Page 402 - HIVMED_v21_i1.indb

Page 2 of 13 Original Research

parents to use developmentally appropriate health literacy caregivers in contexts of parental HIV in South Africa, and
11
strategies in the home setting. In turn, this could increase almost no interventions have focused on primary school-
preadolescent children’s capacity to remain free from HIV in aged children. 11,24 One maternal HIV-disclosure intervention
later life. Utilising caregivers to strengthen HIV prevention (Amagugu) focused on supporting maternal disclosure to
10
in the home during the preadolescent years, before the onset HIV-uninfected primary school-aged children has been
of the high-risk adolescent period, has substantial potential shown to be effective in improving mother-led health
but has been underexploited and under-researched in South behaviours and health promotional activities (such as taking
Africa. children to clinic to learn about health services); in improving
maternal HIV-disclosure rates; and in strengthening the
In South Africa, the predominant HIV health literacy quality of the mother-child relationship in South Africa. 11,24,25,26
strategies are implemented in school-based education This manuscript undertakes a detailed analysis of the
models which tend to target older children aged Amagugu process evaluation with the aims of (1) evaluating
14–16 years. These strategies have been moderately whether Amagugu materials improved health literacy
13
successful in targeting HIV risk behaviours and increasing leading to changes in parental behaviour towards
HIV-related knowledge in low- and middle-income communicating on topics such as HIV, health behaviours and
14
countries. However, the quality and delivery of HIV, sex education, and (2) identifying what additional
health and sex education in rural South African schools are informational needs (over and above existing Amagugu
considered to be poor, and inconsistent, as the teachers content) might be helpful for parents.
themselves often lack the capacity to fulfil this educational
role. Evidence has shown that targeting the caregiver in Methods
15
the home setting is a cost-effective response to increasing
health education, in particular, in resource-scarce settings. Study design and intervention
16
Globally, interventions which target parents in the home are The Amagugu intervention was based on a health literacy
on the increase, for example, countries such as France, the and promotion conceptual framework that was informed by
Netherlands, Australia and the United States are increasingly an extensive body of literature. In summary, the conceptual
10
focused on parental capacity as a strategy for promoting framework hypothesised that the relationship between
healthy ideas around reproductive health in young parental HIV and child outcomes was mediated through
people. 17,18 Research to date has shown that caregivers have parenting and that parent–child communication is central to
an influential role in HIV prevention and in ensuring the
optimal development of children. 8,18 improving parent-led health promotion. Specifically,
Amagugu hypothesised that non-disclosure and avoidant
coping leads to low-quality parent–child communication
Central to achieving increased health promotion by caregivers
is providing them with the necessary skills and training. which, in turn, decreases the likelihood of health and sex
Health promotion is broadly defined as a process of enabling education. These children then enter adolescence with a
people to increase control over and improve their health. diminished capacity for healthy behaviours resulting in
19
The World Health Organisation includes three key elements increased risk-taking and adverse outcomes such as HIV
in its definition of health promotion: (1) governance to ensure infection. The conceptual framework has been described in
10
the removal of structural barriers to adequate access to detail elsewhere.
health; (2) healthy cities which limit geographical hindrances
to health and (3) most relevant to this study is to ensuring The intervention model (see Figure 1) was designed to
health literacy. Health literacy refers to the knowledge, skills disrupt these risk pathways by targeting the avoidant
and information individuals need to make healthy choices behaviour, facilitating maternal HIV-disclosure thereby
and central to improving health literacy is ensuring that improving parent–child communication, and fostering
individuals have the capacity to obtain, process and parent-led health education, engagement with primary
understand health information. More recently, the literature healthcare services and custody planning for their child.
20
has begun to emphasise the need to go beyond simply Mothers were supported to disclose their HIV status to their
providing health information and to move towards ensuring child at a level with which they felt comfortable. This
capacity to change behaviour, which from a psycho-social included either ‘partial disclosure’ using the word ‘virus’, or
perspective is critical. 21 ‘full disclosure’ using the word ‘HIV’. 25,27

However, very little is available to support parent’s health Amagugu involved six home-based sessions delivered by
literacy, with many parents reporting that they feel ill- experienced lay counsellors. 11,25 Lay counsellors had
equipped to provide education to their children with HIV or completed high school, had previous counselling experience
11
22
sex education. In response, the South African National and were trained on Amagugu. The intervention package
Strategic Plan for HIV, tuburculosis (TB) and sexually (Figure 1) included low-cost, age-appropriate materials that
transmitted infections (STI) 2017–2022 has included a focus were given to the mother to use with her child. The health
on early parenting interventions to support resilience in literacy materials supported HIV disclosure and education,
children. However, these focus predominantly on the early health information on the importance of nutrition, hygiene,
23
years, while little is known about the support needs of physical activity and health promotion activities which

http://www.sajhivmed.org.za 394 Open Access