An exploration of learners integration into the mainstream: a case study approach

Magister Artium (Psychology) - MA(Psych)The aims of the study were to: (1) explore the education support services required by three learners who were integrated into the mainstream, (2) determine the level of support required by these learners to function maximally in the mainstream, (3) specifically explore the socioemotional ability of these learners to adjust to the mainstream setting. Three cases were explored within an eco-systemic approach. Each case consisted of a learner with a physical disability, the learner’s mother and the educator/s who first taught the learner at the mainstream school. Interviews were conducted with all of the participants and subsequently transcribed verbatim. Thematic analysis was then conducted to extract themes from the transcriptions.South Afric

Intimate Partner Violence, Depression, and Anxiety Are Associated With Higher Perceived Stress Among Both Young Men and Women in Soweto and Durban, South Africa

Objectives: Psychological stress is an important determinant of health, including for mental well-being and sexual health. However, little is known about the prevalence and psychosocial and sexual health correlates of perceived stress among young people in South Africa, where elevated life-stressors are an important driver of health inequities. This study examines the association between intimate partner violence (IPV), psychosocial and sexual health, and perceived stress, by gender, among South African adolescents and young adults. Methods: Using baseline survey data from AYAZAZI, a cohort study enrolling youth (16–24 years) from Durban and Soweto, we used the 10-item Perceived Stress Scale (PSS-10) to measure the degree to which an individual perceives their life situations as unpredictable, uncontrollable, and overloaded. Possible scores range between 0 and 40; higher scores indicating higher perceived stress. Crude and adjusted gender-stratified linear regression models examined associations between sexual health factors, experiences (young women) and perpetration (young men) of IPV, anxiety (APA 3-item Scale, ≥2 = probable anxiety), and depression (10-item CES-D Scale, ≥10 = probable depression) and perceived stress. Multivariable models adjusted for age, income, sexual orientation, and financial dependents. Results: Of the 425 AYAZAZI participants, 60% were young women. At baseline, 71.5% were students//learners and 77.2% earned ≤ ZAR1600 per month (~id="mce_marker"00 USD). The PSS-10 had moderate reliability (α = 0.70 for young women, 0.64 for young men). Young women reported significantly higher mean PSS scores than young men [18.3 (6.3) vs. 16.4 (6.0)]. In adjusted linear regression models, among young women experiences of IPV (β = 4.33; 95% CI: 1.9, 6.8), probable depression (β = 6.63; 95% CI: 5.2, 8.1), and probable anxiety (β = 5.2; 95% CI: 3.6, 6.8) were significantly associated with higher PSS scores. Among young men, ever perpetrating IPV (β = 2.95; 95% CI: 0.3, 5.6), probable depression (β = 6; 95% CI: 4.3, 7.6), and probable anxiety (β = 3.9; 95% CI: 2.1, 5.8) were significantly associated with higher perceived stress. Conclusion: We found that probable depression, anxiety, perpetration of IPV among young men, and experiences of IPV among young women, were associated with higher perceived stress. Critical efforts are needed to address the gendered stressors of young men and women and implement services to address mental health within violence prevention efforts

A qualitative study to explore daily versus on-demand oral pre-exposure prophylaxis (PrEP) in young people from South Africa, Uganda and Zimbabwe.

BACKGROUND: Adolescents in sub-Saharan Africa (SSA) remain vulnerable to HIV infection. While pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV transmission as a daily or on-demand regimen, tailored approaches are necessary. The Combined HIV Adolescent PrEP and Prevention Study (CHAPS) is a mixed-methods research program investigating the acceptability and feasibility of implementing daily and on-demand PrEP among young people in SSA. It also aims to determine an on-demand dosing schedule for insertive sex. For this paper, we explored preferences for daily versus on-demand PrEP amongst adolescents as part of CHAPS. METHODS: Purposive sampling was used to recruit participants from Soweto and Cape Town (South Africa), Wakiso district (Uganda) and Chitungwiza (Zimbabwe). At the time of the study in 2018/2019, Uganda had not rolled out PrEP to the general population; in Zimbabwe, PrEP for young people was only available at selected sites with one located within the study recruitment area. In South Africa, PrEP was made available to selected high-risk groups. We conducted 60 in-depth interviews and 24 group discussions amongst young people aged 13-24 without HIV in South Africa, Uganda, and Zimbabwe. All in-depth interviews and group discussions were audio-recorded, transcribed verbatim and translated to English. Data were analysed using framework analysis. The main themes were centered around preferences for daily and on-demand PrEP. RESULTS: Reasons for on-demand preferences included stigma, pill fatigue, adherence and side effects. Reasons for daily PrEP preferences included factors related to sexual risk behaviour, continuous protection against incidents of unintentional exposure, and the increased efficacy of a daily dose. Participants at all sites preferring daily PrEP identified the same reasons, with more males than females citing inadvertent blood contact or perceived increased efficacy. Similarly, participants at all sites preferring on-demand PrEP gave the same reasons for their preferences for on-demand PrEP; the exception was South Africans who did not mention the hope of having fewer side effects by not taking daily PrEP. Additionally, more males than females cited intermittent sex as a reason for opting for on-demand PrEP. CONCLUSIONS: Our study is the first known to explore and describe youth preferences for daily versus on-demand PrEP. While the choice is clear-cut, the reasons cited in the different options provide invaluable insights into their decisions, and the actual and perceived facilitators and barriers to access to PrEP. Further education is needed amongst young people, not only about PrEP but also in other areas of comprehensive sexuality education. Exploring all options of HIV prevention is crucial to provide a tailored, one-size-does-not-fit-all approach to adolescent care in SSA to reduce and, the continued and increasing risk of this preventable infection

The potential effect of pre-exposure prophylaxis (PrEP) roll-out on sexual-risk behaviour among adolescents and young people in East and southern Africa.

Pre-exposure prophylaxis (PrEP) is an HIV-prevention strategy recommended for those at high-risk of infection, including adolescents and young people (AYP). We explored how PrEP roll-out could influence sexual risk behaviour among AYP in East and southern Africa. Twenty-four group discussions and 60 in-depth interviews were conducted with AYP between 13 and 24 years old, recruited from community settings in Uganda, Zimbabwe and South Africa, from September 2018 to January 2019. Participants perceived that PrEP availability could change sexual behaviour among AYP, influencing: (1) condom use (increased preference for condomless sex, reduced need and decrease in use of condoms, relief from condom use discomfort, consistent condom use to curb sexually transmitted infections and pregnancies); (2) sexual activities (increase in sexual partners and sexual encounters, early sexual debut, sexual experimentation and peace of mind during risky sex, sexual violence and perversion); (3) HIV risk perception (neglect of other HIV prevention strategies, unknown sexual partner HIV status, adoption of PrEP). PrEP initiation may be associated with increased interest in sexual activities and risky sexual behaviour among AYP. PrEP should be included as part of a combination package of HIV prevention strategies for AYP with methods to prevent other sexually transmitted infections and unwanted pregnancies

Exploring Perceived Barriers and Facilitators of PrEP Uptake among Young People in Uganda, Zimbabwe, and South Africa.

Pre-exposure prophylaxis (PrEP) is an effective HIV prevention strategy. Few studies have explored adolescents and young people's perspectives toward PrEP. We conducted 24 group discussions and 60 in-depth interviews with males and females aged 13-24 years in Uganda, Zimbabwe, and South Africa between September 2018 and February 2019. We used the framework approach to generate themes and key concepts for analysis following the social ecological model. Young people expressed a willingness to use PrEP and identified potential barriers and facilitators of PrEP uptake. Barriers included factors at individual (fear of HIV, fear of side effects, and PrEP characteristics), interpersonal (parental influence, absence of a sexual partner), community (peer influence, social stigma), institutional (long waiting times at clinics, attitudes of health workers), and structural (cost of PrEP and mode of administration, accessibility concerns) levels. Facilitators included factors at individual (high HIV risk perception and preventing HIV/desire to remain HIV negative), interpersonal (peer influence, social support and care for PrEP uptake), community (adequate PrEP information and sensitization, evidence of PrEP efficacy and safety), institutional (convenient and responsive services, provision of appropriate and sufficiently resourced services), and structural (access and availability of PrEP, cost of PrEP) levels. The findings indicated that PrEP is an acceptable HIV prevention method. PrEP uptake is linked to personal and environmental factors that need to be considered for successful PrEP roll-out. Multi-level interventions needed to promote PrEP uptake should consider the social and structural drivers and focus on ways that can inspire PrEP uptake and limit the barriers

A multi-country cross-sectional study to assess predictors of daily versus on-demand oral pre-exposure prophylaxis in youth from South Africa, Uganda and Zimbabwe.

INTRODUCTION: Sub-Saharan Africa (SSA) carries the burden of the HIV epidemic, especially among adolescents and young people (AYP). Little is known about pre-exposure prophylaxis (PrEP) uptake and preferences among AYP in SSA. We describe preferences for daily and on-demand PrEP among AYP in South Africa, Uganda and Zimbabwe. METHODS: A cross-sectional survey was conducted in 2019 among 13- to 24-year olds, capturing socio-demographics, HIV risk behaviours and preferences for daily or on-demand PrEP. Logistic regression models were used to estimate odds ratios, adjusting for site, sex and age. RESULTS AND DISCUSSION: A total of 1330 participants from Cape Town (n = 239), Johannesburg (n = 200), Entebbe (n = 491) and Chitungwiza (n = 400) were enrolled; 673 (51%) were male, and the median age was 19 years (interquartile range 17-22 years). Of 1287 participants expressing a preference, 60% indicated a preference for on-demand PrEP with differences by site (p < 0.001), sex (p < 0.001) and age group (p = 0.003). On-demand PrEP was most preferred in Entebbe (75%), among males (65%) versus females (54%) and in older participants (62% in 18- to 24-year-olds vs. 47% in 13- to 15-year-olds). After adjusting for site, sex and age group, preference for on-demand PrEP decreased as sex frequency over the past month increased (p-trend = 0.004) and varied with the number of partners in the last 6 months, being least popular among those reporting four or more partners (p = 0.02). Participants knowing further in advance that they were likely to have sex were more likely to prefer on-demand PrEP (p-trend = 0.02). Participants having a larger age gap with their most recent partner and participants whose last partner was a transactional sex partner or client were both less likely to prefer on-demand compared to daily PrEP (p = 0.05 and p = 0.09, respectively). Participants who knew their most recent partner was living with HIV or who did not know the HIV status of their most recent partner were less likely to prefer on-demand PrEP (p = 0.05). CONCLUSIONS: Our data show that AYP in four SSA communities prefer on-demand over daily PrEP options, with differences seen by site, age and sex. PrEP demand creation needs to be reviewed, optimized and tailored to socio-demographic differences and designed in conjunction with AYP

Adapting a Psychosocial Intervention to reduce HIV risk among likely adolescent participants in HIV biomedical trials

Thesis (PhD)--Stellenbosch University, 2015ENGLISH ABSTRACT : In 2010, young people aged 15–24 years accounted for 42% of new HIV infections globally. In 2009, about five million (10%) of the total South African population was estimated to be aged 15–19 years. Current South African national sero-prevalence data estimate the prevalence of HIV to be 5.6% and 0.7% among adolescent girls and boys aged 15–19 years, respectively. HIV infections are mainly transmitted via sexual transmission. Adolescent sexuality is multi-faceted and influenced at multiple levels. In preparing to enroll adolescents in future biomedical HIV prevention trials, particularly prophylactic HIV vaccine trials, it is critical to provide counseling services appropriate to their needs. At the time of writing, there was no developed psychosocial intervention in South Africa for use among adolescent vaccine trial participants. Thus, the aim of the present study is to adapt and pilot-test a psychosocial intervention, namely, the Centers for Disease Control and Prevention (CDC) risk reduction counseling intervention of Project Respect, an intervention tasked at being developmentally and contextually appropriate among potential adolescent participants in HIV biomedical trials in the future. To achieve this overall aim, I qualitatively explored adolescent sexuality and risk factors for HIV among a diverse sample of participants aged 16–18 from Soweto. Thereafter, I developed a composite HIV risk scale in order to measure the variance in HIV risk among the sample of adolescents studied. The study followed a two-phased, mixed method research design and was informed by ecological systems theory and integrative model of behavioral prediction. The aim of Phase 1, split into phases 1a and b, was to conduct focus group discussions (FGDs) and to undertake a cross-sectional survey, respectively, to determine psychological (for example, self-esteem and depression), behavioral (specifically, sexual behavior) and social (specifically, social support, parent-adolescent communication) contexts that placed adolescents at risk for HIV infection. Phase 1a was qualitative, with data collected via nine FGDs: three involved parents of adolescents, four involved adolescents aged 16–18 years and two counselors. Nine key themes related to adolescent sexuality and risks for HIV acquisition were identified, namely: (1) dating during adolescence; (2) adolescent girls dating older men; (3) condom use amongst adolescents; (4) teenage pregnancies; (5) views about homosexuality; (6) parent-adolescent communication about sexual health; (7) the role of the media; (8) discipline and perceived government influence; and (9) group sex events. Phase 1b was quantitative and the data were collected via a cross-sectional survey to investigate the variance of risk for HIV. For Phase 1b, the sample consisted of 506 adolescents with a mean age of 17 years (interquartile range [IQR]: 16–18). More than half the participants were female (59%, n = 298). I used a three-step hierarchical multiple regression model to investigate the variance in risk for HIV. In step 3, the only significant predictors were “ever threatened to have sex” and “ever forced to have sex”, the combination of which explained 14% (R2 = 0.14; F (12, 236) = 3.14, p = 0.00). Depression and parentadolescent communication were added to steps 2 and 3, respectively, with both variables insignificant in these models. In Phase 2, I adapted and pilot tested the CDC risk reduction counseling intervention. The intervention was intended to be developmentally and contextually appropriate among adolescents from Soweto aged 16–18 years, viewed as potential participants in future HIV biomedical trials. Participants in Phase 2 were aged 16–18 years; the sample was mainly female (52%, n = 11) and most (91%, n = 19) were secondary school learners in grades 8 to 12. Participants provided feedback about their experiences of the adapted counseling intervention through in-depth interviews. I identified three main themes in this regard, namely: benefits of HIV testing services, reasons for seeking counseling and HIV testing services, and participants’ evaluation of the study visits and counseling sessions. The adapted CDC risk reduction counseling intervention was found to be acceptable with favorable outcomes for those adolescents who participated in the piloting phase. This study adds to the literature on risks for HIV among adolescents in Soweto, South Africa, by considering multiple levels of influence. Reaching a more complete understanding of ecological factors contributing to sexual risk behaviors among adolescents in the pilot-study enabled the development of a tailored counseling intervention. The findings showed the adapted CDC risk reduction counseling intervention to be feasible and acceptable among adolescents likely to be participants and eligible to participate in future HIV biomedical prevention trials. Thus, this study provides a much needed risk reduction counseling intervention that can be used among adolescents, an age group likely to participate in future HIV vaccine prevention research.AFRIKAANSE OPSOMMING : In 2010 het jongmense tussen die ouderdomme van 15 en 24 jaar 42% van nuwe MIV-infeksies wêreldwyd uitgemaak. In 2009 was omtrent 5 miljoen mense (10%) van die Suid-Afrikaanse bevolking tussen 15 en 19 jaar oud. Volgens data oor die huidige Suid-Afrikaanse nasionale sero-voorkoms, word die voorkoms van MIV onderskeidelik op 5.6% en 0.7% onder tienermeisies en -seuns tussen die ouderdomme van 15 tot 19 jaar beraam. MIV-infeksies word hoofsaaklik deur seks oorgedra. Adolessente seksualiteit het baie fasette en word op verskeie vlakke beïnvloed. Ter voorbereiding van die werwing van adolessente vir toekomstige biomediese proewe, veral proewe oor profilaktiese MIVentstowwe, is dit van kritiese belang dat beradingsdienste verskaf word wat geskik is vir hul behoeftes. Op die tydstip wat hierdie tesis geskryf is, het daar nog geen psigososiale intervensie in Suid-Afrika bestaan vir gebruik onder adolessente deelnemers aan entstofproewe nie. Daarom is die doel van hierdie studie om ʼn psigososiale intervensie ‒ die Centers for Disease Control and Prevention (CDC) se Projek Respek, ʼn beradingsintervensie vir die vermindering van risiko ‒ aan te pas en met ʼn loodsprojek te toets. Hierdie intervensie is geskik vir die ontwikkelings- en kontekstuele vlak van adolessente deelnemers aan toekomstige MIV- biomediese proewe. Ten einde hierdie oorkoepelende doelwit te bereik, het ek adolessente seksualiteit en die risikofaktore vir MIV onder ʼn diverse steekproef deelnemers tussen die ouderdomme van 16 en 18 jaar van Soweto kwalitatief ondersoek. Daarna het ek ʼn saamgestelde MIV-risikoskaal ontwikkel om die variansie van MIV-risiko onder die groep adolessente te meet. Die studie se navorsingsontwerp het uit twee fases en gemengde metodes bestaan, en is gebaseer op ekologiesestelsel-teorie en die integrerende gedragsvoorspellingsmodel. Die doel van fase 1, wat in fases 1a en 1b verdeel is, was om onderskeidelik fokusgroepbesprekings te hou en om ʼn deursnitopname te doen om die sielkundige kontekste (byvoorbeeld elemente van selfbeeld en depressie), gedragskontekste (spesifiek seksuele gedrag) en sosiale kontekste (spesifiek sosiale ondersteuning en ouer-adolessent-kommunikasie) te bepaal waarin adolessente die risiko loop om MIV-infeksie op te doen. Fase 1a was kwalitatief en data is deur middel van nege fokusgroepbesprekings ingesamel: drie met die ouers van adolessente, vier met adolessente tussen 16 en 18 jaar oud en twee met beraders. Nege sleuteltemas is geïdentifiseer wat verband hou met adolessente seksualiteit en risiko’s om MIV op te doen: (1) verhoudings tydens adolessensie, (2) tienermeisies wat verhoudings met ouer mans het, (3) die gebruik van kondome onder adolessente, (4) tienerswangerskappe, (5) sienings oor homoseksualiteit, (6) ouer-adolessent-kommunikasie oor seksuele gesondheid, (7) die rol van die media, (8) dissipline en die ervaarde regeringsinvloed en (9) groepseksgeleenthede. Fase 1b was kwantitatief en data is deur middel van ’n deursnitopname ingesamel om die variansie van risiko vir MIV te ondersoek. Vir Fase 1b het die steekproef bestaan uit 506 adolessente met ’n gemiddelde ouderdom van 17 jaar (interkwartielwydte [IKW]: 16–18). Meer as die helfte van die deelnemers was vroulik (59%, n = 298). Ek het ’n hiërargiese meervoudige regressiemodel met drie stappe gebruik om die variansie van risiko vir MIV te ondersoek. Die enigste beduidende voorspellers in stap 3 was “ooit gedreig om seks te hê” en “ooit geforseer om seks te hê”. Die kombinasie hiervan het 14% (R2 = 0.14; F (12, 236) = 3.14, p = 0.00) verklaar. Depressie en oueradolessent- kommunikasie is onderskeidelik in stappe 2 en 3 bygevoeg, en albei veranderlikes was onbeduidend in hierdie modelle. In Fase 2 het ek die CDC se intervensie vir die verlaging van risiko aangepas en met ’n loodsprojek getoets. Die intervensie was bedoel om geskik te wees vir die ontwikkelings- en kontekstuele vlakke van 16- tot 18-jarige adolessente van Soweto wat beskou is as potensiële deelnemers aan toekomstige MIV- biomediese proewe. Deelnemers in Fase 2 was 16 tot 18 jaar oud, die steekproef was hoofsaaklik vroulik (52%, n = 11) en die meeste van die deelnemers (91%, n = 19) was in grade 8 tot 12 op hoërskool. Deelnemers het tydens indringende onderhoude terugvoering oor hulle ervarings van die aangepaste beradingsintervensie verskaf. Ek het drie hooftemas in hierdie verband geïdentifiseer, wat die volgende insluit: voordele van MIV-toetsingsdienste, redes waarom berading en MIV-toetsingsdienste verlang word, en die deelnemers se evaluering van die studiebesoeke en beradingsessies. Daar is bevind dat die aangepaste beradingsintervensie van die CDC aanvaarbaar was en gunstige uitkomste gelewer het vir die adolessente wat aan die loodsfase deelgeneem het. Hierdie studie dra by tot die literatuur oor MIV-risiko’s vir adolessente in Soweto, Suid-Afrika, deur meervoudige invloedsvlakke te oorweeg. Die feit dat ’n meer volledige begrip tydens die loodsondersoek verkry is van die interaksie van die ekologiese faktore wat tot seksuele risikogedrag onder adolessente bydra, het die ontwikkeling van ʼn doelgemaakte intervensie deur berading moontlik gemaak. Die bevindings het getoon dat die aangepaste beradingsintervensie van die CDC lewensvatbaar en aanvaarbaar is vir gebruik onder adolessente wat waarskynlik geskikte deelnemers aan toekomstige biomediese proewe oor MIV-voorkoming kan wees. Hierdie studie verskaf dus ʼn noodsaaklike beradingsintervensie om die MIV-risiko onder adolessente ‒ ʼn ouderdomsgroep wat waarskynlik aan toekomstige biomediese navorsing oor MIV-voorkoming sal deelneem ‒ te verminder

Antiretroviral Treatment Adherence: Knowledge and Experiences among Adolescents and Young Adults in Soweto, South Africa

Human immunodeficiency virus (HIV) management of adolescents and young adults (AYAs) is particularly pertinent to sub-Saharan Africa, where the pediatric HIV burden is marked. Antiretroviral treatment (ART) adherence is a major challenge for AYAs. This qualitative study explored knowledge and experiences of adherence amongst AYAs attending treatment at the Perinatal HIV Research Unit (PHRU), Soweto, South Africa. Four focus group discussions (FGDs) and eight in-depth interviews (IDIs) were conducted with HIV-infected 15–25-year-old ART recipients. Transcripts were coded thematically. Participants (n=26) were aged median 18.5 years, 59.1% female and 69.2% virally suppressed <400 cp/ml. Three main themes emerged during FGDs and IDIs: (i) correct knowledge about how to be adherent, benefits, and nonadherence consequences, (ii) social, personal, and medication-related barriers to adherence, and (iii) reminder, concealment, and motivational strategies to optimize adherence. Interventions to improve AYA adherence could focus on practical strategies, including status disclosure and medication concealment

Intersections between COVID-19 and socio-economic mental health stressors in the lives of South African adolescent girls and young women

Background- In contexts where poverty and mental health stressors already interact to negatively impact the most vulnerable populations, COVID-19 is likely to have worsened these impacts. Before the COVID-19 pandemic, adolescent girls and young women (AGYW) in South Africa already faced intersecting mental health stressors and vulnerabilities. It is critical to understand how additional challenges brought on by COVID-19 have intersected with existing vulnerabilities and mental health risks AGYW faced, particularly given the intersections between psychological distress and increased risk behaviours that impact sexual and reproductive health. We aimed to examine socio-economic and mental health impacts of COVID-19 on South African AGYW in order to understand how additional challenges brought on by COVID-19 have intersected with existing challenges, compounding AGYW vulnerabilities. Methods- Using qualitative and quantitative methods, framed by the syndemic theory, we examined the intersections between mental health and the COVID-19 epidemic amongst AGYW in six districts of South Africa characterised by high rates of HIV, teenage pregnancy and socio-economic hardship. Between November 2020 and March 2021 we conducted a cross-sectional telephone survey with 515 AGYW, and in-depth interviews with 50 AGYW, aged 15 to 24 years. Results- Our findings reveal how COVID-19 restrictions led to increased experiences of stress and anxiety. Poor mental health was compounded by strained family relationships, increased fear of domestic violence, household unemployment, economic stress and food insecurity. Respondents described feelings of boredom, frustration, isolation, loneliness, fear and hopelessness. However, despite the multitude of challenges, some AGYW articulated emotional resilience, describing ways in which they coped and retained hope. Conclusion- Various psycho-social risk factors already disproportionally affect the mental health of AGYW in these communities; the COVID-19 pandemic intersects with these pre-existing social and environmental factors. Understanding strategies AGYW have used to positively cope with the uncertainty of COVID-19 amongst an array of pre-existing mental health stressors, is key in informing efforts to respond to their needs. Multisectoral interventions are needed to address the drivers of poor mental health among AGYW, and bolster healthy coping mechanisms; interventions seeking to mitigate the mental health impacts on this vulnerable population need to be responsive to the unpredictable pandemic environment