Abstract Background People with severe mental health conditions (SMHC) and caregivers in South Africa experience high rates of poverty. The PRIZE feasibility trial found that recovery groups were broadly acceptable and feasible and potentially effective in reducing relapse. Addressing economic needs was identified as a means to increase impact. This study aimed to understand experiences of financial insecurity and acceptability of poverty alleviation interventions as an adjunct to psychosocial interventions amongst people with SMHC and caregivers. Methods We conducted two focus group discussions and 12 in-depth interviews in isiXhosa with a total of 14 people with SMHC and 13 caregivers who had participated in PRIZE in Eastern Cape Province, South Africa. An inductive thematic analysis was conducted. Results We identified four major themes. Theme 1: Financial insecurity as a defining influence on life We found that financial security was crucial to recovery, through bringing status and dignity. However, participants experienced substantial financial insecurity, which impacted on social and mental wellbeing. Financial insecurity was entrenched due to fractured and violent communities, cycles of debt and stigma amongst employers. Theme 2: Government disability grants are not a panacea. Difficulties accessing disability grants included problems attending assessments and rejection of applications. Whilst they were generally welcomed, receipt of disability grants sometimes caused problems such as increased stigma and family disagreements about how the money should be spent. Theme 3: Group savings offer conditional hope if carefully managed. Several caregivers had longstanding experiences of stokvels (community-based credit unions). However, some were fearful of group members absconding with funds. Participants emphasised that trust, safety and fairness are essential for successful group savings. Theme 4: Income-generating activities are desired but need capital and come with safety concerns Many had ideas and motivation for small businesses but stressed the need for financial capital, skills training and financial literacy support. There were serious concerns that owning a business or gaining wealth could make one a target of crime. Conclusion Poverty alleviation interventions could positively impact on the wellbeing of people with SMHC and caregivers in South Africa as an adjunct to psychosocial interventions and psychiatric care. Approaches could include supporting access to social protection or existing savings groups, and nesting new savings groups or income generation initiatives into psychosocial interventions. Any model would need to incorporate robust mechanisms to ensure the safety of participants. All approaches would be enhanced by parallel social and public health interventions to build social capital and reduce violence in neighbourhoods.

Reliance on purely face-to-face in-service training for primary healthcare workers in low-and middle-income countries is increasingly unsustainable. The COVID-19 pandemic accelerated the transition of the University of Cape Town Knowledge Translation Unit's Practical Approach to Care Kit programme from a facility-based cascade model to online and blended learning formats. This paper analyses the implementation of this transition across 29 courses between 2020 and 2023 in South Africa. Using the Health System Process Goals framework, we reflect on the challenges and enablers of e-learning, shifting the focus from digital training as a standalone technical solution to a systemic enabler of health system strengthening. While e-learning expanded access and standardised content, successful implementation relied on addressing systemic barriers. Key learnings include the necessity of subsidised ('reverse-billed') data to ensure equitable access; the superiority of a'blended' pedagogical model that combines digital content with peer interaction and in-person technical support and the value of automated reporting for workforce management. The systemic barriers included the lack of protected time for learners, which risks placing an inequitable burden on the workforce and reliance on donor funding, challenging long-term institutionalisation. For e-learning to effectively strengthen the health system, it must be integrated into administrative workflows and budget lines. We provide actionable recommendations for Ministries of Health, funders and implementers, advocating for a transition to government-owned platforms, accredited blended learning models and policy that mandates protected time for capacity development.

The Community Mental Health Education and Detection (CMED) tool was designed and validated for community health workers (CHWs) in South Africa to promote mental health education, detection and linkage to care for adults at risk of mental health conditions. This study evaluated CMED scale-up using implementation research to understand reach and adoption.Routinely collected CHW data from three scale-up community areas were analysed over six months. Using the Reach and Adoption components of the RE-AIM framework, data included the (i) number of CMED administrations; (ii) proportion of identified presumptive cases; and (iii) proportion of referred cases who received care. These data identified high-and low-adopting CHW teams. Observations and repeated group discussions explored factors influencing adoption. CHWs completed 2,135 CMED administrations. Seventeen percent screened positive and were referred for further assessment at PHC facilities; 62% of those referred presented for assessment, diagnosis, and management. Adoption varied across teams. Barriers included poor data systems and inconsistent supply of mental health services. Supportive leadership and supervision were strong facilitators of adoption. Policy uptake signalled maintenance. Findings suggest the CHW-delivered CMED tool is viable and useful for narrowing the treatment gap by strengthening demand for and access to mental health services.

Despite global progress in developing integrated mental healthcare on primary healthcare level, particularly in low-and-middle income countries, descriptions of scaling-up efforts remain scarce. The aim of this study was two-fold. First, to describe a collaborative approach to embed a common mental health conditions screening tool and process within district primary health care systems in KwaZulu-Natal, South Africa. Second, to explore perceptions of participating frontline workers and policy makers of the barriers and facilitators to embedding the tool using this collaborative approach as part of a scale-up process. Following a participatory action research approach, a learning collaborative was established that involved (1) mental health service coordinators from each district of the province of KwaZulu-Natal (n = 11), (2) provincial managers and policymakers (n = 4), and (3) members of the local research team. The capacity building programme was co-developed during a series of participatory workshops, and the common mental health conditions screening tool and associated processes were implemented and workshopped iteratively. The development and implementation of this programme as part of scaling up the screening intervention was assessed drawing from workshop proceedings, individual interviews with district coordinators (n = 11), and a focus group discussion (n = 8). Data were transcribed verbatim and thematically analysed guided by the Consolidated Framework for advancing Implementation Research. The participatory development and implementation process resulted in consensus building, curriculum development, situational analyses, training, and continuous quality improvement. The collaborative and co-development approach to the capacity building curriculum was broadly favoured. Outer Settings emerged in terms of a lack of formal guidance documents for district mental health services, limited intersectoral collaboration, and limited community mental health literacy. In terms of Inner Settings, mental health continued to be under-prioritised in district services, with a lack of ring-fenced funding and data monitoring systems. Regarding Individuals, PHC staff were less well-trained and did not always want to engage in mental healthcare, with limited opportunity for capacity development. In terms of Implementation Processes, the flexibility of programme was particularly well illustrated during the disruptions of COVID-19, and adaptations were added to the programme to help address mental health and containing leadership among primary healthcare workers. While this period resulted in virtual workshops, face-to-face meetings were favoured. The scaling-up of an integrated primary mental health screening innovation requires capacity building among mid-level management, and a co-developed, collaborative programme built on continuous quality improvement provides promise in providing flexibility and communal problem-solving for more sustained implementation.

BACKGROUND:The World Health Organization's Framework on Integrated, People-Centred Health Services (IPCHS) proposes five interdependent strategies to guide health system transformation. In low- and middle-income countries (LMICs), implementation of IPCHS is often fragmented due to limited understanding of how its strategies interact in practice. Community Health Workers (CHWs), situated between households and formal health systems, offer a unique lens to examine these dynamics. METHODS:This study used a multi-phase realist approach, integrating a realist synthesis and two realist evaluations in KwaZulu-Natal, South Africa. Findings from each phase contributed to refining an initial programme theory into a dynamic, mechanism-sensitive model that captures how IPCHS strategies function interdependently. Findings were analysed using context-mechanism-outcome (CMO) configurations. Systems thinking tools, including causal loop diagrams, were used to visualise mechanism chaining and feedback loops across system levels and strategies. RESULTS:Three cross-cutting meta-mechanisms: trust, motivation, and professional legitimacy (with institutional support) were found to underpin CHW performance across all five IPCHS strategies. These mechanisms interacted recursively, meaning activation or erosion of one affected others. People-centred care is not the outcome of any single strategy but rather emerges from the alignment and interaction of mechanisms triggered by multiple strategies in different contexts. When mechanisms align, they reinforce CHW performance and advance IPCHS; when misaligned, they contribute to system fragility and poor outcomes. CONCLUSION:People-centred care is an emergent property of aligned, interacting IPCHS strategies, as opposed to isolated interventions. Further research should test and refine the proposed mechanism-sensitive approach to implementing the IPCHS framework.

IntroductionWhile antiretroviral therapy (ART) has significantly improved HIV outcomes, viral load remains unsuppressed for 6% of the people on ART globally in 2024. In South Africa, 5.7 million people are on ART, and viral load non-suppression was reported in 8% of them in 2022. Viral load non-suppression during ART is associated with health decline and HIV transmission. Weight is also a vital component for the management of HIV. High body mass index (BMI) increases the risk of non-communicable diseases, increasing the risk of multimorbidity in people living with HIV. Both ART effectiveness and obesity have been shown to be affected by socioeconomic, psychological and health related factors, but their interrelationships in South Africans living with HIV are not well known. This study aims to investigate the effects of socioeconomic and health related factors at enrolment, and their changes over time in viral load non-suppression and BMI among people receiving ART who have depression symptoms.MethodsThis was a secondary analysis of data from a randomised controlled trial of depression management in 2002 adults receiving ART. We investigated the effects of sociodemographic characteristics, comorbidities, depression symptoms (Patient Health Questionnaire-9 (PHQ-9)), functional disability (WHODAS-2.0), AIDS-related stigma and ART adherence - all measured at baseline - on viral load non-suppression (viral load ≥1000 copies/ml) and on body mass index (BMI), at baseline and on changes 12 months later, using longitudinal mixed effect logistic and linear regression models. A P-value of 0.05 or less was considered statistically significant. Potentially confounding covariates were selected and adjusted for using least absolute shrinkage and selection operator (LASSO) inference as a sensitivity analysis.ResultsPeople with viral load non-suppression at baseline were more likely to be male, younger and to earn lower income. Health characteristics associated with viral load non-suppression at baseline were previous tuberculosis, having been on ART for less than 6 months or more than 10 years, and self-reported non-adherence to ART. Higher disability score and ART duration <6 months or >10 years at baseline were associated with an increasing likelihood of viral load non-suppression 12 months later. Higher BMI at baseline was associated with being female, being married, earning higher income and hypertension, no history of tuberculosis and not having viral load non-suppression. BMI increased from baseline to follow-up, and women and younger people had greater increases in BMI 12 months later. Depression symptom scores and stigma scores were not associated with viral load non-suppression or BMI.ConclusionsThis study identified sociodemographic risk factors associated with viral non-suppression in PLWH, but most of them were not associated with further changes over time. Functional disability, however, was a risk factor with long-term implications. Younger people and women were at greater risk of BMI increasing over time. This suggests a need for ART programs to integrate long-term support services like frequent adherence assessment, mental health, rehabilitation and weight management strategies tailored to high-risk groups. ClinicalTrials.gov (NCT02407691), Pan African Clinical Trials Registry (201504001078347), South African National Clinical Trials Register (SANCTR) (DOH-27-0515-5048, NHREC 4048).

People with severe mental health conditions (SMHC) and caregivers in South Africa often experience poverty. The PRIZE trial found that recovery groups were acceptable, feasible and potentially effective in reducing relapse. Addressing economic needs was identified as a means to increase impact. This study aimed to understand the acceptability of poverty alleviation interventions as an adjunct to psychosocial interventions.We conducted two focus group discussions and 12 in-depth interviews with 14 people with SMHC and 13 caregivers in Eastern Cape Province, South Africa. An inductive thematic analysis was conducted. We identified four themes. 1: Financial insecurity as a defining influence on life. Participants perceived financial security as crucial to recovery. However, financial insecurity was entrenched due to violence in neighbourhoods and fractured communities. 2: Government disability grants are not a panacea. There were difficulties accessing disability grants. Whilst welcomed, they sometimes caused problems such as family disagreements about how the money was spent. 3: Group savings offer tentative hope if carefully managed. Several caregivers had experiences of community-based credit unions. However, some were fearful of members absconding with funds. Participants emphasised that trust, safety and fairness are essential for successful group savings . 4: Income-generating activities are desired but need capital and come with safety concerns. Many had ideas and motivation for small businesses but needed financial capital. There were concerns that gaining wealth could make one a target of crime. Poverty alleviation interventions could positively impact the wellbeing of people with SMHC in South Africa as an adjunct to psychosocial interventions and psychiatric care. Approaches could include supporting access to social protection or existing savings groups, and nesting new savings groups or income generation initiatives into psychosocial interventions. Any model would need to incorporate mechanisms to ensure participants’ safety and would be enhanced by public health interventions to build social capital and reduce violence.

Background Community Health Workers (CHWs) are central to South Africa’s primary health care (PHC) reforms yet remain under-recognised as actors who can coordinate care across sectors. This paper reconceptualises CHWs as boundary spanners and presents a realist-informed Theory of Change (RiToC) to support this shift. Methods We conducted a qualitative realist-informed conceptual synthesis, drawing on four interlinked data sources: a realist synthesis of CHW studies from sub-Saharan Africa, a realist evaluation of CHW-household interactions, a realist evaluation of a collaborative governance platform, and a systems-level reframing of the WHO Integrated People-Centred Health Services (IPCHS) framework. Insights were synthesised into a RiToC to guide how CHWs can be supported to perform integrative functions across health, social, and governance systems. Findings: CHWs already perform relational and coordinative functions that connect communities with clinics, social services, and local governance structures, though these roles are often informal and under-recognised. We identify seven strategic levers to strengthen CHWs’ capacity as boundary spanners: layered accountability, shared ownership, equitable resourcing, multisectoral training, professional recognition, adaptive models, and multisectoral integrated tools. The RiToC provides a roadmap for embedding CHWs into PHC reform and multisectoral governance by clarifying enabling conditions and mechanisms that support them as boundary spanners who can deliver IPCHS. Conclusion CHWs are already de facto boundary spanners. Unlocking their potential requires redesigning systems and policies to support their roles across sectors. Methodologically, this study advances RiToC as an innovation that combines explanatory depth with practical design, offering a transferable approach for strengthening community health systems in complex settings.

The global mental health (GMH) field aims to equitably improve mental health and well-being everywhere. This article reviews persistent common challenges hindering sustained, high-quality delivery of mental health and psychosocial support (MHPSS). Our focus is on programming that is funded or implemented by external organizations, typically universities or international non-governmental organizations from high-income countries. It is a consensus statement of MHPSS practitioners, programmers and researchers working for these organizations and some who are locally based who observe these programs in action. We comment on progress to date, barriers and recommendations for change and the importance of promoting sustained integration of MHPSS into health and social service systems through a comprehensive, recovery-oriented system of care. We call for prioritizing often-neglected issues (e.g., stigma, severe mental health conditions and neurodevelopmental conditions), strengthening workforce training and supervision and monitoring and evaluation systems to ensure program quality. The continued dominance of the Global North in shaping GMH programming priorities remains a concern. We advocate for a greater involvement of local workers and communities in agenda-setting for programs, culturally grounded implementation and long-term capacity building. Evidence-based practices must be met with contextual relevance, and comprehensive guidelines for sustained support are needed for development settings. For persistent funding challenges, we recommend clearer funder objectives, investment in in-house mental health expertise and funder coordination with prioritization of complementary programming. These recommendations are essential to realizing equitable, comprehensive, evidence-based and contextually grounded GMH programming.

Background: South Africa is faced with a mental health burden attributed to a large treatment gap for common mental disorders (CMDs), and a shortage of mental health professionals. Although comorbidity of CMDs with chronic diseases is common, chronic and non-communicable diseases may receive more attention than CMDs highlighting the need for contextually appropriate, culturally relevant counselling to increase access to mental healthcare for CMDs at primary health care (PHC). Aim: To explore the experiences of patients with comorbid chronic medical conditions and depression attending PHC, to inform the adaptation of an existing evidence-based lay counselling intervention developed in South Africa for human immunodeficiency virus (HIV)-positive patients. Setting: Dr Kenneth Kaunda district, North West province, South Africa. Methods: Semi-structured qualitative interviews were conducted with 16 Sestwana speaking adult chronic care patients with hypertension and HIV who screened positive for depressive symptoms using the Patient Health Questionnaire (PHQ-9), to explore their lived experiences of depression. Results: Poor understanding of depression and poor mental health literacy were highlighted. Depressive symptoms were commonly associated with social determinants including poverty, interpersonal conflict, stigma, illness and grief and bereavement. Most participants were unaware of available depression treatments. Conclusion: Psychoeducation to improve mental health literacy, cognitive behavioural interventions and problem-solving techniques using task sharing are recommended. Contribution: There is limited evidence of explanatory models for depression among this population in South Africa. To our knowledge, this is the only study that focused on a predominantly Setswana-speaking chronic care adult population with comorbid depression.

Districts are key administrative health units for implementing and scaling up community-based mental health services in low-resource settings. This chapter describes the development, implementation, and evaluation of district mental health care plans in five countries involved in the Programme for Improving Mental health carE (PRIME): Ethiopia, India, Nepal, South Africa, and Uganda. The chapter reflects on key lessons that can inform the scale-up of community-based mental health services in low-resource settings. District-level planning and delivery of community mental health care facilitates a population health approach to measuring coverage, detection, care, and individual outcomes. It enables integrated planning that links community with primary care and health management levels. It supports the integration of mental health into other general health services. It helps with collaborative planning and engagement of stakeholders. It also provides an opportunity to address both demand-side and supply-side constraints on community mental health service delivery.

Community Health Workers (CHWs) play a crucial role to support health care delivery in underserved communities. Although the value of CHWs' contributions is widely recognised, there is limited evidence on the mechanisms that enable CHWs to deliver people-centred care. Using a realist evaluation approach guided by WHO's Integrated People-Centred Health Services (IPCHS) framework, the study focused on how different contexts and mechanisms interact to align with the IPCHS strategies to shape CHWs' capacity to deliver people-centred care. This realist qualitative study was conducted in five rural communities in KwaZulu-Natal, South Africa. Data was collected through structured observations of CHWs' interactions with households; interviews with CHWs, service users, household decision makers, outreach team leaders (CHWs' supervisors), and clinic operational managers. Data was further corroborated through three focus group discussions with CHWs. Using thematic analysis and realist evaluation methods, we identified Context-Mechanism-Outcome (CMO) configurations influencing CHWs' delivery of people-centred care, followed by refinement of the programme theory and development of middle-range theories. The study identified meta-mechanisms (trust, legitimacy, and motivation) that operate across all domains of the IPCHS framework and underpin the ability of CHWs to engage communities, coordinate care, and deliver integrated, people-centred services. These meta-mechanisms are triggered within enabling conditions, notably formalized supervision, CHW integration into the formal health system, and intersectoral collaboration. However, governance gaps such as precarious employment, inadequate remuneration, poor resourcing, lack of data feedback loops, and insufficient institutional recognition of CHWs' intersectoral role undermines these interactions, resulting in the poor delivery of IPCHS. The study contributes to policy discussions by providing middle-range theories that explain how, why, and when CHW-led people-centred interventions fail or succeed. Critical findings include the need for a dynamic Integrated, Mechanism-Sensitive Model of the IPCHS and governance reforms that include structured workforce integration for adequate resourcing and intersectoral action.

Introduction The role of Community Health Workers (CHWs) in sub-Saharan Africa is critical to achieve people-centred health systems. Despite a large evidence base, there is a dearth of knowledge regarding the contextual factors and mechanisms that shape CHW performance in providing people-centred care. This study aims to map out conditions that enable people-centred care by CHWs in sub-Saharan Africa by identifying the key mechanisms and contextual factors. Methodology A realist synthesis approach was employed to explore how, why, and under what conditions CHW interventions lead to desired outcomes for people-centred care. A systematic review of the literature was undertaken from 2014 to 2024, focusing on studies conducted in sub-Saharan Africa. The review followed a six-phase process, including the development of the initial programme theory, search for evidence, evidence review and quality appraisal, data extraction, data synthesis and analysis, and refinement of the programme theory, followed by formulation of context-mechanism-outcome (CMO) configurations. Results This synthesis included 36 studies from 14 sub-Saharan African countries. In total, 101 CMO configurations were identified and condensed into 17 preliminary configurations. Specific contexts and mechanisms emerged that influence outcomes related to CHW programmes. The study identified trust, motivation, and adaptive leadership as fundamental meta-mechanisms that challenge the siloed structure of the IPCHS framework, emphasizing the need for greater flexibility to capture interactions across different strategies of the framework. Conclusion This study demonstrates that integrating CHWs into formal systems, aligning CHW-specific interventions with community-based initiatives, establishing intersectoral partnerships, and updating the IPCHS framework to incorporate adaptive leadership and feedback mechanisms can enhance the delivery of people-centred care.

The low recognition of depression in primary healthcare (PHC) remains a major obstacle to rendering adequate care for people with depression globally. This study aimed to evaluate the feasibility and potential benefit of a contextually developed multicomponent and multilevel intervention to improve the identification of depression in PHC. A pilot, four-arm, parallel-group, cluster, non-randomised controlled trial was conducted in a predominantly rural district in Ethiopia. The active interventions were allocated to three PHC facilities: (1) a core multicomponent intervention focusing on providers—a manualised training package along with system intervention (mobile application, posters, quality improvement and supervision) (Level-I/Arm I), (2) Level-I intervention plus a 4-item screening questionnaire administered by triage nurses (Level-II/Arm II), (3) Level-II intervention plus service user awareness raising (Level-III/Arm III). In the control facility, standard integrated mental healthcare (care by providers trained in the standard WHO mhGAP intervention guide) was available. The outcomes were the identification of depression and the feasibility and acceptability of implementation by PHC clinicians. Quantitative and qualitative data were collected post-intervention. Descriptive analysis and thematic analysis were used to analyse the data. A total of 21 providers (14 clinicians and 7 triage nurses) and 1659 adult outpatients participated in the study. Overall, 116 outpatients (7.0

Introduction: Reliable epidemiological data are crucial to make evidence-based decisions about youth mental health. Yet little is known about the epidemiology of child and adolescent mental health in sub-Saharan Africa. We conducted a systematic review and meta-analysis on the prevalence of mental disorders, suicidal behaviors, mental well-being and mental health awareness/literacy among children and adolescents in South Africa (SA). Methods: We searched PubMed, PsycINFO, Web of Science, Scielo.org, and Google Scholar from their inception to 19th February 2025. We performed random effects meta-analysis for all disorders that had 5 or more prevalence estimates. Meta-regressions were used to investigate factors associated with prevalence estimates. Results: We screened 12,768 records and identified 40 studies with 56 prevalence estimates for mental disorders and 30 prevalence estimates for suicidality. Across all studies on mental disorders, the pooled prevalence for all disorders was 8.53% \[6.1; 11.9\] (k=56, N=39,962), with significant heterogeneity (I^2=99.0%, Q (55) = 5467.0, p<.001). Pooled prevalence estimates for depressive disorders, anxiety disorders, PTSD and behavioural disorders were 10.1% \[4.9; 19.9], 6.7% [3.4; 12.8], 17.6% [8.5; 33.1], 3.9% [1.8; 8.5], respectively. All other disorders had 5 or fewer prevalence estimates. Pooled prevalence estimates for suicidal ideation, plan and attempt were 12.0% [7.8; 18.0\] (k=10, N=41489), 11.8% \[7.7; 17.6\] (k=8, N=39,928), and 10.3% \[6.2; 16.6\] (k=9, N=40,294), respectively. No papers reported mental well-being, quality of life, mental health literacy, mental health awareness, or cognitive impairment. It is not possible to reliably assess the mental health of SA youth due to the small number of studies, narrow focus on few disorders and heterogeneity. Conclusion: There is clear need for a reliable national survey of child and adolescent mental health in SA, using well validated instruments that can assess a wide range of disorders and mental well-being among a representative sample of young people. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This work was funded by the Stavros Niarchos Foundation (SNF) Global Center for Child and Adolescent Mental Health at the Child Mind Institute. Additional support was provided by the South African Medical Research Council. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present work are contained in the manuscript and supplementary materials.

Introduction:Unsuppressed viral load during antiretroviral therapy (ART) is associated with health decline and HIV transmission. Being overweight or obese increases the risk of non-communicable diseases, increasing the risk of multimorbidity in people living with HIV. Both ART effectiveness and obesity have been shown to be affected by socioeconomic, psychological and health related factors, but their interrelationships in South Africans living with HIV are not well known. Methods:This was a secondary analysis of data from a randomised controlled trial of depression management in 2002 adults receiving ART. We investigated the effects of sociodemographic characteristics, comorbidities, depression symptoms (Patient Health Questionnaire-9 (PHQ-9)), functional disability (WHODAS-2.0), AIDS-related stigma and ART adherence on viral load non-suppression (viral load ≥1000 copies/ml) and on body mass index (BMI), at baseline (baseline) and on changes 12 months later, using longitudinal mixed effect logistic and linear regression models. Potentially confounding covariates were selected and adjusted for using least absolute shrinkage and selection operator (LASSO) inference. Results:People with viral load non-suppression at baseline were more likely to be male, younger and to earn lower income. Health characteristics associated with viral load non-suppression at baseline were previous tuberculosis, having been on ART for less than 6 months or more than 10 years, and self-reported non-adherence to ART. Higher disability score and ART duration <6 months or >10 years at baseline were associated with an increasing likelihood of viral load non-suppression 12 months later. Higher BMI at baseline was associated with being female, being married, earning higher income and hypertension, no history of tuberculosis and not having viral load non-suppression. BMI increased from baseline to follow-up, and younger age was associated with a greater increase in BMI 12 months later. Depression symptom scores and stigma scores were not associated with viral load non-suppression or BMI. Conclusions:Viral load non-suppression was associated with lower BMI, most likely due to its effects on HIV-related illness. Viral load non-suppression and BMI were both associated with a variety of sociodemographic factors, while viral load non-suppression was also associated with disability and ART non-adherence. These findings together indicate subgroups of people with HIV who most need improved ART access and adherence support. Neither outcome was associated with severity of depression symptoms or self-reported stigma.ClinicalTrials.gov (NCT02407691), Pan African Clinical Trials Registry (201504001078347), South African National Clinical Trials Register (SANCTR) (DOH-27-0515-5048, NHREC 4048).

This paper determines the predictors of psychological well-being among nurses in NHI pilot clinics. Re-engineering of Primary Health Care and the introduction of the National Health Insurance (NHI) in South Africa increased nurses' workload. The study uses a quantitative, cross-sectional design with a sample of 36 nurses. The study used the Psychological Capital questionnaire, Maslach Burnout Inventory, General Health Questionnaire, and Job Content Questionnaire. Results indicate that self-efficacy is the only positive predictor of psychological well-being.

Background: People with severe mental health conditions, such as schizophrenia, and their family caregivers are underserved in low- and middle-income countries where structured psychosocial support in the community is often lacking. This can present challenges to recovery and for coping with additional strains, such as a pandemic. Aim: This study explored the experiences and coping strategies of people with lived experience of a severe mental health condition, and family caregivers, in South Africa during the initial stages of the coronavirus disease 2019 (COVID-19) pandemic. Setting: This qualitative study was conducted in the Nelson Mandela Bay District, Eastern Cape, South Africa, in the most restrictive period of the COVID-19 lockdown. Methods: Telephonic qualitative interviews were conducted with people with lived experience (n = 14) and caregivers (n = 15). Audio recordings were transcribed and translated to English from isiXhosa. Thematic analysis was conducted with NVivo 12. Results: Participants described negative impacts including increased material hardship, intensified social isolation and heightened anxiety, particularly among caregivers who had multiple caregiving responsibilities. Coping strategies included finding ways to not only get support from others but also give support, engaging in productive activities and taking care of physical health. The main limitation was inclusion only of people with access to a telephone. Conclusion: Support needs for people with severe mental health conditions and their families should include opportunities for social interaction and sharing coping strategies as well as bolstering financial security. Contribution: These findings indicate that current support for this vulnerable group is inadequate, and resource allocation for implementation of additional community-based, recovery-focused services for families must be prioritised.