disorders (HAND) in HIV infected adults. A cross-sectional clinical cohort study was initiated in Cape Town, in which 120 participants, including a HIV negative healthy control group for comparison, completed clinical and neurocognitive assessments. HIV infected children were either stable on antiretroviral treatment (ART) for a minimum of 6 months or ART naïve. Neuroimaging was completed on 105 children in the cohort study. We compared 75 children vertically infected with HIV aged 6 to 16 years, including both children on antiretroviral therapy (ART) and ART-naïve, with 30 matched controls using diffusion tensor imaging (DTI) measures. We then used the detailed neurocognitive battery; an assessment of adaptive functioning and the AAN system for diagnosing ND to establish whether this system could detect a spectrum of ND in HIV infected older children and adolescents. When comparing HIV uninfected children to HIV infected children this DTI study found damaged neuronal microstructure in the HIV infected children. Significant associations were found between failing first line ART regimen, socio-demographic factors, nutritional-hematological status, HIV-relevant clinical variables, cognitive functioning and white matter integrity in children stable on ART. Children with a clinical diagnosis of encephalopathy (HIVE) had greater white matter damage when compared ART treated children without encephalopathy. DTI also found significant myelin loss in ART naïve children when compared with ART treated children. Using the AAN criteria for HAND, we found that 45.35% of the HIV infected children had a ND. ART naïve slow progressors, who receive limited attention from heath care service s, as they are thought to be 'well', were found to have neurocognitive impairment and white matter microstructural damage. HIV infected children were also more likely to have impaired competence in various domains of functioning. The current findings also underline the possible association of first line treatment failure with white matter brain dysfunction in children on ART. Despite the use of ART and improved virological control with immune reconstitution, there were still a significant percentage of children in this study who were found to have ND. Our findings also suggest that children on ART remain at risk for developing CNS disease, and that this risk extends to physically well ARV naïve slow progressors. The AAN HAND criteria designed for adults was able to identify children and adolescents with important functional cognitive impairments who don't fit criteria for HIVE and would therefore not have been identified otherwise.
- ItemOpen AccessDisability grant utilization and barriers to access for patients with personality pathology: A mixed methods study(2023) Julius, Hayley; Temmingh, Henk; Lund CrickBackground Personality disordered (PD) patients suffer the misnomer of “difficult to treat”. Difficulties in interpersonal style attendant with this diagnosis can impact on clinician attitude. This suggests that negotiating access to government health and social services, including the disability grant, might be a process with unique barriers for this group of patients. This study aims to investigate barriers that patients with PD (disorder or traits) experience in accessing the government disability grant. Methods A multi-method approach was used to identify barriers and facilitators to accessing the government disability grant in a group of psychiatric patients attending the Ward 1 therapeutic programme at Valkenberg hospital, South Africa. In the first phase, files of patients attending the programme in 2018 and 2019 were reviewed. Variables related to PD diagnosis, disability grant and others of interest were analysed using SPSS. In the second phase, purposive sampling for patients with PD and disability grant was done to conduct semi-structured interviews. Nvivo software was used to categorise and assist with analysis of themes. In the third phase an online clinician survey was conducted amongst psychiatrists and psychiatry registrars within the Department of Health, Western Cape who are tasked to assist with disability grant applications for this patient group. This was done to determine clinician beliefs and attitudes to making disability grant applications for patients with PD that may serve as barriers. Results File review: Valid data from 237 patient folders indicated that a total of 53 (22.4 %) patients had everaccess to the government disability grant (DG) and 6 (2.5 %) to private disability pay-out (Total: n = 59, 24.9 %). Half of patients admitted over the two years had a PD diagnosis (n = 122, 51.5 %). Borderline personality disorder was the most diagnosed PD (n = 68, 29 % of the sample). Although the majority of those with disability grant access had a PD diagnosis (n = 31, 52.5 %), there was no significant association between having a PD and receiving DG support. Patient interviews: Framework analysis was used to derive at 5 themes that related to Knowledge and beliefs about impairment and the disability grant, Course and access to the grant, Barriers to access, the Psychosocial impact of the disability grant, and Participant service needs related to recovery and possible sustained economic participation. Sub-theme findings related to the relationship with mental health professionals as facilitators to access, the impact of disability grant lapse on mental well-being, and three-way stigma related to having a 1) disability grant, 2) psychiatric diagnosis and 3) disability grant access for a psychiatric diagnosis. Internalised stigma was a significant finding and stigmatising judgement was experienced in interaction with general health professionals and may serve as a barrier to first access . Clinician survey: Respondent rate to the survey was low (n = 12, 21.8 %). Clinicians had much experience working with adult patients with PD, but most did not consider disability grant assessments with PD patients a routine part of their work. Confusion about how to make disability assessments for this group, compared to those with a primary common mental disorder or a serious psychiatric disorder, was salient. Most clinicians experienced dual role conflict in treating the PD patient and assessing them for a disability grant application, endorsing that the task should be delegated to another professional. Interpersonal interaction with PD patients was a challenge for clinicians but they did not believe this prevented them from considering treatment options for the patient that could support recovery and more sustained economic participation. Discussion and Recommendations: Barriers to initial access to the disability grant related to internalised stigma and patient readiness, as well as general health professional attitude. Recipients of disability grants motivated for access based on impaired functioning, in keeping with recommendations by the Department of Social Development (DSD). Functional impairment related to instability of affect, mood dysregulation that contributed to inconsistencies in behaviour, and interpersonal difficulties. These were implicated in difficulties returning to work and continuation of the disability grant. The disability grant was experienced as a significant source of support and relationships with mental health practitioners were an invaluable source of mental health support. Stigma was experienced from communities and general health professionals. The DSD mandate to routinely review access to the disability grant was a barrier contributing to distress, deterioration in mental health and socioeconomic well-being, and avoidant engagement with employment options. Recommendations to the DSD are highlighted to address realignment of the ‘temporary' grant with incentivisation for recovery and economic participation. Government multi-sectoral coordination to address stigma is highlighted. Recommendations for clinician training and practice for more confident assessment of impairment in PD patients, and to support mental health in this patient population, are made.
- ItemOpen AccessEconomic costs, impacts and financing strategies for mental health in South Africa(2020) Docrat, Sumaiyah; Lund, Christopher; Cleary, SusanOver the past decade, calls to address the increasing burden of mental, neurological and substance-use (MNS) disorders and to include mental health care as an essential component of universal health coverage (UHC) have attracted mounting interest from governments. With the inclusion of mental health in the 2015 Sustainable Development Goals (SDGs) there is now a global policy commitment to invest in mental health as a health, humanitarian and development priority. Low and middle-income countries (LMICs) such as South Africa, contemplating mental health system scale-up embedded into wider SDG- and UHC-related health-sector transformations, must address a number of key mental health financing policy considerations for attaining population-based improvements in mental health. Despite ongoing transformations in the South African health sector, there has been an implicit neglect of the integration of mental health services into general health service development. This has been driven in part by a lack of locally-derived evidence in several areas, including: the economic basis for investing in mental health, the current resourcing of the mental health system, opportunities for improved efficiency and equity, and how reforms may be structured and paid for in light of the country's ongoing efforts to implement a National Health Insurance (NHI) scheme. This thesis therefore attempts to address these gaps and aims to generate new knowledge on the economic costs, impacts and financing strategies for mental health in South Africa. This aim is achieved by fulfilling the following research objectives: 1. To examine the impact of social, national and community-based health insurance on health care utilization for MNS disorders in low- and middle-income countries. 2. To examine the policy context, strategic needs, barriers and opportunities for sustainable financing for mental health in South Africa. 3. To quantify public health system expenditure on mental health services, by service level and province, and to document and evaluate the resources and constraints of the mental health system in South Africa. 4. To examine the household economic costs and levels of financial risk protection associated with depression symptoms in South Africa. In the first part, the systematic review reports on the impact of social, national and community based health insurance on health care utilization for MNS disorders in LMICs, published until October 2018. As a secondary goal, the systematic review identifies whether there are any specific lessons that can be learnt from existing approaches to integrate mental health care into financing reforms towards universal health coverage. In the second part, a qualitative examination of the policy context, strategic needs, barriers and opportunities for sustainable financing for mental health in South Africa was conducted through a situational analysis that was complimented with a synthesis of key stakeholder consultations. The findings provide recommendations for how scaled-up mental health services can best be paid for in a way that is feasible, fair and appropriate within the fiscal constraints and structures of the country. In the third part, the thesis then empirically quantified public health system expenditure on mental health services, by service-level and province for the 2016/17 financial year, and documented and evaluated the resources and constraints of existing mental health investments in South Africa through a national survey; achieving one of the highest sample sizes of any costing study conducted for mental health in LMICs. In the fourth and final part, a household survey study was conducted to determine the level of financial protection for persons living with depression symptoms in the Dr. Kenneth Kaunda health district of South Africa, which is serving as a pilot site for the NHI. The household economic factors associated with increased depression symptom severity on a continuum are reported; and demonstrate that financial risk protection efforts are needed across this continuum. The thesis concludes by synthesizing findings towards an improved understanding of the key lessons that can be learned from other LMICs toward sustainable financing for mental health; the economic burden of inadequate mental health care to households in South Africa; and the efficiency of existing mental health investments and inequities in resourcing and access. Through this lens, and borrowing from the experiences of other LMICs, recommendations for key priorities for health service and financing reforms towards the scaled-up delivery of mental health services in South Africa are generated. The thesis is presented as papers embedded in a narrative that includes an introduction and synthesis discussion. Four papers (3 published and 1 under review) form the basis of the results chapters.
- ItemOpen AccessEvaluating the knowledge and attitudes of trainee clinical officers (COs) and the behavior of qualified COs in identifying and managing common mental disorders in Malawi(2024) Matoga, Ellliot; Schneider, Marguerite; Abrahams ZulfaBackground: A high proportion of individuals with serious mental illness remain without treatment partly due to serious shortages of healthcare workers. The result is a large treatment gap for mental disorders in Malawi and globally. To expand mental health coverage in low-income countries (LIC) we require the implementation of strategies that have shown to be feasible and effective such as: integration of mental health into primary healthcare, and expansion of human capacity through task shifting and training of non-specialist health workers. Adequate training is required to improve Clinical Officers' (CO) professional knowledge, attitudes and skills about mental illness so that they are better able to assess, identify and manage mental illness. COs' training consists of a two week psychiatry and mental health theory module, followed by four weeks of practical attachment at a psychiatric hospital. Currently, we do not know whether the curriculum for COs in its present form is effective in increasing knowledge and addressing attitudes of COs towards mental illness. Aim: The aim of this study was to evaluate the impact of training on knowledge and attitudes of trainee COs and explore the qualified COs' experience of the Malawian clinical context and their application of learned skills in identifying and treating mental health disorders in primary healthcare patients. The specific objectives for the study were as follows: 1) To measure changes in mental health knowledge and attitudes of trainee COs before and after receiving psychiatry and mental health training; 2) To explore the application of taught skills by qualified COs in identifying and treating people with mental disorders in Primary Health Care (PHC) clinics. Methods: This study consists of a quantitative and a qualitative component. In the quantitative phase, sixty-two trainee COs at the Malawi College of Health Sciences (MCHS) in Malawi completed pre- and post-training questionnaires assessing knowledge, attitudes and skills. The questionnaire comprised the following sections: 1) Socio-demographic questions, 2) The Mental Illness: Clinician's Attitudes Scale (MICA) Version 4 and 3) WHO mental health gap action plan (mhGAP) questionnaire for assessing knowledge. In the qualitative phase, nine COs working in PHC facilities in the Southern Region in Malawi were interviewed using semi-structured interviews to explore the application of skills in identifying and treating mental disorders. Results: There was a significant difference in attitude scores before and after the training (t (61) = 3.77, p < 0.001). The overall mean score of the MICA-4 was 45.03 (SD: 6.86) before training and 41.18 (SD: 8.31) after training suggesting decreased levels of stigmatizing attitudes. Knowledge mean scores increased from 11.16 (SD: 3.01) before training to 12.69 (SD: 2.66). There was a statistically significant difference in knowledge mean scores indicating an improvement in knowledge before and after the training (t (61) = - 4.39, p < 0.001). The qualitative interviews provided insight into the difficulties COs experience in the application of skills learnt in pre-service training. The key service level barriers to the provision of mental health service in Malawi were identified as lack of knowledge, lack of in-service training, drug shortages and inadequate pre-service training programs. Conclusion: The two-week psychiatry training for COs improved knowledge and attitudes but may not be sufficient in ensuring adequate mental health services at PHC level. Qualified COs working in the healthcare system identified factors such aslack of knowledge, inadequate pre-service training programs, lack of in-service training and drug shortages as key service level barriers to the provision of effective mental health services in Malawi. The training of COs could be strengthened by improving the assessment and management of mental health conditions
- ItemOpen AccessExecutive function and contingency management for methamphetamine use disorder in South Africa: a comparison pre- and post-treatment(2021) van Nunen, Lara Jane; Ipser, Jonathan; Stein DanBackground: Methamphetamine dependence is associated with impairment in executive function, as well as brain functional and structural alterations, findings on the relationship between executive function impairment and brain alterations seem inconsistent. Methamphetamine dependence may respond to contingency management, yet it is unclear if the treatment response is predicted by these neuropsychological, and brain functional and structural changes, and whether treatment alters neuropsychological impairment. I first conducted a systematic review to rigorously assess available findings on the relationship between executive function impairment and brain functional changes. I then explored data from a study of contingency management in methamphetamine dependence with the aims of determining 1) whether treatment response was predicted by executive function impairment and brain functional and structural alterations, and 2) whether treatment led to changes in executive function and brain functional and structural impairment in treatment responders and non-responders. Methods: The systematic review involved a rigorous search and assessment of articles on the association of stimulant use and resting state functional connectivity. In the empirical study, 33 subjects underwent executive function testing, resting state-fMRI, and structural neuroimaging prior to contingency management treatment. Executive function was assessed with the trail making task, the Stroop-word task, and the Connors continuous performance task. Seed-based analysis was used for functional MRI, with a focus on brain regions associated with executive function, and brain structural alterations were assessed using measures of cortical thickness and surface area. In the statistical analysis, first associations of baseline executive function, rs-fMRI, and brain structural alterations with treatment outcome were assessed using linear regression, and second, comparison of executive function, rsfMRI, and brain structural parameters at baseline versus at treatment end in treatment responders and non-responders was undertaken using linear regression, Cohen's d and a change score. Results: The systematic review noted specific associations between executive function impairment and resting state-fMRI. While in the study, treatment responders had improved executive function at baseline as assessed by two measures (faster completion times on the trail making, and greater accuracy on the Connors continuous performance task), but worse executive function on a third measure (lower accuracy on the Stroop word task) when compared with non-responders. No statistically significant differences between groups was found with regards to rsFC, however greater cortical thickness was found in responders brain regions associated with executive function, in comparison to non-responders. Analysis of pre vs post treatment findings showed that in treatment responders there was better executive function after treatment, in comparison to non-responders (as assessed by greater accuracy on the Connors continuous performance task). Furthermore, in treatment responders there was greater increase in cortical volume in regions associated with executive function, than in non-responders. Conclusion: These findings support the hypothesis that better executive function at baseline (task switching and selective attention) is associated with better outcomes in a contingency management trial of 8-weeks. There is also evidence of improved executive function post trial (in selective attention and cortical thickness findings support improved executive function) implying that abstinence as a consequence of a contingency management trial of 8-weeks may improve executive function, a larger sample size would be needed to determine if improvements extend to other regions of executive function
- ItemOpen AccessExploring nurses? experiences in community mental health care delivery during the covid-19 pandemic: a qualitative study in the Accra metropolis(2023) Morson, Nana; Garman, EmilyMental health care in Ghana recently shifted from a focus on institutional care to the inclusion of community-based care. This shift helped to broaden the scope of mental health care in the country through the establishment of community psychiatric units in most regional and district health facilities across the country. Mental health nurses are posted to these units, and their work includes visiting clients in their homes for reviews (a formal assessment and evaluation of the patient's health, progress, and medication) and follow-ups, health education and case finding. The COVID-19 pandemic however affected the activities of the community mental health nurses due to the implementation of lockdowns and other restrictions. This study explored the experiences of community mental health nurses during the COVID-19 pandemic. The objectives of the study were to investigate nurses' perspectives on how the COVID-19 pandemic has affected community mental health care delivery, to assess the nurses' views on the barriers and facilitators of mental health care delivery during the pandemic and to explore the nurses' recommendations for improving community mental health care (CMHC) in the context of the COVID-19 pandemic and beyond. Fifteen community mental health nurses from five health facilities in the Accra metropolis were interviewed. Thematic analysis of the data was conducted using NVivo software. Findings suggested that the nurses had to suspend most direct-contact community-based activities and instead conducted patient reviews via telephone. They also maintained a limited amount of clinic-based care. COVID-19 had a major impact on CMHC delivery through the suspension of health education and home visits, the move towards clinic-based only reviews, financial constraints, the unavailability of medicines and the reassigning of staff to provide COVID support. The nurses mentioned several barriers to CMHC, both prior to and during the pandemic, including financial and logistical constraints such as lack of transportation, infrastructure and inadequate personal protective equipment (PPE). These challenges were overcome through the nurses' commitment and dedication to their work, as well as the provision of periodic support from the health facilities. The nurses however recommended that there should be sustained logistic and health systems support, an increase in the use of technology, provision of medical aid for mental health, increased mental health education and promotion and incentives for community health workers to help improve CMHC amid any pandemic. In conclusion, the COVID-19 pandemic served to highlight pre-existing issues with CMHC in Ghana. To improve these services, it may be appropriate to take the following steps, among others: increasing funding for mental healthcare in the midst of any pandemic; training more mental health professionals and integrating mental healthcare into primary care. Additionally, it is recommended that further research on community mental healthcare and issues related to it may help to increase access to care and prepare the CMHC system for any potential pandemics.
- ItemOpen AccessFactors associated with psychological distress among youth and adults living with HIV in South Africa(2023) Ncitakalo, Nolusindiso; Joska, JohnBackground Mental disorders represent a growing public health challenge globally. Evidence shows that mental disorders like depression and anxiety are more prevalent in people living with HIV (PLHIV) than in the general population. South Africa carries the world's heaviest burden with 7.9 million people (14% of the population) living with HIV in 2017. However, there is limited literature on mental health disorders among PLHIV in South Africa particularly populationbased cross-sectional studies, as most available evidence of mental disorders among PLHIV is from small-scale studies. Studies have shown the relationship between mental disorders and HIV to be complex and bidirectional. The bidirectional nature of the relationship between mental disorders and HIV implies a complex relationship between factors associated with both health conditions where they co-exist. Improved understanding of the relationship between mental disorders, HIV and associated factors is important for designing interventions to mitigate the impact of both conditions among coinfected individuals. In epidemiological surveys, the presence of common mental disorders may be measured in terms of caseness or through a set of defined questions known as an instrument or scale. While there is a relationship between psychological distress, depressive and the anxiety symptoms, psychological distress scales are usually slightly broad but capture construct. Studies that are attempting to describe the prevalence of anxiety and depression sometimes use measures of psychological distress as a proxy. In large epidemiological surveys, psychological distress measures are used, as opposed to smaller and clinical studies. Similarly for this study, psychological distress was measured by both depressive and anxiety symptoms. Aim and objectives The aim of this study was to explore the extent and effect of psychological distress among youth and adults with HIV in South Africa. The specific objectives were as follows: 1) To conduct a systematic review and meta-analysis of studies on prevalence and correlates of depressive and anxiety symptoms among PLHIV in Southern Africa; 2) To determine the prevalence of depressive and anxiety symptoms and associated risk factors among PLHIV in South Africa; 3) To explore the relationship between HIV-related stigma and psychological vi distress among PLHIV in South Africa; 4) To explore the complex pathways linking HIV status as a mediator in the relationship of psychological distress with socio‑demographic and health related factors in South Africa. Methodology Different sub-samples were used for each paper, depending on the focus or aim of the paper. For the first objective, the systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. To fulfil the second objective, descriptive statistics were used to summarize background characteristics of the study sample and the prevalence of psychological distress. Bivariate logistic regression analysis were used to assess the relationship between psychological distress and each explanatory variable. Additionally, statistically significant variables were entered into a multivariate logistic regression analysis to identify factors independently associated with psychological distress. For the third objective, bivariate and multivariate logistic regression models were used to identify factors associated with stigma among PLHIV with psychological distress. Lastly, generalised structural equation modelling (G-SEM) path analysis was used to explore the direct and indirect relationships of socio-demographic, health and HIV-related factors with psychological distress using HIV status as a mediator. Findings The results of this study were published in four papers, which constitute Chapters 2, 3, 4 and 5. Chapter 2, in the systematic review a total of 27 articles met the eligibility criteria out of the 467 articles. The overall pooled prevalence for depression was 23%, and anxiety was 15%. Prevalence of depressive and anxiety symptoms was significantly higher among females, separated or widowed, unemployed and older age. Additionally, depressive and anxiety symptoms were significantly associated with low income, low education, urban residence, low physical activity, violence and/or partner conflict exposure, lack of social support, stigma and alcohol in PLHIV. In Chapter 3, the prevalence of psychological distress was significantly higher among females (38.2%) than males (28.5%). Psychological distress was significantly associated with being female, low socio-economic conditions, low educational attainment, marital status (being divorced/ separated), unemployment, having chronic conditions, hazardous alcohol drinking and low social support. In Chapter 4, the findings showed that psychological distress among HIV positive individuals was 34.4% and of these, 37.9% vii experienced high levels of HIV-related stigmatizing attitudes. Stigmatizing attitudes among PLHIV were significantly associated with no schooling/primary level education, incorrect knowledge about HIV and myths about HIV and never testing for HIV. In Chapter 5, the HIV positive status was shown to be a mediating factor. Psychological distress was significantly associated with female gender, not being married, having no education/primary level education, reproductive age group 25–49 years, 50 years and older, residing in urban areas, high risk drinkers, hazardous drinkers, ever testing for HIV and reporting of fair /poor selfrated health. Conclusion The systematic review and secondary analysis of the nationally representative populationbased household survey confirmed that psychological distress, as measured by depressive and anxiety symptoms was associated with specific socio-demographic, socio-behavioural and HIV-related factors including stigma among PLHIV in South Africa. The findings also suggest that HIV positive status was a mediating factor in the relationship between psychological distress and identified covariates. These findings highlight the importance of integrated screening and management of psychological distress and HIV. Furthermore, the findings underscore the need for highly targeted interventions tailored for identified groups of PLHIV. Lastly, more longitudinal studies are needed to track changes and trends over time on factors associated with mental disorders and HIV and the impact of respective interventions.
- ItemOpen AccessFilling the gap: development and qualitative process evaluation of a task sharing psycho-social counselling intervention for perinatal depression in Khayelitsha, South Africa(2018) Munodawafa, Memory Nyasha Lynnette; Schneider, Marguerite; Lund, CrickPerinatal depression is a major public health issue which contributes significantly to the global burden of disease, especially in low resource settings in South Africa, where there is a shortage of mental health professionals. New psychological interventions delivered by non-specialists are needed to fill the treatment gap. Task sharing of psycho-social interventions for perinatal depression has been shown to be feasible, acceptable and effective in low and middle-income countries. However; there are limited data on process evaluations of task shared interventions for perinatal depression. This thesis attempts to address this gap by presenting four papers based on a study that undertook a qualitative process evaluation on a task shared psycho-social intervention. The thesis integrates all the papers under one primary aim (a process evaluation) which triangulated data from four sources which were published literature, perspectives of local depressed women, and perspectives of the counsellors in the trial and recipients of the intervention in the trial. The thesis will be presented in six chapters. The first chapter provides a background with current issues in global mental health, psycho-social interventions, task sharing in low and middle income countries and the United Kingdom (UK) Medical Research Council (MRC) framework for developing and evaluating interventions. A second chapter presents a systematic review on qualitative evidence of process evaluations of task sharing interventions for perinatal depression in LAMICs in relation to the UK MRC framework for conducting process evaluations. The systematic review reveals a paucity of qualitative evidence of process evaluations together with several crucial factors related to context, implementation and mechanisms of an intervention including: content and understandability, counsellors facilitating trust and motivation to conduct the intervention and participant factors such as motivation to attend the sessions and willingness to learn and change their behaviour. The third chapter provides information on development of the intervention and determining the feasibility in line with the MRC framework. Qualitative semi-structured interviews were conducted with 26 participants, including service providers and service users at a clinic in Khayelitsha. After the semi-structured interviews, a workshop was conducted with mental health experts on evidence-based psychological interventions for depression, together with a document review of counselling manuals for community health workers in South Africa. The feasibility study showed that a task sharing counselling intervention was acceptable and feasible for depressed women in Khayelitsha, under the following conditions: (1) respondents preferred a female counsellor and felt that a clinic based individual sessions should be provided at least once a month by an experienced Xhosa speaking counsellor from the community; and (2) the content of a counselling intervention should include psycho-education on cognitive and behavioural effects of depression, how to cope with interpersonal problems, and financial stressors. Based on these conditions, the review of manuals and expert consultation, key components of the counselling intervention were identified as: psycho-education, problem solving, healthy thinking and behaviour activation. These were included in the final counselling manual. The fourth chapter, presents the first of two perspectives of the post-intervention qualitative process evaluations, with lay counsellors. Post intervention qualitative semi-structured interviews were conducted with six counsellors from the AFrica Focus on Intervention Research for Mental Health (AFFIRM-SA) randomized controlled trial on their perceptions of delivering a task shared psycho-social intervention for perinatal depression. These interviews revealed that facilitating factors in the delivery of the intervention included intervention related factors such as: the content of the intervention, ongoing training and supervision, using a counselling manual, conducting counselling sessions in the local language (isiXhosa) and fidelity to the manual. Counsellor factors including counsellors’ confidence and motivation to conduct the sessions and participant factors included older age, commitment and a desire to be helped. Barriers included contextual factors such as poverty, crime and lack of space to conduct counselling sessions and participant factors such as the nature of the participant’s problem, younger age, and avoidance of contact with counsellors. Fidelity ratings and dropout rates varied substantially between counsellors. The fifth chapter presents the second of two perspectives of post intervention qualitative process evaluation with participants. Stratified purposeful sampling based on non-attendance, partial attendance and complete attendance of the intervention resulted in 34 participants being selected for semi-structured interviews. All interviews were recorded, transcribed and translated. Transcripts were analysed using a framework analysis in NVivo v11. Several factors acted as either barriers or facilitators of the participants’ context, mechanisms of the intervention and the implementation of the intervention. Contextual factors included the nature of problem such as unplanned pregnancy, interpersonal difficulties and location of the counselling. Mechanisms included participant factors such as willingness to learn new skills and change behaviour, counsellor factors such as motivation and empathy and intervention factors such as the content of the intervention. Implementation factors included the perception of the use or inability to use material such as the counselling manual, homework book and relaxation CD. The majority of the participants found the following sessions to be most valuable; “psycho-education for depression”, “problem solving” and “healthy thinking”, although a few participants did not have good recall of the sessions. The final chapter presents a discussion of key findings together with their implications for researchers, policy makers and other stakeholders. The chapter concludes with recommendations for future research in order to understand the contextual, participant, counsellor and intervention factors involved in the implementation of task sharing interventions.
- ItemOpen AccessFrontal lobe dysfunction, as measured by the frontal systems behavioural scale, in the context of HIV infection and heavy episodic drinking(2021) Smith, Everhardus Johanne; Joska, John; Ipser, JonathanBackground: The frontal lobe of the human brain is integral in regulating behaviour. Behavioural disturbances such as apathy, disinhibition, and dysexecutive function are well-known consequences of frontal lobe pathology, leading to significant impairment. Heavy episodic drinking (HED) and HIV are common conditions that impair the frontal lobe, with disinhibition frequently being seen in people with HED, apathy in HIV positive patients and both HIV and HED leading to executive dysfunction. There is a paucity of research on the interplay between HIV and HED and how this impacts behaviour associated with frontal lobe dysfunction. The Frontal Systems Behaviour Scale (FrSBe) is a questionnaire designed to measure problematic behaviour associated with frontal systems impairment. It has been used in a range of clinical populations. It consists of a total score and three subscale scores, namely apathy (Scale A), disinhibition (Scale D) and executive dysfunction (Scale E). This tool is easy to administer and has the potential to provide clinically useful information that could guide management of patients with these conditions. Aim: As a first step to knowing more about the complex interplay between HIV and HED and its effects on frontal lobe function, the aim of this study was to determine the relationship between HIV status, HED and frontal-systems behavioural dysfunction (impulsivity, apathy, and executive dysfunction) as measured by the FrSBe. Methods: Participants for this quantitative, cross-sectional, and analytical study were recruited from the Nolungile Clinic in Khayelitsha, Cape Town. They were grouped according to their HIV- and HED status. Relevant demographic and clinical data were obtained. Participants completed the Substance Abuse and Mental Illness Symptoms Screener (SAMISS) questionnaires and the FrSBe self-report measure that was translated into isiXhosa. Both measures were scored and the FrSBe raw scores were converted to T-scores. Results: A total of the 99 participants met the inclusion criteria, of which 25 were in the HED only group, 22 in the HIV+ only group, 26 in the dual group, and 26 were in the control group. The mean age (SD) of the sample was 37.92 (8.8) years. There was a statistical difference between groups for the total drinking score on the SAMISS (p = 65), were present on the FrSBe Total Score in 29 of the participants. On the apathy subscale score, 36 participants had clinically significant (T-score >= 65) deficits, 14 had deficits on the disinhibition subscale, and 34 had on the executive dysfunction subscale. There were no statistically significant differences in the proportion of participants with clinically significant deficits between groups for any FrSBe scores. Conclusions: This study shows that people with HED have more dysfunctional behaviour associated with frontal system impairment and are more disinhibited. HIV status does not appear to influence frontal system behaviour. These finding needs to be interpreted with caution as the study FrSBe was administered in isiXhosa, in which it has not been validated, and no normative data was available for the study population. Future studies validating the FrSBe in a South African context and deriving normative data for South African populations would be a first step into developing the FrSBe into a clinically useful tool. This could, in turn, potentially lead to improved care and treatment in these conditions by identifying specific impairments and problematic behaviours as targets for intervention.
- ItemOpen AccessIntergenerational effects: child and maternal outcomes related to exposure to intimate partner violence and trauma in a South African community(2021) Barnett, Whitney Christine; Stein, Dan J; Donald, Kirsten A; Halligan, SarahIntimate partner violence (IPV) constitutes a major global health problem, affecting one in three women worldwide at some point during their life. IPV is particularly high in low and middle income countries (LMICs) and is associated with a wide range of adverse maternal and child health outcomes. Despite evidence that exposure to IPV affects child development and growth at birth and in infancy, there are limitations to our existing knowledge. First, few studies have considered the impact of maternal emotional IPV separately on child outcomes investigated, focusing primarily on physical and/or sexual IPV. Second, much of the existing data derives from high income countries, rather than from LMIC settings, where the majority of the world's child population lives and where many children are exposed to disproportionately high levels of poverty and violence-related risk factors. Third, there is limited information from well characterized longitudinal studies in these settings and a lack of investigation of associations in very young children, despite the fact that children under 2 years may be particularly at risk for long-term health sequelae relating to IPV exposure. Lastly, few studies have formally investigated potential mediators, inclusive of both behavioral and biological mechanisms underlying associations between IPV and food security and early-life child growth or development. In high-risk settings such as South Africa it is critical to gain improved understanding of pathways by which violence affects child health. This may be especially important given that LMIC contexts often have fewer programs in place to address IPV, and that associated mental health issues and risk factors may be different than in higher income countries. This thesis aimed to investigate IPV in a South African birth cohort, the Drakenstein Child Health Cohort, to understand better the patterns of IPV amongst pregnant and postpartum women, the impact antenatal and postnatal IPV exposure may have on their child's growth and development, and the pathways by which IPV may impact child health sequelae. Chapter 1 reviews the relevant literature, discusses key gaps and presents thesis aims and structure. Chapter 2 comprises a methods chapter which provides an overview of the study population, measures and ethical considerations. Chapter 3 (Paper 1) presents longitudinal profiles of maternal IPV exposure by sub-type from pregnancy through 24 months post-partum and associations between maternal childhood maltreatment and longitudinal frequency and severity of IPV. Chapter 4 (Paper 2) investigates the association between maternal childhood trauma as well as IPV and food insecurity among pregnant women, and examines whether maternal depression mediates these relationships. Chapter 5 (Paper 3) investigates associations between IPV sub-types and growth at birth and 12 months. Further, multiple psychosocial (substance use, depression) and clinical factors (number of hospitalizations) are tested to determine whether any of these may be mediators in the relationship between IPV and child growth. Chapter 6 (Paper 4) investigates emotional, physical and sexual IPV and their relationship with child development at 24 months of age, and whether depression or maternal alcohol dependence mediates these relationships. Chapter 7 presents a summary of findings across results chapters and includes recommendations for future policy and research. Key findings in this population show that: i) a high proportion of mothers are exposed to chronic IPV during and after pregnancy and that maternal childhood abuse or neglect is associated with higher frequency and severity of IPV exposure; ii) maternal IPV and childhood trauma are each associated with food insecurity during pregnancy and that depression partially explains these relationships; iii) emotional and physical IPV are associated with reduced fetal growth and reduced growth through infancy, and maternal substance use (alcohol or tobacco) partially explains these relationships; iv) both emotional and physical IPV are associated with poorer child development at 2 years, and neither maternal current depression nor alcohol dependence explain these relationships. Overall, the findings highlight that emotional IPV in addition to physical IPV is a key risk factor for child growth and development, and identify potential pathways underlying explored relationships. Maternal depression and substance use emerged as partial explanatory variables for nutritional outcomes, specifically food insecurity during pregnancy and growth outcomes at birth and through infancy. The high prevalence of IPV and its negative impact on child health, together comprise a major public health problem, causing significant hardship and representing a significant burden for families, economies and health systems. Findings presented in this thesis suggest that comprehensive and intersectoral programs are needed to 5 address IPV and associated adverse child health outcomes, inclusive of efforts to address maternal mental health and substance use. Further, it is also vital to ensure emotional IPV is included in training and intervention efforts. Clinical implications and areas for future research are discussed.
- ItemOpen AccessLeisure boredom and risk behaviour in adolescence(2008) Wegner, Lisa; Flisher, Alan JThere has been very little research investigating leisure boredom and risk behaviour among adolescents in South Africa. The purpose of the research reported in this thesis was to investigate how adolescents experience leisure and boredom in their free time, and how this is associated with risk behaviour - specifically substance use, sexual risk behaviour and premature school leaving (dropout). The thesis comprises five interrelated studies.
- ItemOpen AccessThe lived experience of male intimate partners of female rape victims in Cape Town, South Africa(2010) Van Wijk, Evalina; Duma, Sinegugu ; Mayers, PatThe primary purpose of the study was to explore, analyse and interpret the lived experiences of male intimate partners of female rape victims and the meaning of such experiences within six months of the rape. A secondary purpose was to formulate a framework grounded in the data gathered from the intimate partners to understand and conceptualise their experiences. The research question that guided the study was the following: What are the lived experiences of intimate partners of female rape victims during the six months following the rape? Selection of study participants involved purposeful sampling. After providing informed consent, nine intimate partners of female rape victims living in Cape Town, South Africa, participated in four separate face-to-face, semi-structured interviews: (a) within 14 days of, (b) a month after, (c) three months after and(d) six months after the rape.The hermeneutic-phenomenological approach of Paul Ricoeur formed the framework for the analysis and interpretation of the findings to ensure congruence between the present study‘s philosophical underpinnings and the research method. Colaizzi‘s procedural steps and the within-case and acrosscase approach, as suggested by Ayres, Kavanaugh and Knafl (2003:873), functioned to supplement Ricoeur‘s method (Speziale & Carpenter, 2003:58-64).
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