Agincourt Child Health and Resilience Project

1. Agincourt Child Health and Resilience Project Mercy Hlungwani University of the Witwatersrand. SA Mina Fazel Oxford University. UK

2. Outline of the Presentation • Background, Area • Context • Pilot study • Planned Intervention • Current Status and Future • Acknowledgements

3. Agincourt Health & Demographic Surveillance System (DSS) • Involves continuous demographic monitoring of a geographically-defined population, with timely production of data on all vital events (births, deaths and migrations) Additional information may be collected on: verbal autopsies, morbidity and disability, pregnancies & partner relationships, economic and social activity, lifestyle etc Baseline census 1992; annual update rounds births, deaths, in- and out-migrations • 2003 study population: 21 villages with ~70,250 people in ~11,650 households

4. Agincourt study site • Rural but densely settled • ~30% Mozambican • Education to primary, most secondary, few 3o • High unemployment • High labor migration • Arid, no subsistence farming • Poor water and sanitation • Health center, five clinics, 3 district hospitals 25-60 kms away

5. Border region of Southern Africa

6. Agincourt Study Site

7. Agincourt Villages

8. Research framework • Health, population and social transitions • Measuring and monitoring • Investigating • Responding

9. Program focus Societies in transition Impact on vulnerable groups Measures to offset/overcome these impacts “promoting resilience in transitioning societies”

10. Resilience • Resilience is defined as: “The human capacity to face, overcome and be strengthened by or even transformed by the adversities of life” (Grotberg, 2005)

11. Aim of project To develop and evaluate a sustainable school-based intervention to deliver to primary school children that decreases emotional and behavioural problems, encourages resilience and improves the school environment.

12. Specific objectives • To deliver a primary prevention programme for all school children with special attention to the most vulnerable groups • To develop an evidence-based intervention that will be replicable and sustainable • To promote healing from trauma as measured by increased awareness of the impact of trauma on mental health by teachers and children and a reduction of symptoms in the children at the schools • To promote prosocial skills by helping children build coping skills and improve emotional intelligence • To measure short and long-term outcomes in the children and schools/communities • To develop a curriculum suitable for integration into the ongoing school context through teacher participation and curriculum development • To develop a culturally appropriate intervention that builds on inherent community strengths

13. Hypotheses • A school based programme using teachers as the key mediators can have a positive impact on the emotions and behaviour of children, improve their resilience and social skills and also improve the school climate and general school performance • An intervention at both the individual and school level will have greatest effect • Continuation with this intervention will have positive impacts on the life skills of the children, on the school and the community in general

14. context • A rural setting • Children exposed to chronic and ongoing adversities; in particular children whose lives are affected by the escalating HIV/AIDS pandemic. (living with chronic illness, dying, bereavement, orphans, economic deprivation, multilevel vulnerabilities caused by the pandemic, prime age adults, needs of children easily overlooked) • Agincourt DSS site has unique opportunities for accessing data from the past, present and future also provides a population context to the school data • International partnership to build on the combined expertise on the best understanding in terms of mental and public health

15. Diverse, Experienced Partnership • Agincourt Primary Schools • Education District and Circuit Offices • Linc Office • Wits School of Public Health • Oxford University Child Psychiatry • Harvard School of Public Health

16. Strong Theoretical Foundation • Innate strength and resiliency of youth • Social learning Theory • Emotional Intelligence Theories • Understanding the role trauma, grief and loss play in the choices children make and in social and cognitive development

17. Link between Violence Exposure and Chronic PTSD with: • Substance Abuse • Reckless Behavior • High-risk Sexual Behavior • Gang Participation • Disturbances in Academic Functioning Kilpatrick, Saunders & Resick, 1998

18. Pilot Study • Needs identified by teachers and district office • Two Schools –Primary and High School • Number of Children • Strenghts and Difficulties Questionnaire -Teacher Completed questionnaire • Psychological functioning of children • validated

19. What is the SDQ? • Behavioural screening questionnaire about 3-16 year olds.  • Exists in several versions to meet the needs of researchers, clinicians and educationalists • Each version includes between one and three of the following components: A) 25 items on psychological attributes B) An impact supplement C) Follow-up questions

20. 25 items on psychological attributes • All versions of the SDQ ask about 25 attributes, some positive and others negative.  These 25 items are divided between 5 scales: 1) emotional symptoms (5 items) 2) conduct problems (5 items) 3) hyperactivity/inattention (5 items) 4) peer relationship problems (5 items) 5) prosocial behaviour (5 items)   Added together to generate a total difficulties score (based on 20 items)

23. Planned Intervention • Intervention will be a primary intervention • Focus on both education and mental health • Focus on the whole primary school climate/ethos • Develop a generic framework that can be replicated in different contexts and allow flexibility to ensure that existing community and individual assets and cultural strategies can be incorporated • Develop a conceptual framework/theoretical model incorporating the range of theoretical perspectives on how to promote children’s resilience in context of ongoing life stressors on a background of various levels of cumulative disadvantage • Capturing a critical time in development and transition of a society • Incorporate relevant stakeholders

24. Intervention Plan Components • In-class Curriculum • Parent Involvement • Staff Training • School Based Counselor • Community Service • Infrastructure/School Climate Assessment • Monitoring and evaluation

25. Outcome Measures • School measures • Individual measures • Teacher measures • Community measures

26. Current Status and Future • International team established • Community networks established • Planned meetings and workshops • Intervention schools and control schools • Funding

27. Acknowledgements • Prof SteveTollman: member of research and trouble shooting team, supporting proposal development, enable the project within Agincourt, Wits and SA • Dr KathyKahn: involved in supporting intervention development, strategy, access and relevant developments within Agincourt. Assist on working out the budget. Finding synergies with the child development project that is also in its development phase. • Mark Collinson: leader of DSS on the ground, including managing the DSS team to facilitating and conducting data processing, data requests and secondary data analysis. • Prof Deborah Prothrow-Stith: member of research and trouble shooting team, support intervention development and finding funding opportunities, facilitate proposal development, supporting Mercy and Rhian in career development • Prof AlanStein: member of research and trouble-shooting team, facilitate proposal development and finding funding opportunities • Rhian Evans: contact person on Agincourt site, helping collecting some local information, facilitate contacts with schools and key education people, link role and member of the research team, inform to the communities and link back to communities