Ronel Ferreira

A randomized clinical trial of an intervention to promote resilience in young children of HIV-positive mothers in South Africa

Objective:The objective of this study is to assess the efficacy of an intervention designed to promote resilience in young children living with their HIV-positive mothers. Design/methods:HIV-positive women attending clinics in Tshwane, South Africa, and their children, aged 6–10 years, were randomized to the intervention (I) or standard care (S). The intervention consisted of 24 weekly group sessions led by community care workers. Mothers and children were in separate groups for 14 sessions, followed by 10 interactive sessions. The primary focus was on parent–child communication and parenting. Assessments were completed by mothers and children at baseline and 6, 12 and 18 months. Repeated mixed linear analyses were used to assess change over time. Results:Of 390 mother–child pairs, 84.6% (I: 161 and S: 169) completed at least two interviews and were included in the analyses. Childrens mean age was 8.4 years and 42% of mothers had been ill in the prior 3 months. Attendance in groups was variable: only 45.7% attended more than 16 sessions. Intervention mothers reported significant improvements in childrens externalizing behaviours (ß = –2.8, P = 0.002), communication (ß = 4.3, P = 0.025) and daily living skills (ß = 5.9, P = 0.024), although improvement in internalizing behaviours and socialization was not significant (P = 0.061 and 0.052, respectively). Intervention children reported a temporary increase in anxiety but did not report differences in depression or emotional intelligence. Conclusion:This is the first study demonstrating benefits of an intervention designed to promote resilience among young children of HIV-positive mothers. The intervention was specifically designed for an African context and has the potential to benefit large numbers of children, if it can be widely implemented.

Formative evaluation of the STAR intervention: improving teachers’ ability to provide psychosocial support for vulnerable individuals in the school community

The article describes the pilot phase of a participatory reflection and action (PRA) study. The longitudinal investigation explores teachers’ ability to provide psychosocial support within the context of HIV/AIDS following an asset-based intervention. The study ensued from our desire to understand and contribute to knowledge about the changed roles of teachers due to adversity in the community, specifically in relation to HIV/AIDS and education. The supportive teachers, assets and resilience (STAR) intervention was facilitated from November 2003 to October 2005 and consisted of the research team undertaking nine field visits and facilitating 20 intervention sessions (2–3 hours each), and 12 post-intervention research visits have been conducted to date. Ten female teachers were selected for participation through random purposeful sampling at a primary school in an informal settlement outside Port Elizabeth, South Africa. Data-generation included PRA activities, observation, informal interactive interviews, and focus group discussions. The data were analysed by means of inductive thematic analysis. We found that the teachers did not view vulnerability as being related to children or HIV/AIDS in isolation, but rather that their psychosocial support to children and the school community was inclusive across a spectrum of vulnerabilities and services. We argue that teachers who are inclined to provide such support will fulfil this role irrespective of understanding policy or receiving training. We contend that teachers are well-positioned to manage school-based psychosocial support in order to create relevant and caring spaces for vulnerable individuals in the school community.

Development and piloting of a mother and child intervention to promote resilience in young children of HIV-infected mothers in South Africa.

This paper describes the process of developing a parallel intervention for HIV-positive mothers and their young children (6-10 years) with a view to strengthening the relationship between them. Strong mother-child relationships can contribute to enhanced psychological resilience in children. The intervention was developed through action research, involving a situation analysis based on focus group discussions; intervention planning, piloting the intervention and a formative evaluation of the intervention. Participants supplied feedback regarding the value of the intervention in mother-child relationships. The findings obtained from the formative evaluation were used to refine the intervention. Two parallel programmes for mothers and children (15 sessions each) were followed by 10 joint sessions. The intervention for mothers focused on maternal mental health and the strengthening of their capacity to protect and care for their young children. The intervention for children addressed the development of their self-esteem, interpersonal relationships and survival skills. The formative evaluation provided evidence of good participation, support and group cohesion. Qualitative feedback indicated that the activities stimulated mother-child interaction. A similar intervention can easily be applied elsewhere using the detailed manual. The insights gained and lessons learnt related to mother and child interaction within an HIV-context that emerged from this research, can be valuable in other settings, both in Sub-Saharan Africa and elsewhere.

Behavior and psychological functioning of young children of HIV-positive mothers in South Africa

Adults with HIV are living longer due to earlier diagnosis and increased access to antiretroviral medications. Therefore, fewer young children are being orphaned and instead, are being cared for by parents who know they are HIV positive, although they may be asymptomatic. Presently, it is unclear whether the psychological functioning of these young children is likely to be affected or, alternatively, whether it is only when a mother is ill, that children suffer adverse effects. We, thus, aimed to compare the behavior and psychological functioning of young children (aged 6–10 years) of HIV-positive and HIV-negative mothers. We also aimed to examine the association between HIV status disclosure and child outcomes. This study uses cross-sectional data from the baseline assessment of a randomized controlled trial conducted in Tshwane, South Africa. Participants (n=509) and their children were recruited from area health clinics. Among the 395 mothers with HIV, 42% reported symptoms of HIV disease. Multivariate linear regression models suggested that after adjusting for socio-demographic characteristics, children of HIV-positive mothers had significantly greater externalizing behaviors than children of HIV-negative mothers. Importantly, children whose mothers were symptomatic had greater internalizing and externalizing behaviors compared with children of HIV-negative mothers, but this was not true for children of asymptomatic mothers. Additionally, among children of HIV-positive mothers, those who had been told their mothers were sick compared with children who had been told nothing had less internalizing and externalizing behaviors and improved daily living skills. This study, therefore, provides evidence that maternal HIV disease can affect the behaviors of young children in South Africa but, importantly, only when the mothers are symptomatic from their disease. Furthermore, results suggest that disclosure of maternal illness but not HIV status was associated with improved behavior and psychological functioning among young children.

The case of expectant fathers : negotiating the changing role of males in a 'female' world

Research was carried out to investigate the needs of expectant fathers and to determine whether television can be implemented to provide parent guidance to South African expectant fathers during the transition into fatherhood. Focus was on understanding the specific type of information required by expectant fathers, in conjunction with their perceptions of the most suitable form of media to provide such guidance. Sixty‐five fathers were involved in a telephone survey, after which in‐depth interviews were conducted with four fathers to establish their perceptions regarding the possible use of television to provide guidance to expectant fathers. It seems that expectant fathers experience a need for information to help prepare them for their role as a father, require more knowledge regarding the topic of fatherhood and pregnancy, wish to receive guidance to develop certain basic childcare skills, and perceive television to be the most suitable medium for providing them with such guidance.

Teachers becoming lay practitioners of school community psychology

This article reports on a study that explored how a community-based intervention with ten teachers could enhance their knowledge and skills related to supporting community members coping with HIV/ AIDS. We conducted a case study using participatory action research methods. Individual interviews, observation, field notes, visual data and reflective journals were utilised as data sources. We found that the participating teachers displayed a willingness to support their community in coping with HIV/AIDS, yet did not perceive themselves as being adequately equipped to do so, and therefore refrained from acting intuitively. The intervention did, however, show signs of an emergent sense of ‘becoming’ lay practitioners in the face of the social upheaval brought on by the pandemic.

Culture at the Heart of Coping with HIV/AIDS

This study explored the manner in which a South African informal community coped with living with HIV/AIDS by relying on existing assets and local resources. A case study research design applying participatory reflection and action principles was used. Focus group/workshop sessions were conducted with ten selected female educators from the community. In addition, individual interviews with stakeholders and other members of the community (n=31, males=6, females=25) were also carried out. Supplemental data collection methods included observation, visual techniques, field notes and a reflective journal. The study found that community members coped with HIV/AIDS by relying on culture and family, faith in God, religiosity and prayer. Inner strength, hope, optimism and expectancy appeared to be key resources for informal settlement residents.

In-service teacher training to provide psychosocial support and care in high-risk and high-need schools: school-based intervention partnerships

This article uses a South African case study to argue that postcolonial, emerging economy societies in transition often contain schools characterised as high risk and high need. Such schools require teachers to adapt to roles other than facilitating learning, such as psychosocial support and care, and which requires additional professional development. In the absence of structured teacher professional development programmes, alternatives are required to assist teachers. The paper describes a nine-year partnership between higher education researchers and teachers in high-risk and high-need schools in three South African provinces. The participatory reflection and action (PRA) study served as platform for a school-based intervention to assist in-service teachers to adapt to their additional responsibilities. Thematic analysis was used to identify the ways in which teachers’ adaptation to high risk benefitted from the programme, and self-determination theory is used to argue for a dynamic and interconnected relationship between the teachers’ demonstrated pathways to psychosocial support and care. The article argues that in socio-politically transforming societies where need is high for in-service teacher training and formal structures for teacher professional development may be limited, partnerships between researchers and teachers appear to be useful platforms for school-based interventions to support teacher resilience.

Teachers' Use of Memory-Box-Making to Provide Psychosocial Support in Their Pastoral Role

This study investigated the use of memory-box-making by teachers in their pastoral role. Ten female teachers participated in the study. The site of the study is in a South African primary school in an urban informal settlement. We used multiple data collection strategies (observation, focus groups, visual data and research diaries), which were documented in various ways (field notes, audio recordings and verbatim transcriptions and photographs). Data were analysed by means of thematic analysis from a constructivist grounded theory approach. The study found that (1) teachers were aware of pastoral role policy, but their task functioning in the role varied; (2) memory-box-making provided a pastoral space for teachers to apply basic counselling skills with children; (3) memory-box-making enabled teachers to perform pastoral role tasks; and (4) teachers ventured to transfer memory-box-making skills collaboratively. The study highlights the importance of considering cultural beliefs regarding death when utilising memory-box-making.

Intervention Groups for HIV-Infected Women: The Need for Additional Services

The Kgolo Mmogo study is a randomised controlled intervention trial that examines the effectiveness of a group intervention to enhance resilience in HIV-infected South African mothers (N = 427) and their young children (N = 435). We describe here how the severity of psychological and social problems experienced by some of the study participants required referrals for other services and discuss the barriers encountered in facilitating such referrals. Over a 30-month period 54 mothers and 59 children were referred for additional support. For mothers, the most frequent reasons for referral related to domestic violence and problems within relationships, while for children the most common grounds for referral were the evaluation and treatment of behavioural problems and severe emotional disturbances, including depression. Eight children were referred for suspected abuse. Observations from the study demonstrate that current systems for referral are overloaded and that there is a paucity of specialised services available. Our experience suggests that participants may benefit from using the intervention as a first point of support and that psychosocial referrals should perhaps be delayed until functional advice is provided (within the group) on ways of accessing wider support effectively. The intervention may also benefit from the inclusion of an intervention team member who is specifically tasked to follow up on referrals. This includes follow-up for participants who were not included in the group intervention. Furthermore, we argue that socio-economic constraints, which often manifest as lack of mobility to access service delivery, can severely impact on the implementation of an intervention study in a developing context. This constraint is experienced in terms of limited access to experimental intervention groups and services from referrals.