Journal of Child and Adolescent Mental Health 2014, 26(3): 165–176 Printed in South Africa — All rights reserved

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JOURNAL OF C H I L D & A D O LES C EN T M EN T A L H EA L T H ISSN 1728-0583 EISSN 1728-0591 http://dx.doi.org/10.2989/17280583.2013.872116

Research Paper Identifying community risk factors for HIV among South African adolescents with mental health problems: A qualitative study of parental perceptions Ashraf Kagee1,*, Geri Donenberg2, Alicia Davids3, Redwaan Vermaak3, Leickness Simbayi3, Catherine Ward4, Pamela Naidoo3, and Jacky Mthembu3 Department of Psychology, Stellenbosch University, Private Bag X1, Matieland 7602, South Africa University of Illinous at Chicago, School of Public Health, 1603 W. Taylor Street, Chicago, Chicago, IL 60612 3Human Sciences Research Council, (HSRC), Plein Park Building, 69 Plein Street, Cape Town 8001, South Africa 4Department of Psychology, University of Cape Town, Private X3 Rondebosch 7701, Cape Town, South Africa *Corresponding author, email: [email protected]

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High risk sexual behaviour, alcohol and drug use, and mental health problems combine to yield high levels of HIV-risk behaviour among adolescents with mental health problems. In South Africa, little research has been conducted on parental perspectives of HIV-risk among this population. We conducted a series of focus group discussions with 28 mothers of adolescents receiving services at two mental health clinics in South Africa to identify, from their perspectives, the key community problems facing their children. Participants indicated that HIV remained a serious threat to their adolescent children’s well-being, in addition to substance abuse, early sexual debut, and teenage pregnancy. These social problems were mentioned as external to their household dynamics, and thus seemingly beyond the purview of the parent–adolescent relationship. These data have implications for the design of family-based interventions to ameliorate the factors associated with HIV-risk among youth receiving mental health services.

Introduction South Africa has the largest number of people living with HIV, estimated at 5.6 million in 2011 (Department of Health 2011). The HIV epidemic in South Africa is believed to have stabilised since 2000 (Shisana et al. 2009) and for the first time a significant decline in HIV incidence among youth aged 15–24 years of age was observed in 2009, especially among females at 60% (Rehle et al. 2010). Rehle et al. (2010) attribute this decline to increased awareness of HIV pandemic by South Africans, leading to a greater willingness to change sexual behaviour such as condom use, especially among youth. These may be responses to extensive national social and behavioural change communication campaigns, including life skills programming conducted at schools and a huge national campaign to counsel and test 15 million South Africans for HIV between April 2010 and June 2011 (which led to more than 20 million South Africans knowing their status) (Motsoaledi 2011). A similar trend has been reported in several countries in Southern Africa (UNAIDS 2011). Journal of Child & Adolescent Mental Health is co-published by NISC (Pty) Ltd and Routledge, Taylor & Francis Group

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Despite these important breakthroughs in the fight against HIV/AIDS, there are still two people becoming HIV-infected for each one who starts on antiretroviral treatment, especially among young people (UNAIDS 2011). Therefore, strengthening prevention remains a top priority to reduce HIV incidence, and youth constitute a uniquely high risk group. Various factors have contributed to the high rates of HIV/AIDS in South Africa, including sexual risk behaviours such as multiple partners, concurrent partners, inconsistent or lack of condom use (Sinha and Kiso 2008, Department of Health 2011), mental health problems (Collins and Freeman 2009) and elevated rates of drug and alcohol use (Flisher, Ziervogel and Charlton 1996). Research in the United States documents greater sexual risk taking and alcohol and drug use among teenagers in mental health care compared to their non-troubled peers (Brown et al. 1997, Donenberg and Pao 2005). Youth receiving mental health services report early sexual initiation, sex with multiple partners, and unprotected sex (Ramrakha, Caspi and Dickson 2000, Shrier et al. 2001, Smith 2001) and they experience individual, interpersonal, familial, and environmental factors that contribute to high-risk sexual behaviours (Donenberg and Pao 2005, Donenberg, Emerson and Mackesy-Amiti 2011, Donenberg et al. 2012b). Data from South African studies report similar associations among teenagers who receive mental health care (Perkel, Strebel and Joubert 1991, Brook et al. 1998, Brook, Cohen and Brook 2006, Nduna et al. 2010). For example, among South African youth, depression and stress are associated with decreased assertiveness and reduced ability to negotiate safer sex (Flisher and Gevers 2010). Hence, South African adolescents with mental health problems may constitute an important vulnerable subpopulation at risk of HIV infection. Background Sexual risk behaviour According to national surveys, the median age of sexual debut in South Africa is 17 years for both sexes (Shisana et al. 2005). Among 16 and 17 year olds, two-thirds of girls and over half of boys reported having had sexual intercourse (Peltzer and Pengpid 2006), indicating that sexual debut as a teenager is normative among South African youth. Moreover, rates of inconsistent condom use are high (Eaton, Flisher and Aaro 2003); 60% of girls and 43% of boys report not using condoms at first sex, 17% report never using a condom at all, and only 45% report always using a condom (Peltzer and Pengpid 2006). South African adolescents have also indicated high rates of non-condom use at last sex, sex with older partners (>30 years), and sex in exchange for gifts (Peltzer and Promtussananon 2005). According to the most recent national survey, adolescents “were starting sex earlier in 2008 than they were in 2005” (Shisana et al. 2009: 39). High rates of alcohol and drug use in South Africa Evidence suggests that alcohol and drug use among South African adolescents show no signs of abating (Parry et al. 2004). Surveys among high school students indicate high rates of lifetime cannabis and alcohol use among females (47.8% and 13.1% respectively) and males (66.4% and 32% respectively) (Parry et al. 2004). Moreover, South Africa has one of the highest volumes of per capita alcohol consumption worldwide (Parry et al. 2005). South African youth report using dagga (cannabis) in the past month (9%), ever having used heroin (12%), and ever having used mandrax (methaqualone) and cocaine (6% each) (Reddy et al. 2010). Secondary data analyses from the 2008 national population-based HIV household survey in South Africa revealed 3.3% cannabis use and less than 1% other drug use among 15–19 year olds (Njuho and Davids 2010). Cannabis use also increased among 13–19 year olds in Cape Town from 1993 to 2002 (Peltzer and Ramlagan 2007). The rate of adolescent admissions to substance use treatment centres significantly increased from 1997 (5.5%) to 2001 (24.1%), with cannabis as the primary drug of abuse, followed by methaqualone (mandrax) (Williams et al. 2004). Mental health problems and HIV risk While few studies have evaluated the links between mental health problems and HIV-risk in South Africa, robust evidence exists of a strong association in the United States (Donenberg et

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al. 2001, Donenberg and Pao 2005). Mental health problems are related to HIV infection and progression to AIDS through their association with increased risk behaviour (Brown et al. 1997), low levels of health promoting behaviours, low medication adherence, and reduced effects of behavioural interventions (Wagner et al. 2004). Untreated mental health problems compromise safe sex decision-making, interfere with positive interpersonal relationships, and decrease assertive communication, all of which are important to prevent HIV transmission (Brooks-Gunn and Paikoff 1997, Brown et al. 1997, Donenberg and Pao 2005). Mental health problems may range from mild to severe in South Africa, as they do in the United States, and it is likely that the associations with HIV risk are similar. Sexual behaviour, drug/alcohol use and mental health problems Studies in the United States show that the combination of mental health problems, sexual risk taking and substance use creates conditions that increase the risk of HIV transmission (Malow et al. 2006, Chasin 2008, Grisso 2008). Indeed, compared to adolescents without mental health problems, teenagers in mental health care are more likely to be sexually active, have multiple partners, and use condoms less consistently (Brook et al. 1998, Donenberg et al. 2001). Mental health problems are also associated with earlier onset and more frequent and chronic drug use (Rohde, Lewinsohn and Seeley 1996, Miller-Johnson et al. 1998). Finally, among teenagers with a mental illness, frequency of drug use is related to high-risk sexual activity (Rowe et al. 2008). In South Africa, several studies link drugs and alcohol with risky sexual behaviour, early sexual debut, and HIV transmission among adolescents (Magnani et al. 2005, Palen et al. 2006). Cannabis use, recent binge drinking, and lifetime marijuana use are also related to HIV status, multiple partners, and increased HIV risk (Taylor et al. 2003). In one study, 20% of South African youth reported cannabis use before sex (Peltzer et al. 2009), and 20% of boys and 5% of girls used drugs, alcohol or both at sexual debut (Peltzer and Pengpid 2006). In sum, South African adolescents with mental health problems may be at elevated risk of contracting HIV and alcohol and drug use are likely conduits for high-risk sexual behaviour. Understanding the role of parents in HIV risk among adolescents Extensive efforts have been made to place adolescent HIV risk within a broad social context that includes the family, community, schools and cultural context. Numerous studies underscore the important role of parents in HIV-risk reduction (Petrie, Bunn and Byrne 2006), primarily through strong parent–child relationships, effective parental monitoring, and high quality parent–child communication (Donenberg and Pao 2005, Bhana et al. 2010). Identifying and understanding parental perspectives of the mechanisms leading to adolescent risk is critical to HIV-risk reduction efforts for several reasons. First, evidence suggests that parents can play a key role in reducing adolescent risk behaviour in the US (Donenberg, Paikoff and Pequegnat 2006) and South Africa (Karim and Karim 2002, Brook et al. 2006, Camlin and Snow 2008). For example, more parental permissiveness and less parental availability are implicated in increased teen sexual behaviour, risky sex and substance use (Davis and Friel 2001, DiClemente et al. 2001, Mounts 2001, Werner and Silbereisen 2003). Similarly, warm and comfortable parent–teen communication is related to increased condom use (Moore and Chase-Lansdale 2001, Bynum 2007) including African families (Adu-Mireku 2003). Hence, enhancing these parenting approaches can reduce HIV-risk. Second, national efforts to curb new adolescent HIV transmissions in South Africa (e.g. Beyond the Awareness, Parker, Dalrymple and Durden 1998, Golstein et al. 2004) have revealed limited effects (Flisher, Mukoma and Louw 2007, Mukomo and Flisher 2008). The low impact of these campaigns may reflect their almost exclusive focus on individual-level behaviour change (Pettifor et al. 2005) and scant attention to teens’ broader social context, such as the family (Bhana and Peterson 2009). Programmes that address the family system may improve intervention effects (Donenberg, Paikoff and Pequegnat 2006). Third, in many historically disadvantaged communities in South Africa, mothers are the primary if not the only caregivers of children and adolescents. Illuminating their perspectives on the key issues affecting the health and well-being of South African youth and incorporating these into prevention programmes will facilitate parental

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engagement in targeted programmes to reduce adolescent risk. Such data will facilitate parental engagement in prevention efforts by incorporating their concerns and capitalising on parents’ firsthand knowledge of the most important areas to address in targeted programmes. The objective of this pilot study was to explore parental views regarding the most important factors associated with increased HIV risk among South African adolescents in mental health care. We identified several areas of inquiry based on previous research. We are aware of only one family-based HIV prevention intervention for youth in mental health care, namely Project STYLE (Donenberg et al. 2012b), with evidence of risk behaviour change (Brown et al. 2014). Themes identified in this study can inform the cultural adaptation of Project STYLE for South African adolescents with mental health problems. Method Participants Four groups were conducted with a total of 29 primary caregivers (aged 29 to 65 years), all of whom were women. Limited demographic information was collected from caregivers, however, 39% (N = 12) were ‘coloured’ and 62% (N = 18) were black. The term ‘coloured’ refers to the classification by apartheid legislation for people of mixed race, Malay. Khoi or San origin who are lightskinned when compared to their black counterparts. We use the term here because participants defined themselves this way. Caregivers ranged in age from 25 to 55 years (M = 44.0). Caregivers participated with their 12–18-year-old son/daughter (M = 15.0) receiving outpatient mental health services. Families were excluded from the focus groups if teens were unable to understand the assent process or if the teen’s mental illness and/or cognitive impairment prohibited the ability to function in a group setting (e.g. actively psychotic, severely intellectually disabled). No formal assessment of psychopathology was conducted, but most youth were referred for services by their schools. Both mental health clinics serve families who report a range of mental health concerns that range from mild to severe. Most of the families came from low-income neighbourhoods. Overview of procedures Study procedures were approved by the Institutional Review Boards at the University of Illinois at Chicago, Human Sciences Research Council, Stellenbosch University, and the University of Cape Town. Families were recruited from two outpatient mental health clinics, the Red Cross Children’s War Memorial Hospital in Cape Town and Empilweni-Place of Healing, a child and adolescent mental health service non-governmental organisation, based in a township on the outskirts of Cape Town. We identified a clinic liaison person at each site who contacted families, informed them of the project, and facilitated the enrolment of those interested in the study. Immediately before the focus group discussions (FGD), researchers obtained informed consent and assent from each parent/ youth. Caregivers participated in one of four FGD conducted on Saturday mornings at each site. Two FGD were conducted in the African language, isiXhosa, at the Empilweni site, and two were conducted in English and Afrikaans at the Red Cross Children’s War Memorial Hospital site. Focus group facilitators used interview guides translated into the language of the participants. FGD lasted two hours, and all participants received transport money (ZAR30) and a shopping voucher (ZAR50) for their time. Facilitator training Seven facilitators conducted the focus groups, matched for race and language. Three Afrikaans/ English facilitators conducted the groups at Red Cross Children’s War Memorial Hospital and four isiXhosa-speaking facilitators led the focus groups at Empilweni. All the facilitators had at least an undergraduate degree in psychology and previous knowledge of qualitative research methods. Before leading the FGD, facilitators participated in a three-day training session led by a member of the research team (AK). Training included didactic instruction in qualitative research theory, role plays, rehearsals and feedback. After the training, facilitators were evaluated and determined competent to conduct the focus groups.

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Focus group discussions FGD were semi-structured with open-ended questions designed to elicit a comprehensive and detailed understanding of parent perceptions of community problems linked to HIV-risk facing their adolescents. The discussions were audio recorded, translated into English, and then transcribed by trained individuals. No identifying information was included. The open-ended questions were catalysts for further discussion. Consistent with the qualitative research tradition, we began the discussions with broad questions regarding general issues and followed these with more detailed questions and probes related to participant responses. Parents were asked to explore their responses to elicit specific descriptions of their experiences and ideas. The following questions guided the FGD: 1. What do you think are the most pressing social problems facing teenagers in your community? 2. What about HIV, alcohol and drugs? To what extent are these important problems in your community? What have you heard about them? 3. How do you think mental health and HIV are related to each other, especially for teenagers? 4. How do you think alcohol and drug abuse are related to HIV, especially for teenagers? 5. Given all the problems you mentioned, what kinds of problems does your family specifically face? 6. What do you think you as parents can do to protect your children from these things (HIV, alcohol and drugs)? Each question was followed by relevant probes aimed at eliciting additional detail about the participant’s perspective. The facilitators were trained to make appropriate referrals for mental health care as needed. Overview of data analysis Transcriptions were entered into Atlas.ti 4.2 to facilitate textual analysis and interpretation, particularly selecting, coding, annotating, and comparing important segments of text. The analysis approach was template analysis (Crabtree and Miller 1999, King 2012). A coding ‘template’ was developed a priori, on the basis of the literature review, and the data were then initially coded in accordance with the template. Subsequently, additional codes were developed to describe themes present in the data but not identified in the original template. The data were then re-coded. Three members of the research team read through each focus group transcript and identified quotations pertaining to the research questions (Strauss and Corbin 1997) and agreed on appropriate codes. This reflexive process was intended to prevent distortion of the data during analysis. Findings Several themes emerged from the FGD reflecting diverse parent perspectives of the key problems facing adolescents in their communities: substance abuse as a community problem, unemployment, early sexual debut and teenage pregnancy, lack of community resources, mental health problems as a vulnerability to HIV, and HIV as a community problem. Substance abuse as a community problem related to risky sexual behaviour An isiXhosa-speaking mother who participated in a discussion at Empilweni stated that her son’s abuse of substances made him vulnerable to having unsafe sex. She stated, ‘the danger is that if he feels like he’s in heaven after smoking then under the same influence he must be feeling the same way when he is having sex, therefore increasing the chances of not using protection thus leading to HIV infection.’ Another mother in the same discussion group stated, ‘I think they (substance abuse and HIV risk) are related because they smoke (cannabis), then after that they find a place where they sleep together.’ This participant called attention to high risk behaviour such as not using a condom during sex under conditions of intoxication. She stated, ‘once they are in that drug state they don’t think about condoms...They don’t care...It’s just do it and finish…’ Another stated, ‘the situation is worse when it comes to those who drink, you find a girl drinking together with her boyfriend and after that they go to have sex without protection of a condom, they just jump into bed.’

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These quotations indicate that parents are concerned about the role of alcohol and drugs in facilitating risky sexual behaviour. A mother in the Red Cross group also stated, ‘it (crystal methamphetamine) is the main drug used’ by those teenagers who use substances. Another in the group stated, ‘I think it is the worst’. Unemployment and the lack of resources in the community In the context of economic marginalisation, as was the case for most participants, several parents implicated unemployment (and ‘nothing to do’) in youth risky sexual and drug use behaviour. Similarly, the lack of resources in their communities was also cited as a major problem. An isiXhosa-speaking participant from one of the Empilweni focus groups stated, ‘Many things are not available here. There is nothing in Khayelitsha (the township where the focus group was conducted) because if we had that Early Group Mothers these children were going to learn that a mother has to take care of her child.’ This statement was in reference to a programme that taught young mothers about effective parenting. According to another mother in the same group, the lack of resources was linked to high risk behaviour. She stated, ‘the problem is the boredom adolescents experience and because of the busyness of the parents. I feel there is not creativity…so there are no groups they can go to…so what do they do…they need to explore with drugs and sex and whatever else there is, there is just no supervision.’ For this participant, the absence of alternative activities in the community for young people, combined with a lack of employment or educational opportunities, created conditions for teenagers to experiment with sex and drugs. Early sexual debut One of the major issues to emerge from the discussions was early sexual debut as a risk factor for HIV. One isiXhosa-speaking participant in one of the Empilweni focus groups stated, ‘they (teenagers) are educated on this but they laugh it away because they are already fathers and mothers, you see.’ Another mother in one of the Red Cross focus groups indicated the opposite dynamic by stating, ‘I don’t think teenagers are really aware of (the fact) that early sexual activity can lead to AIDS.’ A mother in one of the Red Cross groups stated that at her daughter’s school, ‘she can count…she can tell me what girls are still virgins…because the rest are all…sexually active. One had a baby and came back.’ It appeared that engaging in high risk sexual activity was normative in the schools attended by children of the participants. Relatedly, the issue of intergenerational sex was also mentioned. One participant stated that the phenomenon of children in intimate relationships with older partners was a major issue in the community. Teenage pregnancy Parents stated that teenage pregnancy was also a serious concern in their communities. An isiXhosa-speaking participant in one of the Empilweni groups appeared to lay the responsibility for reproductive health solely on girls by stating, ‘all the boys in my street are good, the only problem is girls, all of them have babies.’ She appeared not to acknowledge in the discussion the role of boys in impregnating their female sex partners. The statement of another isiXhosa-speaking participant in the same focus group was telling in terms of the magnitude of the problem of teenage pregnancy. She stated, ‘all of them in that street have babies it’s like a competition. They fall pregnant despite the fact that there are contraceptives...’ Caregivers also suggested a kind of negative norming at play in the community. An isiXhosaspeaking parent in one of the Empilweni focus groups stated, ‘if your child does not have a baby they (others in the community) might say you think you are better than them. Once a child has a baby you do not want her to have the same friends.’ This statement revealed that a normative expectation for adolescent girls is to become pregnant and that teenage pregnancy is implicitly condoned. Admittedly, this was the view of only one parent. Yet, in keeping with this narrative, a caregiver in the same focus group called attention to what she regarded as a permissive attitude on the part of schools that allowed pregnant teenagers to attend. She expressed vehement disagreement with such a policy stating, ‘I do not see it as a good thing. I think it makes the problem worse.’ Another isiXhosa-speaking mother also stated that she did not believe adolescents were prepared

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for parenthood, stating, ‘our children get pregnant at that young age and when the baby is there she does not want to look after it.’ Mental health problems as a vulnerability to HIV When participants were asked whether they saw a link between mental health and vulnerability to HIV, several agreed. An isiXhosa-speaking mother in one of the Empilweni groups stated, ‘yes, it can be easy because instead of staying in the house he thinks he is escaping (from psychosocial problems) by going out there, where he might meet a partner who is infected by this illness already.’ A mother in one of the Red Cross focus groups stated, ‘their perceptions are not right or they are not healthy mentally — it’s like normal factors are going against them, they are not seeing clearly, even for them and sleeping around is just normal for them then.’ The issue of HIV risk among adolescents living with a psychological disability was critical to the participants, as all of their children were receiving psychiatric services at the time of data collection. HIV as a community problem When the discussion turned to HIV, several participants indicated that HIV was a significant community problem. An Afrikaans-speaking participant in one of the Red Cross groups stated, ‘there are women who has (sic) AIDS and so on but once they drank then the whole truth… comes out like that.’ This participant appeared to refer to the fact that alcohol lowers people’s inhibitions so that they more readily disclosed their HIV-positive status to others. Another participant in one of the Red Cross groups reflected on the way in which HIV and AIDS were thought of in her community. She stated, ‘it’s quite tough with HIV and AIDS things, it’s not an easy one because people’s mind sets and perceptions are also still so different and so wrong. You cannot touch, you cannot hug, you cannot drink from the same utensils. It’s really just sad that we still all not educated.’ This participant appeared to call attention to the stigmatisation and discrimination that HIV-positive persons experience in many communities. One participant also shared that she had a family member living with HIV, indicating that HIV was a significant personal matter for her as well as being a community matter. Willingness to address community problems When presented with the possibility of family-based programmes to enhance parent–child communication about HIV risk behaviour, the participants responded overwhelmingly positively. An isiXhosa-speaking participant in one of the Empilweni groups stated, ‘we need to get their (teens’) attention and hold their attention to talk about the important things’, while another stated in response to the possibility of a programme, ‘that would be good…because if they see…maybe they will remember that’. A mother in the same focus group who was especially concerned about the threat that HIV posed to her daughter stated, ‘I think they need to be made aware of what the consequences of HIV is…and the impact on their life…their lifespan is going to be reduced…I think they should be made aware of that.’ Another mother also called attention to the fact that her child was in some sense a captive audience. She stated, ‘so we’re speaking to them now, it’s not like they don’t know us and they can’t run away.’ It is clear from the above responses that all the participants expressed a need for action to address the range of social problems that affect their adolescent children, especially when it came to HIV risk behaviour. They also underscored the role they as parents could play in tackling these problems. Discussion In this study, caregivers of adolescents with mental health problems identified several important community problems affecting the health and well-being of their children. These were substance abuse and its relationship with risky sexual behaviour, unemployment, early sexual debut with older partners, teenage pregnancy, lack of resources in the community, mental health problems as creating vulnerability to HIV, and HIV itself. These findings closely approximate the major factors that have been identified in previous literature, for example, early sexual debut (Shisana et al.

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2005), sexual risk behaviour (Eaton et al. 2003), high rates of alcohol abuse (Parry et al. 2004), the relationship between mental health and HIV (Donenberg et al. 2001, Donenberg and Pao 2005), and underscore additional issues unique to the South African context (e.g. lack of community resources and unemployment). However, many of the issues raised by caregivers were perceived as occurring outside of the home, and thus beyond parental control. Caregivers also spoke about these social problems as external to their household dynamics, and thus potentially beyond the purview of the parent– adolescent relationship and parents’ ability to address. In this regard, the data have implications for designing and implementing family-based interventions to alter caregivers’ perceptions of strategies to reduce HIV-risk among their youth. For example, evidence supports the role of parents (e.g. more monitoring, less permissiveness, increased communication and greater attachment) in reducing risk behaviour among youth in mental health services (Donenberg et al. 2002, Donenberg and Pao 2005, Donenberg et al. 2011, Emerson et al. 2012), but the unspoken yet implicit challenge for many caregivers is to engage with these problems in ways that would create opportunities for change. South African parents of youth in mental health care may need assistance recognising how they can influence their children’s decision making and behaviour. Similarly, locating potential solutions to these social problems within existing family relationships, particularly the adolescent–parent dyad, will empower parents and leverage family strengths within a cultural context that highly values family involvement. By shifting the paradigmatic framework for potential solutions to these problems from outside the family to within familial relationships, a wider range of solutions may be sought to address negative social influences on adolescents with mental health problems. As an example, adolescent drug abuse, a serious problem in the Western Cape province where this study was conducted, would benefit from parental involvement and complement the efforts of existing substance abuse programmes. Yet, the sense of parental disempowerment must be interpreted in the context of Cape Town’s high-risk environment, characterised by social marginalisation and resource-constraints. Future research should explore whether parental disempowerment is related to caregivers’ own inability to control theirs or their partners/spouses risk behaviours, such as alcohol, drug abuse, or mental health problems. Many adolescents in mental health care have parents who also have mental health problems (Hadley et al. unpublished data), and the parents may feel particularly challenged to address their youths’ risk taking. These concerns were not disclosed in the FGD, potentially because the key questions probed community-based risks and not specifically family-based risks. Such information would provide valuable insight and direction for enhanced prevention efforts. All caregivers responded positively when asked about participating in a systematic programme to address adolescent sexual risk behaviour that included improving parent–adolescent communication. Effective communication skills are important for healthy child development, and if learned, could have wide implications beyond sexual behaviour. In fact, the positive impact of caregiver openness can be applied to a host of behaviours that lead to negative health outcomes, including substance use, early sexual debut and teenage pregnancy. We are aware of a single family-based HIV prevention intervention for youth with mental health issues, Project STYLE (Donenberg et al. 2012a), and this approach may be adapted for the South African context. This randomised controlled trial revealed reduced sexual risk behaviour among youth in mental health treatment over three months (Brown et al. 2014) and improved parental monitoring and parent–teen sexual communication. Findings must be considered within the context of study limitations. It is possible that saturation regarding community problems linked to adolescent HIV-risk was not reached given the relatively small sample size of this pilot study. The sample size was determined by budgetary and logistical factors limiting our ability to enrol more participants. However, this represents the first exploration of parental attitudes about HIV risk among youth, queried through qualitative means. Future studies should include more families to ensure that saturation is accomplished. Second, the small sample prevented investigation of thematic differences by racial group (‘coloured’ or black) and generation (e.g. mother vs. grandmother). Hence, there may be important differences in perceived risks by race or caregiver age, and these should be explored in future research.

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Third, some key issues may not have been sufficiently interrogated or revealed. For example, the role of social media emerged as an influence on adolescent behaviour, including sexual behaviour, but only one person identified this as an issue. Similarly, gangsterism was raised as a community risk factor, but time prohibited a full discussion of the issue. Future research would benefit from understanding thematic differences for unique subgroups, as well as the role of social media and gangsterism. Fourth, as a result of the small sample and focus group design, findings may not generalise beyond caregivers of teens receiving outpatient psychiatric care in South Africa. Still, caregivers represented diverse communities (black and ‘coloured’), and their perceptions are important to the design and implementation of future intervention programmes. In addition, the community problems raised are highly consistent with earlier research with non-troubled youth lending confidence regarding some generalisability within this unique population. Fifth, as expected, some participants were less vocal than others during the discussions. These caregivers may have benefited more from individual interviews to elicit their opinions. Finally, themes identified in this study cannot be linked with specific mental health problems or diagnoses. However, previous studies designed to understand how mental health is related to HIV risk often involve convenience samples (school-based, medical clinics) with youth who score higher on selected mental health measures. These young people may not represent actual mental health populations. Indeed, the uniqueness of the current sample is that the teens are receiving mental health care, suggesting that the level of psychopathology was severe enough to warrant treatment. As a result, this sample is likely to be more impaired than other research studies with convenience samples, because it requires a higher level of concern by families or teachers to ultimately seek services for their children. Concluding remarks A considerable advantage of the study was that caregivers engaged with one another in the context of a group discussion. In fact, the group format seemed to facilitate idea sharing and contributions from most participants, suggesting that this approach would work well for future programming. An encouraging finding was that all participants saw the need for a family-focused intervention programme to address the community problems associated with adolescent HIV risk behaviour. This approach goes beyond the programming currently available in most of South Africa (e.g. Lovelife and Life Skills) by including caregivers and leveraging family strengths to affect change. Evidence suggests that family involvement has considerable utility and efficacy in reducing adolescent risk (Brown et al. 2014), including youth living in marginalised contexts (Donenberg et al. 2012a). The next step in the trajectory of this research is to adapt and test Project STYLE, a promising US-based intervention for the South African context (Donenberg et al. 2012a). Indeed, Project STYLE has shown positive short-term outcomes in reducing risky sexual behaviour and improving parent–teen sexual communication. Given caregiver enthusiasm in this study, Project STYLE may be useful in the South African context reducing the incidence of HIV among South African youth. Acknowledgements — This research was supported by NIMH grant R34MH092251 to the University of Illinois at Chicago and the Human Sciences Research Council (principal investigators: G Donenberg and P Naidoo). We thank the parents and adolescents who participated in the study, and gratefully acknowledge the administrators and clinical staff at the Red Cross War Memorial Children’s Hospital and Empilweni Place of Healing who worked with us to enrol eligible families.

References Adu-Mireku S. 2003. Family communication about HIV/AIDS and sexual behavior among senior secondary school students in Accra, Ghana. African Health Sciences 3: 7–14. Bhana A, McKay MM, Mellins C, Petersen I, Bell C. 2010. Family-based HIV prevention and intervention services for youth living in poverty-affected contexts: the CHAMP model of collaborative, evidence-informed program development. Journal of the International AIDS Society 13: S8.

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