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early prevention. Based on existing evidence on the engaging and encouraging parental education in areas which
usefulness of dolls in counselling with children, it may also are traditionally difficult for parents to handle.
provide children with a valuable tool for expressing concerns
about emerging risks to which the child is exposed, which Limitations of the study
they feel afraid to disclose, but may disclose inadvertently
through play. 51,52 For example, illustrating to the parent Limitations include that sample size was small and context-
through projective play concerns about bullying at school or specific, thereby limiting generalisability. The sample was
undisclosed sexual abuse. also restricted to mothers, a practical decision because as
mentioned previously, children in rural South Africa are
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In contexts of parental HIV in South Africa, there is very mostly raised by their mothers. Hence, we are not able to
little information on what practical support mothers may determine whether fathers would find such approaches
need to support them in optimising health education with helpful or appropriate. However, Amagugu is easily adapted
24
their children. 11,24 This study provided novel insights into to target fathers and other family members if it were
the type of informational needs the mothers themselves demonstrated to be acceptable to them.
identified to be important for their children as they entered
into adolescence. This included requests for more An additional limitation was that because the data in this
information on family, moral development and aspirations evaluation study were based on self-report, social desirability
for the future, in addition to information on health and sex. bias may have influenced the responses of the mothers
This is an original finding as prior evidence has mainly been regarding health communication and the usefulness of the
restricted to its exploration of parent-led educational topics materials in achieving behavioural change towards increased
to the domain of sexual and reproductive health. 50,53 In communication. The Amagugu evaluation is thus limited in
comparison, our results, which allowed parents to use an its ability to determine the extent to which the intervention
open-ended question to define the topics, illustrate the materials or activities played a direct role in changing
importance of considering a more value-based approach to parental behaviours. This is because the data on disclosure
health education because this emerged as a parental priority and communication outcomes were not measured objectively,
and preference. Interventions which are responsive to this and there was no control group. However, the descriptive
parental desire may benefit from increased engagement and findings of the analysis do suggest that the intervention
motivation amongst parents to undertake what can be a materials in their current form helped to improve the
challenging task. mothers’ capacity for health and sex education, contributing
to their (the mothers) capacity for making behavioural
It is important to consider these parental preferences within changes towards increased health communication. It is
the context of South Africa and the culture of the study thus plausible to infer that potentially the content and
population. The black South African Zulu population have a activities of the package could have led, at least in part, to the
sense of pride in traditional values which emphasise morality. increased rates of disclosure and health education that were
Broadly, in African cultures, values emphasise collectivist reported at the end line assessment. This is particularly so
consciousness where the value of the individual (self- because additional research on the Amagugu intervention
achievement) is not as important as the value of one’s using a randomised controlled design has since, indeed,
relationship with others and how it contributes to a collective demonstrated efficacy in changing parent behaviour towards
or societal achievement, known as ‘Ubuntu’ which represents disclosure and health promotion. 24
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a moral philosophy of life. This may explain why mothers
considered the moral developmental of children as important
requesting material on topics about the importance of family, Recommendations
culture and traditions, as well as education. With regard to A long-term follow-up study, when the children in the sample
the latter, it is also possible that given the South African will reach adolescence, would provide further information
history of exclusion and discrimination, parents would be about whether Amagugu is an effective intervention for HIV
particularly motivated to ensure that their children succeed prevention in later life. Moreover, studies should be
in post-apartheid South Africa. 55 conducted to ascertain whether these findings are replicated
in other population settings. National surveys such as the
Practical implications National Attitudes Survey could help illuminate parental
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perceptions in this area and determine broader acceptability.
The under-utilisation of caregivers in health education and A partial economic evaluation should be conducted to make
disease prevention in current approaches is a missed a stronger case for investment in prevention at home.
opportunity. These findings provide insight into how
parental capacities can be strengthened in a cost-effective Conclusion
way which may guide both researchers and policy makers.
Targeting mothers in the home context has the potential to be This study provided valuable information on what HIV-
a feasible and cost-effective point of entry for intervention in positive mothers need to support their HIV-uninfected
early prevention of disease. Specific tools may be useful in children’s health education as well as the type of

http://www.sajhivmed.org.za 402 Open Access