1. Health Promotion International Advance Access published April 22, 2010Health Promotion International # The Author (2010). Published by Oxford University Press. All rights reserved.doi:10.1093/heapro/daq026 For Permissions, please email: email@example.comMental health promotion initiatives for children andyouth in contexts of poverty: the case of South AfricaINGE PETERSEN1*, LESLIE SWARTZ2, ARVIN BHANA1,3and ALAN J. FLISHER41 School of Psychology, University of KwaZulu-Natal, Durban, South Africa, 2Department ofPsychology, Stellenbosch University, Stellenbosch, South Africa, 3Child, Family, Youth and Social Downloaded from heapro.oxfordjournals.org by guest on February 9, 2011Development Programme, Human Sciences Research Council, Durban, South Africa and 4Departmentof Psychiatry and Mental Health, University of Cape Town Africa, Cape Town, South Africa*Corresponding author. E-mail: firstname.lastname@example.orgSUMMARYIn order to achieve sustainable development and a conse- evidence of the role of mental health promotion initiativesquent reduction in levels of poverty, a multisectoral in mediating these inﬂuences; (ii) a background to theseresponse to development incorporating pro-poor econ- risk inﬂuences in South Africa; and (iii) a review ofomic policies in low- to middle-income countries mental health promotion initiatives addressing distal(LMICs) is required. An important aspect is strengthening upstream inﬂuences at a macro-policy level in Souththe human capital asset base of vulnerable populations. Africa, as well as evidence-based micro- and community-This should include the promotion of mental health, level interventions that have the potential to be scaled up.which can play an important role in breaking the interge- From this review, strengths and gaps in existing micro-nerational cycle of poverty and mental ill-health through and community-level evidence-based mental healthpromoting positive mental health outcomes within the promotion interventions as well as macro-policy-levelcontext of risk. For each developmental phase of early initiatives are identiﬁed, and recommendations made forchildhood, middle childhood and adolescence, this article South Africa that may also have applicability for otherprovides: (i) an overview of the critical risk inﬂuences and LMICs.Key words: poverty; South Africa; mental health promotion; childrenINTRODUCTION low- to middle-income countries (LMICs) have also contributed to increasing poverty and wealthIn high-income neo-liberal societies, increasing disparities in some countries, notwithstandingattention is being paid to the ‘modernity overall economic growth (Kothari, 1999; UNDPparadox’ whereby, in the face of wealth and (United Nations Development Programme),abundance ﬂowing from neo-liberal free market 2003). The challenges confronting the health andeconomic policies, there are increasing wealth well-being of children in these post-colonialdifferentials which are linked to health and well- emerging economies, which have inherited abeing disparities in children (Li et al., 2008). This backlog of disadvantage and have a much lowerhas implications for human development of these health and socio-economic base are, understand-nations. The adoption of similar economic pol- ably, much greater.icies that have favoured wealth creation as a South Africa is no exception. Despite anmeans to enter the global economy in many overall decline in poverty levels in South Africa Page 1 of 11
2. Page 2 of 11 I. Petersen et al.between 2001 and 2005, largely through social In the face of this negative cycle, while theregrants, post-apartheid South Africa remains one is a clear need to address the social determi-of the most unequal countries in the world, with nants or distal upstream risk factors for mentalincome inequality actually increasing over the ill-health, there is increasing evidence in LMICssame period (Woolard and Woolard, 2008). The to support the role of speciﬁc mental healthlegacy of apartheid, which created huge differ- promotion interventions in promoting moreentials in human development, measured by positive mental health outcomes through med-health, education and living standards between iating and promoting resilience within thewhites and blacks, is being perpetuated on a context of risk across the lifespan (Patel et al.,class basis, and aided by the HIV/AIDS pan- 2008; Petersen et al., 2010). Mental health pro-demic. Post-apartheid South Africa has not motion interventions during early childhoodshown substantive gains, being ranked 129th of (0– 5 years) are critical given the disproportion-182 countries on the Human Development ate impact of exposure to risk inﬂuences onIndex in 2007 (UNDP, 2009). With respect to physical, cognitive and socio-emotional devel-life expectancy, South Africa ranks among the opment relative to other developmentalworst 30 countries in the world and under ﬁve periods. The relationship of pre-existing vulner- Downloaded from heapro.oxfordjournals.org by guest on February 9, 2011child mortality, which is commonly used as a abilities to negative health outcomes is,key social indicator of overall development, however, not a linear one. Amelioration of pre-showed no improvement between 2001 and existing vulnerabilities towards healthy out-2004 (Woolard and Woolard, 2008). comes is also possible during middle childhood While health and education are at the core of and adolescence (Richter, 2006; Tomlinson andhuman development necessary for socio- Landman, 2007), and is critical in emergingeconomic development (UNDP, 2003), it economies such as South Africa where thecannot be developed in isolation from social chances of exposure to high risk inﬂuencesand political, economic, physical/infrastructural during the early critical years are much higherand natural capital development which, given widespread poverty and under-developedtogether with human capital, form the pillars of services.the sustainable livelihood developmental frame- To reﬂect the complexities and opportunitieswork (Brocklesby and Fisher, 2003). No single for preventing and ameliorating negative out-approach to addressing absolute and relative comes for each of these developmental phases,poverty in South Africa can be sufﬁcient on its this paper provides an overview of the criticalown. Helping South Africans move out of risk inﬂuences and evidence of the role of prox-poverty is complex, and requires the political imal mental health promotion initiatives inwill of government to adopt policies across a mediating risk inﬂuences during these phases asrange of sectors that will foster greater equity well as risk inﬂuences and the need for mentaland sustainable development. health promotion initiatives in South Africa. Despite the clear need for a multisectoral Adopting Bronfenbrenner’s (Bronfenbrenner,response to poverty alleviation and develop- 1979) ecological – developmental understandingment, the links between mental health chal- of the promotion of protective mediating inﬂu-lenges and poverty are commonly overlooked. ences, whereby proximal health enhancingThis is in the face of evidence that poor mental micro- and community-level processes, charac-health can impede optimal development and terized by speciﬁc mental health promotion pro-functioning and inhibit people from becoming grammes are supported by protective upstreamproductive members of society. Impaired cogni- inﬂuences dependent on distal health enhancingtive and socio-emotional development in early policy-level initiatives, the aim of this study is tochildhood traps people in a negative cycle of provide a narrative review of (i) existing policy-poor educational achievement and reduced pro- level initiatives in South Africa which addressductivity and wage earning potential which is distal upstream risk inﬂuences; and (ii) selectedtransmitted to the next generation (Grantham- evidence-based micro- and community-levelMcGregor et al., 2007). It is estimated that the interventions for each developmental phase.cognitive abilities of over 200 million children From this review, gaps are indentiﬁed and rec-in LMICs is impaired as a result of poverty ommendations made for mental health pro-associated malnutrition and inadequate care motion initiatives in South Africa which may(Grantham-McGregor et al., 2007). also have applicability for other LMICs.
3. Mental health promotion initiatives for children and youth Page 3 of 11METHOD help prevent impaired cognitive development and behavioural and emotional problems in dis-A narrative review approach was used given the advantaged children (Murray and Cooper, 2003;need to cover a wide range of issues (Educational Engel et al., 2007; Rahman et al., 2008).Research Review, 2009). In addition to a reviewof policies across multiple sectors in post-apartheid South Africa which address distal Risk inﬂuences and need for mental healthupstream risk inﬂuences, micro- and community- promotion initiatives in South Africalevel evidence-based studies were selected and In relation to upstream distal inﬂuences, post-reviewed on the basis of the following criteria: (i) apartheid South Africa inherited relatively highthe use of a scientiﬁcally rigorous evaluation levels of malnutrition in children aged 1–6 yearsmethodology, ideally a randomized control trial as revealed by a national food consumption(RCT) design using established outcome survey in 1999—21.6% of children were stuntedmeasures; (ii) other systematic review studies. and 10.3% were underweight. In addition, inadequate micronutrient intakes were reported in 50% of South African children (Bourne et al., Downloaded from heapro.oxfordjournals.org by guest on February 9, 2011 2007). Further, early childhood developmentEARLY CHILDHOOD (ECD) services were highly inequitable across the dimensions of race, location and disability,Critical risk inﬂuences and evidence of the with rural black disabled children having almostmediating role of mental health promotion no service provision (Biersteker and Dawes,programmes 2008) as a result of apartheid policies.It is well documented that poor nutrition; With regard to micro-level risk inﬂuences,exposure to toxic substances, including alcohol maternal depression appears to be particularlyuse; trauma during labour; as well as maternal high compared with other LMICs, where it isdepression and lack of stimulation can impact on estimated to be between 20 and 30% (Rahman,a child’s cognitive development and social- 2005). In Khayelitsha, a township in the Westernemotional status (Richter et al., 2010). Many of Province, 34.7% of women were found to sufferthese negative inﬂuences occur within a child’s from post-natal maternal depression (Coopermicrosystems, deﬁned by Bronfenbrenner et al., 1999) and 41% of women in three typical(Bronfenbrenner, 1979) as a child’s basic antenatal clinics in rural KwaZulu-Natal wererelationships with others. Within a child’s early found to be depressed (Rochat et al., 2006).years, distal upstream protective inﬂuences are While upstream poverty-related social conditionsthus crucial for optimum development, but need such as food insecurity, inadequate housing,to be equally supported by the promotion of unsafe social conditions, unstable income result-health-enhancing microsystem inﬂuences. ing from unemployment or under-employment It is now well established that impaired cogni- and low levels of education have been associatedtive, behavioural and emotional development in with common mental disorders includingchildren has been linked to problems in depression in LMICs (Patel, 2005), maternalparent-infant communication and attachment depression in South Africa has also beenwhich have in turn been linked both to maternal reported to be linked to a number of psycho-depression and to difﬁcult social circumstances social problems including adjusting to an HIVþ(Murray and Cooper, 2003). Infant feeding is an status, social isolation and rejection as well asinteractive process, with infants of depressed interpersonal disputes relating to paternity issuesmothers been shown to develop a ‘depressed (Baille et al., 2009).like’ style of interaction with other adults (Field Further, alcohol use in pregnancy is also aet al., 1985) which may contribute to a negative major problem in South Africa, particularly incycle of neglect. Infant nutritional programmes the Western Cape province, with one commu-may thus need to give attention to maternal nity study recording the highest rate of foetalsensitivity and responsivity to infants as well alcohol syndrome (FAS) in the world (Viljoen(Tomlinson and Landman, 2007). et al., 2005). The high rate of alcohol consump- Psychosocial treatment for depression and tion in the Western Cape can be traced back tospeciﬁc mental health programmes focusing on the ‘dop’ system during apartheid where wineparent– infant interaction have been found to was distributed daily to workers on wine farms
4. Page 4 of 11 I. Petersen et al.as part payment for labour. While this practice a home visitation programme using trainedhas been outlawed, there is a perpetuation of community-based workers to provideheavy episodic alcohol consumption (Viljoen counselling as well as a speciﬁc mother –childet al., 2005). intervention for poor women is available involving 2 antenatal and 14 postnatal visits over 6 months. It was evaluated using an RCTResults of narrative review in the Western Cape (Cooper et al., 2009). ThisMacro-policy-level initiatives addressing RCT showed good effects, improving maternalupstream risk inﬂuences sensitivity and reducing intrusiveness at 12 months post-intervention. At 18 months,Within post-apartheid South Africa, the impor- participant children were more securelytance of ECD is clearly recognized at a attached than controls (Cooper et al., 2009).macro-policy-level across a number of sectors(Richter et al., 2010). The introduction of achild support grant in 1998 for children under Programmes to reduce alcohol use inthe age of 7 years has assisted in alleviating pregnancy. While a non-randomized community Foetal Alcohol Syndrome prevention study is Downloaded from heapro.oxfordjournals.org by guest on February 9, 2011poverty and improving food security in the mostvulnerable populations (Lund, 2006), with 2.86 currently underway in the Western Cape (Parrymillion children between the ages of 0 and 4 and Seedat, 2008), no data as to the efﬁcacy ofyears being in receipt of this grant in 2007 this intervention are yet available.(UNICEF, 2007). Further, the NationalIntegrated Plan for ECD (NIP for ECD)(Departments of Education, Health, and Social MIDDLE CHILDHOODDevelopment, 2005) and the IntegratedNutrition Programme (Department of Health, Critical risk inﬂuences and evidence of theDirectorate of Nutrition, 2002) have both mediating role of mental health promotionassisted vulnerable parents and children. programmesThrough this programme: (i) nutritional policies Middle childhood is commonly understood asinvolving iodization of table salt and food sup- the period between the ages of 6–12 years andplementation have been implemented (Jooste is marked by the commencement of formalet al., 2001; Bourne et al., 2007; UNICEF, 2007); primary schooling. During middle childhood,and (ii) household food security promoted children develop new capacities in terms of cog-through the National School Nutrition nitive, emotional and social functioning whichProgramme, including the provision of food to can be impeded by poor family environmentsEarly Childhood Development Centres as well and schooling (Bhana, 2010). Secure familyas speciﬁc food supplementation programmes attachments during middle childhood arefor underweight and growth faltering important for the development of interpersonalHIV-infected children (Bourne et al., 2007). competence, as they constitute the foundation Within the education sector, post-apartheid for interpersonal relationships outside of theSouth Africa has also made considerable family. Children with insecure attachments havestrides, with the White paper 5 on ECD been found to be at increased risk of being less(Department of Education, 2001) introducing liked by peers and teachers and developingpolicy for all children to have access to a recep- greater behavioural problems than their moretion year of schooling by 2010. In the years attached counterparts (Cohn, 1990).2000–2003, although Grade R enrolment Children growing up in contexts of povertyincreased by 39% in public and independent are at risk of negative inﬂuences within bothschools, the quality of the services provided family and schooling environments. Children inremains uneven across racial and socio- low-income families have been found to beeconomic lines (Biersteker and Dawes, 2008). exposed to greater levels of violence, family dis- ruption and separation from their families thanEvidence-based micro- and community-level those from high-income families (Evans, 2004).interventions School plays an important role in children’sInterventions to promote mother – child social and learning environments. Amongattachment. One evidence-based intervention of school children, school connectedness has been
5. Mental health promotion initiatives for children and youth Page 5 of 11found to be associated with a sense of belonging migration, whereby income earners moveand positive self-esteem, internal regulation of between their rural households and their placesemotions, positive attitudes toward school and of employment or urban dwellings (Lurie et al.,motivation to achieve (Schochet et al., 2006). 1997). Post apartheid, the HIV/AIDS pandemicWhile poor schooling environments, which has added additional disruption to families.characterize many LMICs, impede the develop- South Africa had an estimated 1 400 000 chil-ment of all children, children with emotional dren orphaned to AIDS in 2007 (UNAIDS,and learning disorders are particularly disad- 2008), with children more likely to become avantaged as a result of a lack of special services maternal orphan after the age of 5. Betweento cater for their speciﬁc needs, and are at risk 1998 and 2005, there was a 135% increase inof academic failure and eventual school dropout maternal orphans aged 5– 14 years (Statistics(Patel et al., 2008). South Africa, 2006). As with early childhood, pro-poor multisec- Orphans who have lost their parents to AIDStoral development initiatives that promote distal have been found to display elevated rates ofprotective inﬂuences are crucial for optimal posttraumatic stress disorder (PTSD) anddevelopment during this phase. There is, depression, conduct problems and delinquency Downloaded from heapro.oxfordjournals.org by guest on February 9, 2011however, also evidence that speciﬁc mental when compared with controls (Cluver et al.,health promotion interventions that promote 2007) and these problems have been found toparent– child attachments and parental control be mediated by the experience of AIDS-relatedcan strengthen the protective social net afforded stigma (Cluver et al., 2008). Grandmothers, inby families during middle childhood, helping to particular, have cushioned the psychologicalcounter the conﬂuence of multiple risk elements impact of the AIDS epidemic for many orphansin contexts of poverty (McKay and Paikoff, in southern Africa (Chazan, 2008). While they2007). Further, interventions promoting school have always taken care of grandchildren inconnectedness, which involves a number of Africa, bringing up orphans in the midst of andimensions including a sense of belonging, AIDS epidemic, however, presents withschool involvement and positive school climate, additional challenges, stretching them ﬁnan-including teacher support have also been shown cially, physically and emotionally.to assist in promoting mental health during themiddle childhood years (Bhana, 2010). Results of narrative reviewRisk inﬂuences and need for mental health Macro-policy-level initiatives addressingpromotion initiatives in South Africa upstream risk inﬂuencesIn relation to schooling, post-apartheid South As with early childhood, poverty alleviationAfrica inherited a highly unequal educational policies and plans are paramount, with the childsystem across racial lines as a result of apart- support grant, which assists with poverty allevia-heid’s unequal and segregated educational pol- tion and food security in the most vulnerableicies, which ensured that the black population populations (Lund, 2006), being extended toreceived inferior and poor-quality education. children under the age of 15 years in 2005Further, while prevalence data on learning dis- (Lund, 2008). In addition, a foster care grantorders in South Africa is unknown, rates are assists in the ﬁnancial provision of orphanedestimated to be considerably greater than in children.higher income contexts (Donald, 2007). This is Within the education sector, while educationalbecause of the well-documented impact that policies ensured a rapid increase in access topoverty related poor nutrition and neglect has primary school education in the immediate post-on cognitive development, with over half of apartheid era, problems with the quality of basicSouth Africa’s children still living in conditions general educational provision remain, with Southof poverty, which persist into later life (Richter Africa performing poorly on international assess-et al., 2005; Makiwane and Kwizera, 2009). ments of achievement in mathematics, science With regard to family environments, the and literacy compared with other countries inapartheid migratory labour system severely frac- east and sub-Saharan Africa (Schindler, 2008).tured black families and has been sustained Much more work is required to ensure adequatein post-apartheid South Africa by circular basic education for all, as well as meeting the
6. Page 6 of 11 I. Petersen et al.speciﬁc needs of children with disabilities and others and exposure to new experiences. As a ¨learning disorders (McKenzie and Muller, 2006). result, peer, media and cultural inﬂuencesMainstreaming children with the full range of increase (Breinbauer and Maddaleno, 2005). Indisabilities and learning difﬁculties into the comparison to other age groups, adolescence isgeneral education system is central to contem- typically associated with a greater likelihood ofporary South African policy. There remains con- engaging in experiences and behaviour that maysiderable debate, however, as to whether this is impact negatively on a person’s life course andbeing done with the necessary support and infra- mental health. These include alcohol and drugstructure to make mainstreaming successful. abuse, non-consensual and high-risk sexual be- haviour, self-harm, interpersonal violence andEvidence-based micro- and community-level criminal behaviour (Richter, 2006).interventions Internationally, adolescents living in impover- ished areas are vulnerable to widespreadFamily strengthening programmes. One exposure to substance abuse and violence in theevidence-based programme of an effective family home, school and neighbourhood. Exposure tostrengthening programme was sourced. This violence increases the probability of youth Downloaded from heapro.oxfordjournals.org by guest on February 9, 2011programme, the Collaborative HIV/AIDSAdolescent Mental Health Programme South involvement in violence (Van der Merwe andAfrica (CHAMPSA), uses trained community- Dawes, 2007) and exposure to deviant peersbased workers as facilitators to deliver 10 family increases the likelihood of high-risk behaviourgroup sessions covering a range of topics to (Hoggs and Abrams, 1988; Coleman andmultiple family groups. An RCT in the KwaZulu- Hendry, 2002; Richter, 2006) as adolescentsNatal province demonstrated signiﬁcant impro- afﬁliated to deviant peer groups are at risk ofvements in communication and monitoring and developing a common social identiﬁcation withcontrol in the parents/caregivers receiving the these peers.intervention compared with controls (Bell et al., Salient developmentally timed mental health2008). The programme promoted the develop- promotion interventions to assist with adoles-ment of supportive networks for caregivers which cent developmental tasks and promote healthyassisted in providing greater monitoring and outcomes and build resilience in the context ofcontrol of children (Paruk et al., 2009), which is risk include building life skills and providingparticularly important in contexts of poverty health enhancing peer group opportunities andwhich can compromise the protective parent– a protective neighbourhood ecology.child relationship (Barbarin, 2003; Paruk et al., Lifeskills programmes have been found to2005). It has recently been adapted to support assist adolescents to cope with complex life situ-caregivers of HIVþ children, who are often ations, including decision-making, effectivefoster parents (Petersen et al., 2009a). interpersonal communication, self-regulation and the pursuit of goal directed behaviour (Patel et al., 2007). They assist with building aProgrammes to build school connectedness. No positive self-esteem and self-concept which inevidence-based programmes to promote school turn is associated with fewer emotional pro-connectedness or evidence of effectiveness blems, less sexual and drug-use risk behaviourstudies underway could be sourced for South and better performance in school (BreinbauerAfrica. and Maddaleno, 2005). Interpersonal and social skills training speciﬁcally have been found to assist in reducing violent and anti-social behav-ADOLESCENCE iour in youth (Van der Merwe and Dawes, 2007).Critical risk inﬂuences and evidence of the Youth participation in organized activitiesmediating role of mental health promotion outside of school such as sporting activities andprogrammes clubs has also been shown to have positive con-In adolescence, as parental inﬂuence decreases, sequences for adolescent psychological andthe acquisition of more complex cognitive abil- social adjustment and development, schoolities and socio-emotional changes associated achievement and completion and lowered rateswith individuation allow greater interaction with of smoking and drug use (Mahoney et al., 2006).
7. Mental health promotion initiatives for children and youth Page 7 of 11Risk inﬂuences and need for mental health provision of adequate housing, infrastructurepromotion initiatives in South Africa and community resources are high on SouthApartheid policies of segregation left a legacy Africa’s development agenda, they continue toof impoverished black communities in rural persist in the context of widespread poverty.areas and ‘townships’ in economically margina-lized locations with limited leisure opportunities Evidence-based micro- and community-leveland poor service delivery. Substance abuse, interventionshigh-risk sexual behaviour and violent crime are Lifeskills programmes. The HIV/AIDSall major behavioural problems among youth epidemic in South Africa triggered a plethoraliving in conditions of poverty in South Africa, of lifeskills and AIDS education programmesleading to poor health outcomes and future life for youth by Government Departments,course (Brook et al., 2006a, b; Richter, 2006; non-governmental organizations (NGOs) andVan der Merwe and Dawes, 2007). HIV inci- researchers as a means to reduce risk of HIVdence is highest in the 15 –24 age range (Rehle infection. The majority of these programmeset al., 2007). Youth who are 12– 22 years are have been implemented in schools. At a macro-twice as likely as adults to become perpetrators Downloaded from heapro.oxfordjournals.org by guest on February 9, 2011 policy level, a national lifeskills programme wasor victims of crime in South Africa (Burton, introduced nationwide in 1998 and fully2007). HIV infection is associated with implemented by 2005 (The Transitions toincreased depression and exposure to violence Adulthood Study Team, 2004).is associated with increased emotional and Despite an increased number of lifeskillsconduct problems, particularly PTSD and sub- interventions, the quality of these programmesstance misuse (Van der Merwe and Dawes, has been questioned. A systematic review of2007). school-based lifeskills programmes focusing on School dropout which is associated with these sexual health promotion in South Africa foundrisk behaviours and poor mental health out- that while some of these programmes demon-comes in youth (Townsend et al., 2007; Patel strate positive effects in relation to knowledge,et al., 2008) is a major problem among black attitudes and increased communication aboutadolescents living in impoverished, marginalized sexuality, they have had limited success inareas in South Africa (Wegner et al., 2006). It relation to youths’ perceptions of susceptibilityaccelerates from about grade 9 onwards, the to HIV infection, self-efﬁcacy, behaviouralreasons for this being manifold, including intention or actual behaviour change (Mukomarepeating classes, lack of remedial programmes, and Flisher, 2008). Programmes have beenpoor quality of interaction between teachers implemented unevenly in South Africa, withand learners (Panday and Arends, 2008), leisure those more fully implemented having moreboredom (Wegner et al., 2008) as well as chil- positive effects than those that are only partiallydren’s perceptions of their relative poverty to implemented (James et al., 2006; Mukoma andothers (Dieltiens and Meny-Gilbert, 2009). Flisher, 2008). Facilitating health enhancing peer andResults of narrative review neighbourhood contexts. Despite internationalMacro-policy-level initiatives addressing evidence for the protective inﬂuence ofupstream risk inﬂuences organized ‘out of school’ activities, except for aAt the macro-policy level, as with the earlier few NGO programmes, there are no evidence-phases, poverty alleviation policies and plans based ‘out of school’ programmes for youthare essential, with an extension of the child living in impoverished areas available.support grant beyond 14 years being phased in,starting with 15 year olds from 2010(SabinetLaw, 2009). Within the education CONCLUDING DISCUSSIONsector, the issue of school dropout requires farmore attention, with an improvement in the This review of developmentally timed mentalquality of education provided to poorer commu- health promotion interventions which have thenities being an important consideration. potential to break the intergenerational cycle ofFurther, while the eradication of slums and the poverty and mental ill-health in South Africa
8. Page 8 of 11 I. Petersen et al.suggests unevenness in macro-policy-level school dropout through improving the quality andinitiatives to address distal upstream risk inﬂu- level of educational and other services to impo-ences as well as evidence-based micro- and verished areas is paramount to promote morecommunity-level interventions to promote protective community environmental contexts.human development processes across the devel- The focus of micro- and community-levelopmental phases from infancy to adolescence. mental health promotion interventions for ado- Early childhood in South Africa, as is the lescents has been on lifeskills education, givencase internationally (Richter et al., 2010), has impetus by the HIV/AIDS epidemic. A sys-received signiﬁcant attention across a range of tematic review of these programmes in Southsectors with respect to the development of pol- Africa showed, however, that while such pro-icies to promote protective upstream inﬂuences grammes have a positive impact on knowledge,during this critical developmental phase. attitudes and communication, their impact withParticular successes in relation to policy devel- respect to actual behaviour change is limitedopment and implementation in South Africa (Mukoma and Flisher, 2008). Further, theirrelate to childcare grants, nutritional support as utility was found to be compromised by unevenwell as a commendable ECD policy. delivery, highlighting weak service delivery Downloaded from heapro.oxfordjournals.org by guest on February 9, 2011 With regard to micro- and community-level capacity within the education sector and theevidence-based programmes, one RCT study need for attention to human resource develop-provides evidence of the effectiveness of a ment to sustain such programmes.mother –child stimulation programme using A signiﬁcant gap in evidence-based interven-trained community-based workers in South tions for adolescents is the need for structuredAfrica (Cooper et al., 2009). There is a need for ‘out of school’ programmes for youth toplans within the health sector to ensure reduce leisure boredom and facilitate opportu-resources to scale up this intervention. A gap nities for more health enhancing identities.exists with respect to evidence-based interven- Studies in high-income contexts suggesttions to address alcohol use in pregnant women that they can be implemented with good effectsgiven data that at least one community in South using trained older youth as mentorsAfrica has the highest rate of FAS in the world, [e.g. (Robertson, 2008)].although one study is underway. In conclusion, this review of mental health With respect to middle childhood, at a macro- promotion interventions suggests that post-policy level, the quality of basic general edu- apartheid South Africa has made some gainscation is poor and it is unclear whether the with respect to macro-level policies to facilitateSouth African Department of Education’s more distal protective upstream inﬂuences,policy of inclusive education to address learners especially in relation to ECD. There are,with disabilities and learning disorders is however, substantial gaps across all the develop-addressing the needs of this population. There mental phases. Further, good policies are notis thus an urgent need to understand this. Lack always accompanied by commensurate goodof human resource capacity is bedevilling the practices. Human resource developmentsuccess of mainstream education (Schindler, remains key to ensuring skills and capacity in2008), let alone services for those with disabil- South Africa to deliver on the promises thatities and learning disorders. Further, in relation macro-level policies hold.to micro- and community-level evidence-based This review also demonstrates that, whileprogrammes, one RCT study provides evidence there are some gaps, micro-level evidence-basedof a family strengthening programme using interventions do exist at all three developmentaltrained community-based workers (Bell et al., phases, with gaps largely at the community2008). As with the mother –child stimulation level. In the context of scarce resources, it isprogramme, there is, however, a need for plans also encouraging to note the emerging evidenceto ensure resources to scale up such interven- from South Africa that shows that trained andtions. A gap exists with regard to evidence- supported community-based workers canbased interventions to promote school produce good outcomes. Given the shortage ofconnectedness. specialist professional categories of workers in For adolescents, the need for an acceleration of South Africa, as well as their cost, in a similarmacro-policy-level initiatives to address the vein to the call for task shifting using trainedupstream factors responsible for high levels of and supported community-based workers for
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