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.

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.

Includes bibliographical references (p. 299-315) / This thesis presents an evaluation of a theory-based HIV prevention intervention designed for grade 8 high school students. The intervention was delivered by teachers over a 6-month period. The objectives of the research were (i) to conduct a systematic review of evaluation studies of international and South African school-based interventions aimed at postponing sexual intercourse and increasing condom use; (ii) to conduct a process evaluation documenting implementation of the intervention; and (iii) to conduct an evaluation to assess the intervention effects on the delay of sexual intercourse and condom use. The study was conducted over a period of 15 months, using a cluster randomised controlled trial design. A multi-stage sampling strategy was employed in selecting the participating schools. Twenty-six schools located in various parts of Cape Town participated in the research, 13 in the experimental group and 13 in the control group. Process evaluation data were collected during and after implementation of the intervention. Interviews, focus group discussions, classroom observations and educator lesson logs were the methodologies employed in the process evaluation. Quantitative outcome evaluation data were collected at baseline 6- and 15-months follow-up, using a self administered questionnaire.

Includes abstract. / Includes bibliographical references (leaves 164-191). / A number of African countries have made attempts to officially recognize traditional healers as health care providers and South Africa is no exception. South Africa has made substantial progress in officially recognizing traditional medicine and its integration into the primary healthcare system. The Traditional Health Practitioners Bill and the draft policy on African Traditional Medicine are examples of this. However, there is limited data on traditional healers and their practices specifically for mental health concerns. This thesis attempts to address this gap by conducting four separate studies.

Includes bibliographical references (p. 256-311). / The 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).

Common 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.