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.

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.

Background: In South Africa and internationally, there is policy written and work done around empowering persons with disabilities to earn an income to become economically independent. Similarly, much has been written about the importance of social inclusion for persons with disabilities. However, very little is known about how persons with disabilities use education and training opportunities to advance their social capital in the South African context through being economically empowered. The ultimate goal of education is to obtain and maintain gainful employment but historically, work and disability were mutually exclusive (Howard, 2005). Ville (2005) suggests that while there are studies around the unemployment of persons with disabilities, few examine the experiences of these persons as players in their own lives. The focus of this qualitative study is to explore how persons with disabilities advance their social capital through participation in auxiliary (non-formal) education and training programmes that prepare them for employment, or as a pathway to economic inclusion or employment. This knowledge will inform training providers providing training to persons with disabilities at various levels, potential employers as well as persons with disabilities, on how skills development can include processes that would encourage both social and economic inclusion. Aim: The study aimed to critically examine the experiences of persons with disabilities who participated in the auxiliary programme to determine whether and to what extent it has strengthened and expanded their social capital to advance their opportunities for economic inclusion and/or employment. Objectives: The objectives of the study were to: • Explore how skills development programmes facilitate economic inclusion and/ or employment for persons with disabilities and why persons with disabilities engage in skills development opportunities; • Describe the profiles of persons with disabilities who undertake skills development opportunities, exploring how database information is and can be used to inform the transition to employment or economic inclusion for persons with disabilities; • Identify features of social capital evident in employers' perspectives on the employment of persons with disabilities. Methodology: An intrinsic exploratory case study design was used. Case study design provided contextual boundedness and situatedness to the research. Data was collected from databases developed and utilised by the QuadPara Association of South Africa that contained demographic and training information of participants. In-depth interviews with eight participants who had completed skills development training contributed to the understanding of the experiences of persons with disabilities in seeking employment or economic inclusion following skills development. Critical conversations with employers of persons with disabilities contributed to the understanding of the perspectives and attitudes held in the employment sector, when considering the employment of persons with disabilities. Other methods of data collection included document analysis, naturalistic researcher observations and reflections. The findings are presented as three separate papers. The first paper presents the voices of persons who have undertaken skills development training. This paper asserts that if training providers are able to recognize the determinants of social capital within their trainees, these determinants can be nurtured and developed alongside skills development in order to make their trainees more ‘employable', as well as to facilitate the transition into the labour force more smoothly. The second article argues that while it is necessary that alternative, suitable and sustainable training pathways are developed and recognized, these programmes need to build and present the prospective employee's social capital. This paper presents how information, which is used to facilitate the transition into employment can be better utilised. A database containing only demographic information is seemingly insufficient in the face of the number of barriers to employment that persons with disabilities have to overcome. The last article in this thesis speaks to the role of employers in the development of social capital. In order to further understand and promote the employment of persons with disabilities, efforts have to be made to increase social capital in all of the factors that influence the role of being a worker. To this end, individuals need to acknowledge and expand their own social capital, training providers need to support the expansion of networks and social capital through their engagements with trainees, and employers are required to look beyond the disability so that employment goals are shared and re-enforced. Conclusion: This study has uncovered that current practices related to the employment of persons with disabilities works in a very colonial, top-down fashion and seem to have been uncritically exported/imported from the Global North. This study has highlighted the absence of the African concept of “Ubuntu” - like interaction, which emphasises the self as part of others. In order to use social capital for mutual benefit, the employment of persons with disabilities must look different and have different considerations. A decolonial framework, which places less emphasis on practices used in the global North, will improve employment practices for persons with disabilities, as employers will be forced to look beyond the disability and relevant legislation only.

Background Childhood trauma (CT) has been associated with development of substance use disorders (SUDs) and severe mental illness (SMI) in community cohorts. There is a paucity of data on correlates of CT in dually diagnosed clinical populations in South Africa. We investigated the association among mono-substance use, polysubstance use and CT. Additionally, we explored demographic and clinical correlates of CT. Study aims We investigated associations between CT and SUD in patients with SMI. Setting Participants included patients aged 18–59 years with psychotic disorders attending specialist psychiatric hospital. Methods A cross-sectional study was conducted and the structured clinical interview for DSM-IV, (SCID – I) to determine SUD and SMI, and the childhood trauma questionnaire (CTQ) to measure CT were administered. Results Of the 74 patients, the mean age was 29 years (SD = 8.6) and 64% were male; 64% had schizophrenia-spectrum diagnoses, 23% had BMD-I and 14% had SIPD. Of the patients, 41% were taking no drugs, 22% were mono-drug users and 38% were poly-drug users. There was no significant difference between substance use groups in terms of age or level of education. However, those with no SUDs were significantly more likely to be female, whereas those with mono- or-poly-substance use were significantly more likely to be male. Patients with poly-SUD were significantly less likely to have been married and significantly more likely to have had a diagnosis of SIPD. There were no significant differences in CTQ scores by SUD groups. In this sample of patients with SMI, we found no significant association between CT and SUDs. Conclusion More research is needed into the effects CT has on dual diagnoses to inform treatment approaches to explore traumatic experiences.

Intimate partner violence (IPV) constitutes a major global health problem, affecting one in three women worldwide at some point during their life. IPV is particularly high in low and middle income countries (LMICs) and is associated with a wide range of adverse maternal and child health outcomes. Despite evidence that exposure to IPV affects child development and growth at birth and in infancy, there are limitations to our existing knowledge. First, few studies have considered the impact of maternal emotional IPV separately on child outcomes investigated, focusing primarily on physical and/or sexual IPV. Second, much of the existing data derives from high income countries, rather than from LMIC settings, where the majority of the world's child population lives and where many children are exposed to disproportionately high levels of poverty and violence-related risk factors. Third, there is limited information from well characterized longitudinal studies in these settings and a lack of investigation of associations in very young children, despite the fact that children under 2 years may be particularly at risk for long-term health sequelae relating to IPV exposure. Lastly, few studies have formally investigated potential mediators, inclusive of both behavioral and biological mechanisms underlying associations between IPV and food security and early-life child growth or development. In high-risk settings such as South Africa it is critical to gain improved understanding of pathways by which violence affects child health. This may be especially important given that LMIC contexts often have fewer programs in place to address IPV, and that associated mental health issues and risk factors may be different than in higher income countries. This thesis aimed to investigate IPV in a South African birth cohort, the Drakenstein Child Health Cohort, to understand better the patterns of IPV amongst pregnant and postpartum women, the impact antenatal and postnatal IPV exposure may have on their child's growth and development, and the pathways by which IPV may impact child health sequelae. Chapter 1 reviews the relevant literature, discusses key gaps and presents thesis aims and structure. Chapter 2 comprises a methods chapter which provides an overview of the study population, measures and ethical considerations. Chapter 3 (Paper 1) presents longitudinal profiles of maternal IPV exposure by sub-type from pregnancy through 24 months post-partum and associations between maternal childhood maltreatment and longitudinal frequency and severity of IPV. Chapter 4 (Paper 2) investigates the association between maternal childhood trauma as well as IPV and food insecurity among pregnant women, and examines whether maternal depression mediates these relationships. Chapter 5 (Paper 3) investigates associations between IPV sub-types and growth at birth and 12 months. Further, multiple psychosocial (substance use, depression) and clinical factors (number of hospitalizations) are tested to determine whether any of these may be mediators in the relationship between IPV and child growth. Chapter 6 (Paper 4) investigates emotional, physical and sexual IPV and their relationship with child development at 24 months of age, and whether depression or maternal alcohol dependence mediates these relationships. Chapter 7 presents a summary of findings across results chapters and includes recommendations for future policy and research. Key findings in this population show that: i) a high proportion of mothers are exposed to chronic IPV during and after pregnancy and that maternal childhood abuse or neglect is associated with higher frequency and severity of IPV exposure; ii) maternal IPV and childhood trauma are each associated with food insecurity during pregnancy and that depression partially explains these relationships; iii) emotional and physical IPV are associated with reduced fetal growth and reduced growth through infancy, and maternal substance use (alcohol or tobacco) partially explains these relationships; iv) both emotional and physical IPV are associated with poorer child development at 2 years, and neither maternal current depression nor alcohol dependence explain these relationships. Overall, the findings highlight that emotional IPV in addition to physical IPV is a key risk factor for child growth and development, and identify potential pathways underlying explored relationships. Maternal depression and substance use emerged as partial explanatory variables for nutritional outcomes, specifically food insecurity during pregnancy and growth outcomes at birth and through infancy. The high prevalence of IPV and its negative impact on child health, together comprise a major public health problem, causing significant hardship and representing a significant burden for families, economies and health systems. Findings presented in this thesis suggest that comprehensive and intersectoral programs are needed to 5 address IPV and associated adverse child health outcomes, inclusive of efforts to address maternal mental health and substance use. Further, it is also vital to ensure emotional IPV is included in training and intervention efforts. Clinical implications and areas for future research are discussed.

Introduction: Cognitive impairment is the most significant predictor of long-term outcomes in psychotic disorders, and neuropsychological assessment is therefore recommended in first-episode psychosis patients. However, the literature on neuropsychological assessment for first-episode psychosis patients in low resource settings is limited, the clinical utility of such assessments are unclear, and lengthy assessments may not be practicable in these contexts. This thesis therefore investigated 1) which brief neuropsychological assessment measures researched in patients with psychotic disorders from low and middle-income countries are appropriate for cognitive screening, 2) the differences in prevalence and profile of cognitive impairment between first-episode psychosis patients and healthy peers in one low resource setting, 3) the association of clinical variables with impairment in different cognitive domains in first-episode psychosis patients from one low resource setting, and 4) the validity of the NeuroScreen (a collection of brief neuropsychological test delivered via smartphone) for neuropsychological assessment in first-episode psychosis patients in this setting (as determined by comparison with a gold standard evaluation). Methods: First, a systematic review of articles in which brief neuropsychological assessments were researched in patients with psychotic disorders from low and middle-income countries was performed. The 2014 Working Group on Screening and Assessment (WGSA) guidelines were used as a benchmark of the appropriateness for cognitive screening for the neuropsychological assessment measures employed. Second, first-episode psychosis patients and matched healthy peers were recruited into an observational study at the National mental referral hospital in Uganda. Clinical variables were collated (including sociodemographic characteristics, dietary history, previous childhood trauma and illness severity), and after the resolution of psychotic symptoms, a neuropsychological assessment was performed using the gold standard MATRICS consensus cognitive battery. Student t-tests and chi-square tests were used to determine differences in the prevalence and profile of cognitive impairment in patients with psychosis and healthy peers. Multiple linear regression analyses were used to determined associations between clinical variables and cognitive domains while controlling for potential confounders. Finally, Pearson's rank correlation coefficients and receiver operating curves were computed to examine the validity of the NeuroScreen against the MATRICS consensus cognitive battery. Results: In the 29 articles reviewed, none of the neuropsychological measures researched in patients with psychotic disorders of low and middle-income countries was appropriate for cognitive screening according to the Working Group on Screening and Assessment (WGSA) guidelines. Neuropsychological assessment with the MATRICS consensus cognitive battery found the burden of cognitive impairment in first-episode psychosis patients six times that of healthy peers. The largest cognitive impairment burden was in the visual learning and memory domain. Increased age was associated with impairment in the domains of the speed of processing (p= 0.001). . Cassava rich diets had a negative association with cognitive impairment in the visual learning and memory domain (p=0.04). There were no significant associations between sex, history of childhood trauma or illness severity with any of the seven cognitive domains. A composite score from five cognitive domains of the NeuroScreen had a moderate accuracy of 0.79 compared to the MATRICS consensus cognitive battery. Conclusion: There is need for further research on appropriate measures for neuropsychological assessment in low resource settings. As demonstrated here, the use of such assessments may reveal modifiable risk factors for such impairment; appropriate nutrition may be a particularly important intervention for individuals with psychotic disorders in poorly resourced settings. The NeuroScreen may be useful for neuropsychological assessment of patients with psychotic disorders in low resource settings but needs modification to improve its accuracy.