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  • Second the intervention was delivered by community volunteer

    2019-06-14

    Second, the intervention was delivered by order diprenorphine volunteers and administered through a local non-governmental organisation (NGO) that was committed to ongoing community involvement. Intervention success is dependent on quality. In this Ugandan trial, quality was enhanced by the reputation, maturity, and education of the volunteers (mean age 36 years and mean education level eighth grade), a 14 day training period, and weekly supervision by NGO staff, including direct observations of 50% of the sessions. The attention to quality might have ensured the fidelity of the intervention delivery, with the professional support from the NGO to manage resistance or unanticipated events. Third, the intervention was offered to the entire community through a population-based approach, irrespective of maternal depressive symptoms or enrolment in the protocol. Evidence from prevention science suggests that reduction of the mean level of population risk factors can be more effective than the targeting of a vulnerable minority of high-risk families. In the Ugandan trial, the population-based group session format might have increased acceptance and facilitated a change in parenting norms, as friendships formed and social support was enhanced. Finally, one of the most innovative features of the study was the family focus, with sessions for fathers, sessions about mother–father communication, and men as community volunteers (seven of the 13 volunteers were men). Research across Africa has shown that children\'s access to school and their academic success are dependent on supportive and engaged families. If the study improved couple relationships, which in turn resulted in better maternal wellbeing and parenting practices, child development could have been improved through enhanced family interactions. The findings from this intervention have shown that family perspective can effectively promote children\'s development, halt the progression of maternal depressive symptoms, and alter the underlying parenting and maternal care practices. The involvement of community volunteers in promoting maternal mental health is consistent with activities promoted by Africa Focus on Intervention Research for Mental health (AFFIRM), a collaborative research group that is attempting to narrow the treatment gap for mental health problems in Africa. Evidence from a meta-analytical review of programmes delivered by community health workers in low-income and middle-income countries suggests that perinatal depression can be reduced. Community volunteers have been successfully incorporated into the health-care system in many low-income and middle-income countries, including Uganda, where task shifting has been informally adopted. However, the absence of unified policies, assessment, and incentives, together with concerns about the sustainability of an unpaid work force highlight the need to clarify the roles of community volunteers.
    There is a strong relationship between socioeconomic factors and health outcomes. These links are so well established that there is very little debate among researchers about their existence. However, there are a couple of important exceptions, including the link between education and HIV. In 2002, a systematic review of studies found that education was either not associated or was positively associated with HIV status, suggesting that more education might actually increase exposure to the virus. A much larger 2008 review found that, although education and HIV were positively associated in earlier years, the disease burden now disproportionately falls on the less educated. This finding is in line with a study from Uganda in which the authors reported that more educated girls were better able to take steps, such as using condoms, to protect themselves against infection. Although many of these studies report important correlations, to be able to say that increased education actually protects against HIV infection, investigators should also attempt to show a causal relation. However, education is also correlated with a host of other factors such as family background, income, and geography and so moving from correlation to causal statements has been challenging.