Includes bibliographical references (p. 197-229). / The central hypothesis of this thesis was that HIV psychosis and mania are overlapping manifestations of the neuropathophysiological consequences of HIV characterized by symptoms suggestive of sub-acute delirium and cognitive impairment. It was also hypothesised that HIV-associated mania and psychosis are AIDS-defining features and should be indications for antiretroviral treatment.

Includes abstract. / Includes bibliographical references. / This interdisciplinary study, within the fields of anthropology and medicine, describes my qualitative research as an anthropologist into the mental illness histories of five young Xhosa-speaking men who, within a year of their circumcision, suffered psychotic breakdowns. The study took place in Valkenberg Hospital for the Mentally Unwell and the surrounding disadvantaged, largely Xhosa-speaking communities in Cape Town, South Africa. Numerous admissions were screened over a two-year period, but only these five men met the study criteria. Their case studies describe how they perceived their circumcision and the stresses that may have contributed to the onset of their psychotic illness.

Background: 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.

Bibliography: p. 297-335. / This thesis includes four main aspects. Firstly, a situation analysis was conducted of current national public sector mental health services in South Africa, using nine service indicators. Secondly, a model was developed for estimating the mental health service needs of people with psychiatric conditions in a local South African population. Thirdly, a set of service norms was proposed for each of the nine service indicators, informed by data from the situation analysis. Fourthly, a practical user-friendly planning manual was developed, using the situation analysis, model and norms to provide guidelines for the planning of mental health services by local and provincial planners.

Includes bibliographical references (leaves 197-216). / There 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.

Methamphetamine dependence has been associated with neurological damage resulting in potentially long-lasting changes in cognitive-affective processes, a range of behavioral problems and psychiatric disorders, including psychosis. Poor emotional control and maladaptive social behaviors have been linked to abnormalities in brain function and structure. However, the links between alterations in neurocircuitries, affect dysregulation, and psychotic symptoms in methamphetamine dependence are yet to be fully elucidated. This project aimed to delineate emotion regulation capabilities as well as brain structure and function in methamphetamine-dependent individuals, patients with a history of methamphetamine-associated psychosis, and healthy adults. The four cross-sectional studies presented here investigated socio-emotional behaviour using self-report questionnaires and social cognition tasks; and assessed neural activation during incidental emotion regulation, measured in an affect labelling task as part of functional magnetic resonance imaging. Additionally, structural magnetic resonance imaging and diffusion tensor imaging were employed to determine grey matter and white matter structural abnormalities, respectively, and to correlate findings with the presence/absence of affect dysregulation and psychotic symptoms. Both methamphetamine-dependent groups showed deficits in emotion regulation abilities, as evidenced by increased levels of aggression, impulsivity, and emotion reactivity. Further, social cognition capacities, including recognising emotions and inferring mental states of others, were diminished in both groups, with greater functional decrements in patients with methamphetamine-associated psychosis. These patients further demonstrated grey matter loss in frontotemporal brain regions and hippocampi, as well as globally reduced white matter integrity, compared to methamphetamine-dependent individuals; and structural deficits in prefrontal and temporal brain regions were associated with impaired affect regulation. Frontolimbic hypoactivation during emotion perception further suggests a role of diminished emotional salience attribution in the pathogenesis of methamphetamine-associated psychosis. Whereas methamphetamine-dependent individuals displayed prefrontal hyperactivation during affect labelling, potentially reflecting a compensatory activation to sufficiently regulate affect, or suggesting a cognitive bias towards the negative facial emotions. Longitudinal data and prospective research designs are needed to address the issue of causality as well as the issue of changes in brain structure and function over time as addiction and related psychopathology progress. Therapies targeting socio-emotional perception and affect regulation skills ultimately may help improve social functioning and mitigate relapse rates.

Perinatal 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.

Includes bibliographical references. / Methamphetamine use has become a growing problem in many regions of the world.Cape Town has shown a particularly sharp increase in use over the past six years. The aim of this thesis is to establish the extent of methamphetamine use among adolescents in Cape Town, and to investigate mental health problems and sexual risk behaviour related to methamphetamine use among adolescents. In addition the study aimed to establish whether methamphetamine use is associated with not continuing to attend high school. The results of the thesis are presented through five journal articles, which address the above aims. The articles are based on two quantitative high school surveys and an ongoing surveillance of substance abuse counselling and rehabilitation centres in Cape Town. Findings in the first paper in Chapter 3 indicate that the proportion of individuals seeking substance abuse treatment for methamphetamine related problems increased steadily from 2004 to 2006 and that in 2006 73% of adolescents in treatment for substance abuse reported methamphetamine as their primary or secondary drug. Findings of the high school surveys in Chapters 4-7 indicated that between 9% and 12% of high school students (mean age = 15) reported life-time use of methamphetamine. The second and fourth papers in Chapters 4 and 6 indicated associations between methamphetamine use and sexual risk behaviour, particularly for students who reported recent use of methamphetamine. The third paper in Chapter 5 indicated associations between methamphetamine use in the past year and mental health problems among adolescents, including aggressive behaviour, depression and higher scores on a composite measure of mental health. The fifth paper in Chapter 7 showed that life-time methamphetamine use in addition to other substances was significantly associated with high school nonattendance when other non-substance use factors (repeating a year at school and being older than the norm for current grade) were taken into account. This thesis clearly demonstrates that methamphetamine use is a significant problem in Cape Town, and that developing strategies to curb and address this problem should be given priority. The thesis presents among the first and most comprehensive studies on adolescent methamphetamine use and associated problems internationally, and to our knowledge the first publications on this problem among adolescents in Africa. For South Africa, and Cape Town in particular, the greatest concern remains the associations between methamphetamine use and sexual risk behaviour, leading to an increased exposure to HIV. Further prevention efforts targeting both methamphetamine use and sexual risk behaviour should be a high priority for government and community based prevention efforts.

The HIV/AIDS pandemic has a substantial impact on children across the globe and particularly in sub-Saharan Africa. Across sub-Saharan Africa, there are a number of organisations and programmes providing care and support to children affected by HIV/AIDS. However, this strong programmatic focus on mitigating the impact of HIV/AIDS on children at community level has not been matched with concomitant research investment into the needs of children who attend these programmes at these organisations, their health and development, how these organisations work, and whether they are effective. This thesis attempts to address this gap by reporting on three separate analyses of data from the Child Community Care study in South Africa and Malawi, and a systematic review on interventions to improve psychosocial wellbeing of this group. The first analysis describes developmental outcomes of children affected by HIV/AIDS attending community-based programmes and the types of services these children are receiving. The second analysis reports on the mental health of carers of children affected by HIV. In the third analysis I report on the relationship between different forms of violence and mental health status among children affected by HIV/AIDS in the sample. The fourth part is a systematic review of interventions developed to improve the psychosocial well-being of children affected by HIV/AIDS, published between January 2008 and February 2016. The results of these studies highlight the complex needs of children affected by HIV/AIDS attending these organisations. CBOs are reaching a vulnerable group of children and their families, and are well-placed to intervene with this population. There are promising models of interventions available, although the evidence base remains small. Caregivers should not be neglected in programming; parenting programmes provide a potential mechanism for delivering integrated interventions that address multiple risk factors for caregiver and child wellbeing. Mental health, particularly of caregivers, should be explicitly addressed as a part of CBO programming. However, funding for programming needs to be implemented with opportunities for training and supervision. In addition, there is a need for increased partnerships between practitioners and researchers in order to evaluate existing programmes and to design evaluation studies that suit community settings, and that can feed into the growing evidence base.

Includes abstract. / Includes bibliographical references. / NGO literature is widely dispersed in numerous publications and often laborious to find. This article attempts to enhance understanding of development NGO performance by collating and discussing influencing factors. A systematic review of academic journal articles, published between 1996 and 2008, identified 31 relevant papers. Findings on facilitators and constraints are presented then discussed from a rational choice perspective. The article argues that NGOs are influenced by an intricate web of factors, and puts forward three main standpoints NGOs utilise in making decisions. Depending on one's perspective, NGO action can be interpreted as either rational or irrational behaviour.