Doctoral Degrees (Psychology)

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Adapting a Psychosocial Intervention to reduce HIV risk among likely adolescent participants in HIV biomedical trials
(Stellenbosch : Stellenbosch University, 2015-03) Dietrich, Janan Janine; Kagee, Ashraf; Stellenbosch University. Faculty of Arts and Social Sciences. Department of Psychology
ENGLISH ABSTRACT : In 2010, young people aged 15–24 years accounted for 42% of new HIV infections globally. In 2009, about five million (10%) of the total South African population was estimated to be aged 15–19 years. Current South African national sero-prevalence data estimate the prevalence of HIV to be 5.6% and 0.7% among adolescent girls and boys aged 15–19 years, respectively. HIV infections are mainly transmitted via sexual transmission. Adolescent sexuality is multi-faceted and influenced at multiple levels. In preparing to enroll adolescents in future biomedical HIV prevention trials, particularly prophylactic HIV vaccine trials, it is critical to provide counseling services appropriate to their needs. At the time of writing, there was no developed psychosocial intervention in South Africa for use among adolescent vaccine trial participants. Thus, the aim of the present study is to adapt and pilot-test a psychosocial intervention, namely, the Centers for Disease Control and Prevention (CDC) risk reduction counseling intervention of Project Respect, an intervention tasked at being developmentally and contextually appropriate among potential adolescent participants in HIV biomedical trials in the future. To achieve this overall aim, I qualitatively explored adolescent sexuality and risk factors for HIV among a diverse sample of participants aged 16–18 from Soweto. Thereafter, I developed a composite HIV risk scale in order to measure the variance in HIV risk among the sample of adolescents studied. The study followed a two-phased, mixed method research design and was informed by ecological systems theory and integrative model of behavioral prediction. The aim of Phase 1, split into phases 1a and b, was to conduct focus group discussions (FGDs) and to undertake a cross-sectional survey, respectively, to determine psychological (for example, self-esteem and depression), behavioral (specifically, sexual behavior) and social (specifically, social support, parent-adolescent communication) contexts that placed adolescents at risk for HIV infection. Phase 1a was qualitative, with data collected via nine FGDs: three involved parents of adolescents, four involved adolescents aged 16–18 years and two counselors. Nine key themes related to adolescent sexuality and risks for HIV acquisition were identified, namely: (1) dating during adolescence; (2) adolescent girls dating older men; (3) condom use amongst adolescents; (4) teenage pregnancies; (5) views about homosexuality; (6) parent-adolescent communication about sexual health; (7) the role of the media; (8) discipline and perceived government influence; and (9) group sex events. Phase 1b was quantitative and the data were collected via a cross-sectional survey to investigate the variance of risk for HIV. For Phase 1b, the sample consisted of 506 adolescents with a mean age of 17 years (interquartile range [IQR]: 16–18). More than half the participants were female (59%, n = 298). I used a three-step hierarchical multiple regression model to investigate the variance in risk for HIV. In step 3, the only significant predictors were “ever threatened to have sex” and “ever forced to have sex”, the combination of which explained 14% (R2 = 0.14; F (12, 236) = 3.14, p = 0.00). Depression and parentadolescent communication were added to steps 2 and 3, respectively, with both variables insignificant in these models. In Phase 2, I adapted and pilot tested the CDC risk reduction counseling intervention. The intervention was intended to be developmentally and contextually appropriate among adolescents from Soweto aged 16–18 years, viewed as potential participants in future HIV biomedical trials. Participants in Phase 2 were aged 16–18 years; the sample was mainly female (52%, n = 11) and most (91%, n = 19) were secondary school learners in grades 8 to 12. Participants provided feedback about their experiences of the adapted counseling intervention through in-depth interviews. I identified three main themes in this regard, namely: benefits of HIV testing services, reasons for seeking counseling and HIV testing services, and participants’ evaluation of the study visits and counseling sessions. The adapted CDC risk reduction counseling intervention was found to be acceptable with favorable outcomes for those adolescents who participated in the piloting phase. This study adds to the literature on risks for HIV among adolescents in Soweto, South Africa, by considering multiple levels of influence. Reaching a more complete understanding of ecological factors contributing to sexual risk behaviors among adolescents in the pilot-study enabled the development of a tailored counseling intervention. The findings showed the adapted CDC risk reduction counseling intervention to be feasible and acceptable among adolescents likely to be participants and eligible to participate in future HIV biomedical prevention trials. Thus, this study provides a much needed risk reduction counseling intervention that can be used among adolescents, an age group likely to participate in future HIV vaccine prevention research.
Barriers to and facilitators of paediatric adherence to antiretroviral therapy (ART) amongst children younger than five years in rural South Africa
(Stellenbosch : Stellenbosch University, 2015-12) Coetzee, Bronwynè Jo’sean; Kagee, Ashraf; Bland, Ruth; Stellenbosch University. Faculty of Arts and Social Sciences. Department of Psychology.
ENGLISH ABSTRACT : In the context of the limited availability of antiretroviral drugs for young children and the emergence of drug resistance, excellent adherence is required to achieve an undetectable viral load (VL) and an elevated CD4 count. However, characteristics of the caregiver, child, regimen, clinic and social context affect clinic attendance and medication-taking, both of which constitute adherent behaviour. In this thesis, through the lens of Bronfenbrenner’s Ecological Systems Theory (EST), I explored the barriers to and facilitators of ART administration to children younger than five years in a rural area of South Africa with a high prevalence of HIV. The research was conducted in two phases. Phase 1 included nine interviews and three focus groups to determine how doctors, nurses, counsellors, traditional healers and caregivers understood the barriers and facilitators to ART adherence among children residing in rural South Africa. The data were transcribed, translated into English from isiZulu where necessary, and coded using ATLAS.ti version 7. At the level of the microsystem, the unpalatability of medication and large volumes of medication were problematic for young children. The characteristics of the caregivers that contribute to poor adherence were absent mothers, grandmothers as caregivers and denial of HIV amongst fathers. At the level of the mesosystem, language barriers and inconsistent attendance of caregivers to monthly clinic visits were factors affecting adherence. At the level of the exosystem, the nature of adherence counselling and training of counsellors were the most problematic features influencing adherence. At the level of the macrosystem, the effects of food insecurity and the controversy surrounding the use of traditional medicines were most salient. I concluded Phase 1 of the thesis by recommending increased supervision and regular training amongst lay adherence counsellors, as well as regular monitoring of the persons attending the clinic on the child’s behalf. In Phase 2, I purposively recruited 33 caregiver-child dyads from the Hlabisa HIV Treatment and Care Programme database. Children were divided into three groups based on their VL at the time of recruitment. Children with a VL ≥ 400cps/ml were grouped as unsuppressed (n=11); children with a VL ≤400 cps/ml were grouped as suppressed (n=12); and children with no VL data were grouped as newly-initiated (n=10). I observed caregiver-child dyads at their monthly adherence counselling visit to document information they received from adherence counsellors. I then visited caregiver-child dyads at their households to document, by means of video-recording, how treatment was administered to the child. Observational notes and video-recordings were entered into ATLAS.ti v 7 and analysed thematically. On average counselling sessions lasted 8.1 minutes (range 2 - 18). Little behaviour change counselling was conducted, even in instances where children were doing poorly on treatment. Thematic video analysis indicated five key areas of caregiver practices that may contribute to poor outcomes. These were context-related, medication-related, caregiver-related, and child-related factors and interactions between caregiver and child. Although the majority of children in this sample took their medicine successfully, the way in which medications were prepared and administered by their caregivers was problematic. I concluded Phase 2 of the thesis by recommending that with emerging drug resistance, efforts are needed to carefully monitor caregiver knowledge of treatment administration by counsellors during monthly clinic visits.
Common mental and substance use disorders among people seeking HIV testing
(Stellenbosch : Stellenbosch University, 2017-03) Saal, Wylene Leandri; Kagee, Ashraf; Stellenbosch University. Faculty of Arts and Social Sciences. Dept. of Psychology.
ENGLISH SUMMARY: The baseline prevalence of common mental disorders (CMDs) and symptoms of distress, depression, anxiety and hazardous alcohol use prior to the receipt of a HIV diagnosis is unknown. The primary aim of this research was to determine the prevalence of CMDs, such as major depression, persistent depressive disorder, generalized anxiety, and alcohol use disorders among a sample of people seeking HIV testing. The second aim was to determine the extent of general distress among the sample of HIV test seekers. The third aim of the study was to determine the ability of the Hopkins Symptom Checklist (HSCL), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI) and the Alcohol Use Disorder Identification Test (AUDIT) to discriminate between CMD caseness and non-caseness. Utilizing a cross-sectional design, 500 participants were recruited while seeking HIV testing at five non-medical testing sites in the Western Cape, South Africa. The research version of the Structured Clinical Interview for the DSM-5 (SCID-RV) was administered to assess the CMDs. Furthermore, the extent of distress, depression, anxiety and hazardous alcohol use was assessed using the HSCL-25, BDI, BAI, and AUDIT, respectively. Descriptive statistics were used to evaluate the prevalence of CMDs and receiver operating characteristic (ROC) curve analysis was used to determine the effectiveness of the screening instruments in predicting CMD caseness against the SCID as gold standard. The results demonstrated that 28.4% (95% CI [24.45, 32.35]) of the sample had at least one common mental disorder. Elevated prevalence rates for major depression (14.4%; 95% CI [11.32, 17.48]), persistent depressive disorder (7.2%; 95% CI [4.93, 9.47]), generalized anxiety disorder (3.4%; 95% CI [1.81%, 4.99%]) and alcohol use disorder (19.6%; 95% CI [16.12, 23.08]) were reported. The results further showed that the HSCL-25, BDI, BAI, and the AUDIT were effective in identifying CMD caseness. Even the subscales of the HSCL-25 were successful in detecting most of the cases of depression (MDD, and PDD) and generalized anxiety. Of the sample, 41.2% were psychologically distressed, while 21% had moderate depression, 13.6% had moderate anxiety and 34.6% reported hazardous alcohol use. The findings of the research indicated that it is important to screen people for CMDs and distress prior to communicating an HIV diagnosis as these disorders may have a negative impact on quality of life and adherence to ART. A further contribution of the study is that the screening instruments may be used as proxies in identifying people seeking HIV testing with a CMD. Given that HIV testing and mental health services are available independently, fragmented services are provided in public health facilities in South Africa. Future research may need to focus on the integration of referral trajectories with routine screening and HIV testing.
The construction and validation of a health-related quality of life measure for women with endometriosis
(Stellenbosch : Stellenbosch University, 2017-03) Roomaney, Rizwana; Kagee, Ashraf; Stellenbosch University. Faculty of Arts and Social Sciences. Dept. of Psychology.
ENGLISH SUMMARY: The purpose of this study was to construct and validate a health-related quality of life (HRQOL) measure for patients with endometriosis. The study employed an exploratory, sequential mixed methods research design, consisting of a qualitative phase, followed by a quantitative phase. The study consisted of three aims. The first aim was to describe and understand the QOL-related experiences of women with endometriosis. This qualitative phase of the study involved in-depth, semi-structured interviews with 25 women diagnosed with endometriosis. I recorded and transcribed the interviews. I used thematic analysis to code the data and identify themes. Eleven themes emerged from the data, namely psychological functioning, sexual functioning, financial impact and considerations, healthcare and medical treatment, reproductive functioning, information and knowledge, interpersonal functioning, menstrual characteristics, occupational functioning, somatic features and physical functioning. The second aim of the study was to construct items for the instrument based on data collected during the first phase. The initial item pool consisted of 314 items. I then consulted with two experts in psychometry, who provided feedback relating to the clarity, conciseness, wording and ambiguity of items. This process resulted a reduced pool of 184 items. I asked five endometriosis experts to review the items in terms of relevance. Items that the experts regarded as highly relevant were retained in the measure and items that were not regarded as highly relevant were removed from the measure. The review resulted in the retention of 64 items. I piloted these items among seven women with endometriosis in order to assess the readability of the items. The final aim of the study was to determine the test reliability, validity and factor structure of the measure. This formed the quantitative component of the study. I administered the 64-item HRQOL measure, Endometriosis Health Profile 30, Short Form Health Survey World Health Organization Quality of Life Brief scale and the Beck Depression Inventory to 203 patients with endometriosis. I conducted an item analysis and removed 16 items that displayed corrected item total correlations below .35. I then conducted an exploratory factor analysis (EFA) on the remaining 48 in order to establish the factor structure of the measure. The factor analysis identified thirteen items that either cross-loaded on more than one factor or that did not significantly load on any factor. These items were removed. The remaining 35 items produced an eight-dimension factor structure. A second EFA produced the same factor structure. I named the measure the Stellenbosch Endometriosis Quality of life (SEQOL) measure and the named the dimensions as follows: (1) Psychological well-being; (2) Income; (3) Sexual functioning and romantic relationships; (4) Reproductive functioning; (5) Vitality; (6) Occupational functioning; (7) Menstrual characteristics and (8) Support. The SEQOL and its subscales demonstrated excellent internal consistency reliability. The SEQOL produced a Cronbach’s α of .92 and the Cronbach’s α for the subscales ranged from .72 to .88. Correlations between scores on SEQOL, its subscales and other measures indicated promising validity. The initial validation indicates that the SEQOL may be a useful assessment of HRQOL in women with endometriosis, both in research and clinical practice.
Predictors of medication adherence in people hospitalised with tuberculosis: utility of the Health Belief Model
(2021-12) Rynhoud, Leigh; Kagee, Ashraf; Stellenbosch University. Faculty of Arts and Social Sciences. Dept. of Psychology.
ENGLISH ABSTRACT: The purpose of this study was to explore the utility of the Health Belief Model (HBM) to predict adherence to treatment for tuberculosis. The first aim was to develop an appropriate, and freely available instrument to measure tuberculosis medication-taking behaviour. The final scale consisted of four self-reported questions, and one question based on information obtained from reports made by health care-providers. I named this scale the Tuberculosis Adherence Scale (TB-AS). The Cronbach’s alpha calculated for TB-AS was 0.69. The second aim of this study was to construct a questionnaire based on the HBM specific to adherence to tuberculosis medication. I administered the HBM measure to 205 participants. Following an item analysis and exploratory factor analysis, 41 items were retained, and five subscales were extracted. I named the subscales Perceived Threat, Perceived Benefits, Perceived Barriers, Self-Efficacy and Cues to Action. I named the questionnaire the Tuberculosis Health Belief Scale (TB-HBS). The TB-HBS demonstrated excellent internal consistency and produced a Cronbach’s alpha of 0.87. The Cronbach’s alpha for each subscale ranged from 0.72 to 0.81. The final aim of the study was to explore the utility of the HBM and additional variables to predict adherence to tuberculosis treatment. I used a cross sectional design and 175 participants who were hospitalised at two specialised tuberculosis hospitals in the Western Cape, South Africa were recruited. Adherence was measured using the TB-AS, health beliefs using the TB-HBS and beliefs about medicine evaluated by the Beliefs about Medicine Questionnaire, Alcohol use, drug use and depression were assessed using the Alcohol Use Disorders Identification Test, Drug Use Disorder Identification Test and Beck Depression Inventory respectively. The results obtained from the TB-AS indicated that 33.1% of participants had low adherence, 34.3% had medium adherence and 32.5% of participants had high adherence. The HBM factors did not significantly predict adherence and explained an additional 2% of variance when included in the regression analysis. Older age [  = 0.24, t (158) = 3.37, p < 0.01], full time occupation [ = 0.18, t (158) = 2.47, p = 0.01], high belief in the general harm of medication [  = 0.20, t (158) = 2.07, p = 0.04], fewer specific concerns about tuberculosis treatment [  = -0.04, t (158) = -2.11, p = 0.04], lower alcohol use [  = -0.20, t (158) = -2.76, p = 0.01], fewer symptoms of depression [ = -0.16, t (158) = -2.09, p = 0.04] significantly predicted improved adherence to treatment for tuberculosis. The results of the regression analysis indicated that the model explained 21% of the variance in adherence (adj R2 =0.21, F (3, 158) = 5.12, p< 0.01) yielding a moderate effect size (ƒ2 = 0.27). The TB-HBS and the TB-AS showed promise as reliable tools to measure health beliefs and adherence to treatment, respectively. The findings suggest that the HBM may not be an appropriate theoretical model to predict adherence to treatment in this context. Further research is recommended to explore the complex and interacting dimensions that affect adherence to tuberculosis treatment.
Testing the theory of planned behaviour in predicting condom use in eastern Ghana : a three-wave longitudinal study
(Stellenbosch : Stellenbosch University, 2014-12) Teye-Kwadjo, Enoch; Kagee, Ashraf; Swart, Hermann; Stellenbosch University. Faculty of Arts and Social Sciences. Dept. of Psychology.
ENGLISH ABSTRACT: Although young people’s sexual-risk behaviour raises public health concerns in Ghana, there is, however, little theory-guided research investigating this health problem empirically. This study tested the theory of planned behaviour’s (TPB) efficacy to explain intended condom use and self-reported condom use, using latent variable structural equation modelling. Public senior high school students (N = 684) aged 14-20 years from eastern Ghana completed measures based on the TPB’s components across three measurement occasions, spaced approximately three months apart. Consistent with the TPB, latent variable structural equation models showed that attitudes were positively associated with intended condom use over time. Subjective norms and perceived behavioural control were, however, not statistically significantly associated with intended condom use over time. Moreover, intended condom use was not significantly associated with self-reported condom use behaviour over time. Other analyses revealed that gender moderated the TPB components. These results highlight the importance of focusing adolescent sexual risk reduction programmes on intra-individual attitude formation and activation. The current data partially validate the TPB as a fairly robust model to guide the design of adolescent sex education programmes in eastern Ghana. The practical, theoretical, and the methodological implications of these results are discussed.
Willingness to participate in an HIV vaccine trial : construction and initial validation of the Willingness to Participate Scale (WTPS), and an application and extension of the Theory of Planned Behavior
(Stellenbosch : Stellenbosch University, 2008-12) Fincham, Dylan Shaun; Kagee, Ashraf; Swartz, Leslie; Stellenbosch University. Faculty of Arts and Social Sciences. Dept. of Psychology.
ENGLISH ABSTRACT: Background South Africa is the country with the largest number of HIV infections in the world. As behaviour change initiatives have been suboptimal in curbing the spread of the pandemic, an HIV vaccine is likely to be an important development as a biological agent may circumvent some of the challenges of initiating widespread behaviour change. The development of an HIV vaccine will require several thousands of HIV negative participants who are at high risk of HIV infection to participate in HIV vaccine clinical trials. Before recruitment for such trials may begin, various scientific, ethical, and sociobehavioural issues need to be considered. One of the key sociobehavioural issues concerns the willingness of individuals at high risk of HIV infection to participate in HIV vaccine trials. However, a psychometric measure of willingness to participate (WTP) has not been constructed, and there is a paucity of theory to guide studies of WTP. Objectives The first objective of this study was to construct a psychometric measure of WTP in an HIV vaccine trial, and to derive the exploratory factor structure of the measure. The second objective was to examine the extent to which the Theory of Planned Behavior (TPB) could predict variance in WTP, and to determine whether the TPB was strengthened by the inclusion of mistrust of researchers, knowledge of HIV vaccines and HIV vaccine trials, altruism, and perceived risk of HIV infection as additional predictor variables. Methodology This study was a research survey with a cross-sectional design. A convenience sample of 399 participants was recruited from an urban-informal settlement near Cape Town. As 79 of the questionnaires were poorly completed, the final sample size was 320. To develop a measure of WTP in an HIV vaccine trial, an item pool was developed whereby items directly reflected inhibitors and facilitators of WTP. After an iterative process of refinement, the final scale consisted of 35 items and was named the Willingness to Participate Scale (WTPS). A principal component Kaiser normalised exploratory factor analysis (EFA) was conducted on the items that constituted the WTPS. This procedure was performed to identify latent factors which were informed by the items of the scale. To test the predictive capacity of the TPB and the additional predictor variables, a two-step linear hierarchical multiple regression analysis was performed. At step 1, the TPB variables were entered simultaneously. At step 2, the TPB variables along with the additional predictor variables were entered simultaneously. Results The WTPS demonstrated excellent internal consistency (α = 0.90) and initial construct validity, as evidenced by the presence of seven latent factors. The factors accounted for 53.15% of the variance in WTP and were: (i) Social approval and trust; (ii) Stigmatisation; (iii) Personal costs; (iv) Personal gains; (v) Personal risks; (vi) Convenience; and (vii) Safety. The TPB significantly accounted for 6.4% (R² = 0.06) of the variance in WTP [F(3, 316) = 7.16, p < 0.001], yielding a small effect size (ƒ2 = 0.06). The TPB, together with mistrust, knowledge of HIV vaccines and HIV vaccine trials, altruism, and perceived risk of HIV infection as additional predictor variables significantly accounted for 10.2% (R² = 0.10) of the variance in WTP [F(7, 312) = 5.06, p < 0.001], yielding a small to medium effect size (ƒ2 = 0.11). Subjective norms, mistrust of researchers, altruism, and perceived risk of HIV infection were significant independent predictors of WTP. Conclusion Against the backdrop of the study limitations, the results of this study provide initial support for the reliability and construct validity of the WTPS among the most eligible trial participants in the Western Cape of South Africa. The findings also suggest that the TPB may not be an appropriate theoretical framework for predicting WTP in an HIV vaccine trial in this context. Nonetheless, normative pressure by others, mistrust of researchers, altruism, and perceived risk of HIV infection may influence WTP in this population. Implications for future research are discussed.

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