Family-centred approaches to the prevention of mother to child transmission of HIV

Background: Prevention of mother to child transmission (PMTCT) programmes have traditionally been narrow in scope, targeting biomedical interventions during the perinatal period, rather than considering HIV as a family disease. This limited focus restricts programmes' effectiveness, and the opportunity to broaden prevention measures has largely been overlooked. Although prevention of vertical transmission is crucial, consideration of the family environment can enhance PMTCT. Family-centred approaches to HIV prevention and care present an important direction for preventing paediatric infections while improving overall family health. This paper reviews available literature on PMTCT programmatic models that have taken a broader or family-centred approach. We describe findings and barriers to the delivery of family-centred PMTCT and identify a number of promising new directions that may achieve more holistic services for children and families. Methods: Literature on the effectiveness of family-centred PMTCT interventions available via PubMed, EMBASE and PsycINFO were searched from 1990 to the present. Four hundred and three abstracts were generated. These were narrowed to those describing or evaluating PMTCT models that target broader aspects of the family system before, during and/or after delivery of an infant at risk of acquiring HIV infection (N = 14). Results: The most common aspects of family-centred care incorporated by PMTCT studies and programme models included counselling, testing, and provision of antiretroviral treatment for infected pregnant women and their partners. Antiretroviral therapy was also commonly extended to other infected family members. Efforts to involve fathers in family-based PMTCT counselling, infant feeding counselling, and general decision making were less common, though promising. Also promising, but rare, were PMTCT programmes that use interventions to enrich family capacity and functioning; these include risk assessments for intimate partner violence, attention to mental health issues, and the integration of early childhood development services. Conclusions: Despite barriers, numerous opportunities exist to expand PMTCT services to address the health needs of the entire family. Our review of models utilizing these approaches indicates that family-centred prevention measures can be effectively integrated within programmes. However, additional research is needed in order to more thoroughly evaluate their impact on PMTCT, as well as on broader family health outcomes

A qualitative case study of child protection issues in the Indian construction industry: investigating the security, health, and interrelated rights of migrant families

Background: Many of India’s estimated 40 million migrant workers in the construction industry migrate with their children. Though India is undergoing rapid economic growth, numerous child protection issues remain. Migrant workers and their children face serious threats to their health, safety, and well-being. We examined risk and protective factors influencing the basic rights and protections of children and families living and working at a construction site outside Delhi. Methods: Using case study methods and a rights-based model of child protection, the SAFE model, we triangulated data from in-depth interviews with stakeholders on and near the site (including employees, middlemen, and managers); 14 participants, interviews with child protection and corporate policy experts in greater Delhi (8 participants), and focus group discussions (FGD) with workers (4 FGDs, 25 members) and their children (2 FGDs, 9 members). Results: Analyses illuminated complex and interrelated stressors characterizing the health and well-being of migrant workers and their children in urban settings. These included limited access to healthcare, few educational opportunities, piecemeal wages, and unsafe or unsanitary living and working conditions. Analyses also identified both protective and potentially dangerous survival strategies, such as child labor, undertaken by migrant families in the face of these challenges. Conclusions: By exploring the risks faced by migrant workers and their children in the urban construction industry in India, we illustrate the alarming implications for their health, safety, livelihoods, and development. Our findings, illuminated through the SAFE model, call attention to the need for enhanced systems of corporate and government accountability as well as the implementation of holistic child-focused and child-friendly policies and programs in order to ensure the rights and protection of this hyper-mobile, and often invisible, population

Validation of the “World Health Organization Disability Assessment Schedule for Children, WHODAS-Child” in Rwanda

Overview: The World Health Organization Disability Assessment Schedule for children (WHODAS-Child) is a disability assessment instrument based on the WHO's International Classification of Functioning, Disability and Health for children and youth. It is modified from the original adult version specifically for use with children. The aim of this study was to assess the WHODAS-Child structure and metric properties in a community sample of children with and without reported psychosocial problems in rural Rwanda. Methods: The WHODAS-Child was first translated into Kinyarwanda through a detailed committee translation process and back-translation. Cognitive interviewing was used to assess the comprehension of the translated items. Test-retest reliability was assessed in a group of 64 children. The translated WHODAS-Child was then administered to a final sample of 367 children in southern Kayonza district in rural southeastern Rwanda within a larger psychosocial assessment battery. The latent structure was assessed through confirmatory factor analysis. Reliability was evaluated in terms of internal consistency (Cronbach's alpha) and test-retest reliability (Pearson's correlation coefficient). Construct validity was explored by examining convergence between WHODAS-Child scores and mental disorder status, and divergence of WHODAS-Child scores with protective factors and prosocial behaviors. Concordance between parent and child scores was also assessed. Results: The six-factor structure of the WHODAS-Child was confirmed in a population sample of Rwandan children. Test-retest and inter-rater reliability were high (r = .83 and ICC = .88). WHODAS-Child scores were moderately positively correlated with presence of depression (r = .42, p<.001) and post-traumatic stress disorder (r = .31, p<.001) and moderately negatively correlated with prosocial behaviors (r = .47, p<.001). The Kinyarwanda version of the WHODAS-Child was found to be a reliable and acceptable self-report tool for assessment of functional impairment among children largely referred for psychosocial problems in the study district in rural Rwanda. Further research in low-resource settings and with more general populations is recommended

Mitigating toxic stress in children affected by conflict and displacement

Anushka Ataullahjan and colleagues describe the myriad stressors related to conflict and displacement experienced by children and how best to reduce their negative effec

Implementation and Scale-Up of Psycho-Trauma Centers in a Post-Conflict Area: A Case Study of a Private–Public Partnership in Northern Uganda

As one article in an ongoing series on Global Mental Health Practice, Etheldreda Nakimuli-Mpungu and colleagues describe a private-public partnership that implemented and scaled psycho-trauma centers in Northern Uganda

Exploring potential mental health spillover effects among caregivers and partners of youth in Sierra Leone: A qualitative study

Given the large mental health treatment gap in low- and middle-income countries (LMICs), particularly in post-conflict settings like Sierra Leone, and the limited healthcare infrastructure, understanding the wider benefits of evidence-based mental health interventions within households is critical. This study explored potential mental health spillover effects – the phenomenon of beneficial effects among nonparticipants – among cohabitating caregivers and partners of youth who participated in an evidence-based mental health intervention in Sierra Leone. We recruited a sub-sample of cohabitating caregivers and partners (N = 20) of youth intervention participants; caregivers had enrolled in a larger study investigating indirect benefits of the evidence-based intervention in Sierra Leone (MH117359). Qualitative interviews were conducted at two time points to explore the following: (a) potential mental health spillover effects and (b) through which mechanisms spillover may have occurred. Two trained coders reviewed transcripts and analyzed qualitative data, assisted by MaxQDA. Qualitative findings suggested that spillover effects likely occurred and supported three potential mechanisms: decreased caregiving burden, behavior changes among Youth Readiness Intervention participants and improved interpersonal relationships. Mental health spillover effects may occur following youth intervention participation in a post-conflict LMIC. Investing in evidence-based services may offer indirect benefits that extend beyond those directly receiving services

Navigating the tension between fatherhood ideals and realities of a post-conflict setting: A phenomenological study of former child soldiers in Sierra Leone

The concept of “fatherhood” in many African countries has traditionally been understood in terms of instrumental support to one's family, most notably, financial provision. However, in Sierra Leone and elsewhere, this narrow understanding of fatherhood is changing as a result of shifting demographic trends and in response to crises such as civil war and the recent Ebola outbreak in west Africa. Little is understood about how males formerly associated with armed forces and armed groups during childhood (Children Associated with Armed Forces and Armed Groups/CAAFAG) are navigating fatherhood as young adults. This study uses a phenomenological approach to understand 1) the meaning and importance of fatherhood for CAAFAG and war-affected fathers, 2) what fatherhood looks like normatively and ideally, with attention to norms about nurturing care and violence, and 3) how ideals of fatherhood may or may not be in tension with socioeconomic circumstances. We find that CAAFAG and war-affected fathers are committed to providing emotional support, encouragement, and a loving upbringing in addition to striving to provide financially for their families. Fathers experienced the greatest tension between their ideals of fatherhood and their structural circumstances; in other words, they felt inhibited in becoming the types of fathers they hoped to be due to the realities of living in a post-conflict, resource-constrained environment.https://doi.org/10.1016/j.ssmqr.2023.1002273pubpu

Development of the SAFE Checklist Tool for Assessing Site-Level Threats to Child Protection: Use of Delphi Methods and Application to Two Sites in India

Background: The child protection community is increasingly focused on developing tools to assess threats to child protection and the basic security needs and rights of children and families living in adverse circumstances. Although tremendous advances have been made to improve measurement of individual child health status or household functioning for use in low-resource settings, little attention has been paid to a more diverse array of settings in which many children in adversity spend time and how context contributes to threats to child protection. The SAFE model posits that insecurity in any of the following fundamental domains threatens security in the others: Safety/freedom from harm; Access to basic physiological needs and healthcare; Family and connection to others; Education and economic security. Site-level tools are needed in order to monitor the conditions that can dramatically undermine or support healthy child growth, development and emotional and behavioral health. From refugee camps and orphanages to schools and housing complexes, site-level threats exist that are not well captured by commonly used measures of child health and well-being or assessments of single households (e.g., SDQ, HOME). Methods: The present study presents a methodology and the development of a scale for assessing site-level child protection threats in various settings of adversity. A modified Delphi panel process was enhanced with two stages of expert review in core content areas as well as review by experts in instrument development, and field pilot testing. Results: Field testing in two diverse sites in India—a construction site and a railway station—revealed that the resulting SAFE instrument was sensitive to the differences between the sites from the standpoint of core child protection issues

Caregiving can be costly : a qualitative study of barriers and facilitators to conducting kangaroo mother care in a US tertiary hospital neonatal intensive care unit

Preterm birth is a leading cause of morbidity and mortality in children under five and often requires a newborn to have an extended stay in a neonatal intensive care unit (NICU). Maternal engagement, such as visiting the NICU to provide kangaroo mother care (KMC), can improve outcomes for preterm infants but requires significant investment of time and resources. This study sought to understand barriers and facilitators to provision of KMC in the NICU.; We conducted semi-structured in-depth interviews with mothers of preterm infants (N = 20) at a large academic medical center in Massachusetts. A series of open-ended interview questions were designed to elicit all aspects of mothers' experiences and to understand how these experiences influence provision of KMC. All interviews were recorded and transcribed verbatim. We conducted an inductive thematic analysis to identify themes in the data with a focus on the barriers and facilitators of KMC provision in the NICU.; Findings show that engaging in KMC is heavily influenced by the mental, emotional, and physical effects of preterm birth on the birth mother, such as stress around preterm birth and difficulty recovering from birth. These challenges are compounded by structural barriers such as costly accommodations, unreliable transportation, lack of child care, and inadequate maternity leave policies that limit the frequency and duration of KMC and parental ability to provide care.; A complex array of mental, emotional, physical, and structural factors determine a mother's ability to visit the NICU and provide kangaroo mother care. Providing social supports, such as improved maternity leave policies and reliable hospital access through child care, accommodation, and transportation services, may address the structural barriers that inhibit KMC, reduce burdensome costs, and improve the health of mothers and their preterm infants

Associations between Mental Health and Ebola-Related Health Behaviors: A Regionally Representative Cross-sectional Survey in Post-conflict Sierra Leone

Background: Little attention has been paid to potential relationships between mental health, trauma, and personal exposures to Ebola virus disease (EVD) and health behaviors in post-conflict West Africa. We tested a conceptual model linking mental health and trauma to EVD risk behaviors and EVD prevention behaviors. Methods and Findings: Using survey data from a representative sample in the Western Urban and Western Rural districts of Sierra Leone, this study examines associations between war exposures, post-traumatic stress disorder (PTSD) symptoms, depression, anxiety, and personal EVD exposure (e.g., having family members or friends diagnosed with EVD) and EVD-related health behaviors among 1,008 adults (98% response rate) from 63 census enumeration areas of the Western Rural and Western Urban districts randomly sampled at the height of the EVD epidemic (January–April 2015). Primary outcomes were EVD risk behaviors (14 items, Cronbach’s α = 0.84) and EVD prevention behaviors (16 items, Cronbach’s α = 0.88). Main predictors comprised war exposures (8 items, Cronbach’s α = 0.85), anxiety (10 items, Cronbach’s α = 0.93), depression (15 items, Cronbach’s α = 0.91), and PTSD symptoms (16 items, Cronbach’s α = 0.93). Data were analyzed using two-level, population-weighted hierarchical linear models with 20 multiply imputed datasets. EVD risk behaviors were associated with intensity of depression symptoms (b = 0.05; 95% CI 0.00, 0.10; p = 0.037), PTSD symptoms (b = 0.10; 95% CI 0.03, 0.17; p = 0.008), having a friend diagnosed with EVD (b = −0.04; 95% CI −0.08, −0.00; p = 0.036), and war exposures (b = −0.09; 95% CI −0.17, −0.02; p = 0.013). EVD prevention behaviors were associated with higher anxiety (b = 0.23; 95% CI 0.06, 0.40; p = 0.008), having a friend diagnosed with EVD (b = 0.15; 95% CI 0.04, 0.27; p = 0.011), and higher levels of war exposure (b = 0.45; 95% CI 0.16, 0.74; p = 0.003), independent of mental health. PTSD symptoms were associated with lower levels of EVD prevention behavior (b = −0.24; 95% CI −0.43, −0.06; p = 0.009). Conclusions: In post-conflict settings, past war trauma and mental health problems are associated with health behaviors related to combatting EVD. The associations between war trauma and both EVD risk behaviors and EVD prevention behaviors may be mediated through two key mental health variables: depression and PTSD symptoms. Considering the role of mental health in the prevention of disease transmission may help fight continuing and future Ebola outbreaks in post-conflict Sierra Leone. This sample is specific to Freetown and the Western Area and may not be representative of all of Sierra Leone. In addition, our main outcomes as well as personal EVD exposure, war exposures, and mental health predictors rely on self-report, and therefore raise the possibility of common methods bias. However, the findings of this study may be relevant for understanding dynamics related to EVD and mental health in other major capital cities in the EVD-affected countries of West Africa