Child and adolescent mental health in Africa remains largely neglected. Quick and cost-effective ways for early detection may aid early intervention. The Strengths and Difficulties Questionnaire (SDQ) is globally used to screen for mental health problems, but little is known about its use in Africa. We set out to perform a scoping review to examine existing studies that have used the SDQ in Africa. A comprehensive scoping review methodology was used to identify all peer-reviewed studies ever published that have used the SDQ in Africa. Data were extracted and analysed to assess the countries, languages and SDQ versions used, the purpose of the SDQ studies, psychometric properties of the SDQ, and to consider knowledge gaps for future in-country and cross-country studies. Fifty-four studies from 12 African countries were identified, most from South Africa. Many different languages were used, but authorized SDQs in those languages were not always available on the SDQinfo website. Authors frequently commented on challenges in the translation and backtranslation of mental health terminology in African languages. The SDQ was typically used to investigate internalisation/externalization disorders in different clinical populations, and was most frequently used in the evaluation of children and adolescents affected by HIV/AIDS. Sixteen studies (29.6%) administered the SDQ to participants outside the intended age range, only 4 (7.4%) used triangulation of all versions to generate assessments, and eight studies (14.8%) used only subscales of the SDQ. Only one study conducted thorough psychometric validation of the SDQ, including examination of internal consistency and factor analysis. Where ‘caseness’ was defined in studies, UK cut-off scores were used in all but one of the studies. The SDQ may be a very useful tool in an African setting, but the scoping review suggested that, where it was used in Africa researchers did not always follow instrument guidelines, and highlighted that very little is known about the psychometric properties of the SDQ in Africa. We recommend comprehensive evaluation of the psychometric properties of the SDQ in various African languages, including internal consistency, factor structure, need for local cut-off values and ensuring cultural equivalence of the instrument.

Document analysis is commonly used in health policy analysis (HPA) studies, but the purpose and rigour of application is unclear. This review explored the application and utility of document analysis in HPA studies conducted in low-and-middle income countries (LMICs), intending to derive lessons for strengthening this methodology. Employing a qualitative systematic review approach, nine electronic databases were searched for LMIC HPA articles that employed document analysis. Articles were subjected to systematic retrieval, storage and quality-assessment. Thematic analysis was used in coding, extraction and analysis of data. Only 28 studies had sufficiently detailed document analyses and met the inclusion criteria. Document analyses were mainly complimentary to primary data collection forms. The majority, barring four studies, lacked clear purpose and utility in answering the research questions, and rigour in methodology and the reporting thereof. The approach to document analyses bore no relationship to the policy phase investigated. Challenges in accessing documents contributed to methodological difficulties. Well-executed document analysis has potential to strengthen HPA studies. Health Policy researcher skill in applying this methodology needs strengthening and could be improved by: purposive alignment of the method to research questions; rigorously applying and reporting on search strategy with rigour; source, organize and store documents systematically; apply robust data coding and analysis; and clearly linking document contribution to study findings and conclusions.

The importance of strong and transformative leadership is recognised as essential to the building of resilient and responsive health systems. In this regard, Sustainable Development Goals (SDG) 5 prioritises a current gap, by calling for women’s full and effective participation and equal opportunities for leadership, including in the health system. In South Africa, pre-democracy repressive race-based policies, coupled with strong patriarchy, led to women and especially black women, being ‘left behind’ in terms of career development and progression into senior health leadership positions. Given limited prior inquiry into this subject, we conducted a qualitative exploratory study employing case study design, with the individual managers as the cases, to examine the influence of gender on career progression and leadership perceptions and experiences of senior managers in South Africa in five geographical districts, located in two provinces. We explored this through in-depth interviews, including life histories, career pathway mapping and critical incident analysis. The study sample selection was purposive and included 14 female and 5 male senior-managers in district and provincial health departments. Our findings suggest that women considerably lag behind their male counterparts in advancing into management- and senior positions. We also found that race strongly intersected with gender in the lived experiences and career pathways of black female managers and in part for some black male managers. Professional hierarchy further compounded the influence of gender and race for black women managers, as doctors, who were frequently male, advanced more rapidly into management and senior management positions, than their female counterparts. Although not widespread, other minority groups, such as male managers in predominantly female departments, also experienced prejudice and marginalisation. Affirmative employment policies, introduced in the new democratic dispensation, addressed this discriminatory legacy and contributed to a number of women being the ‘first’ to occupy senior management positions. In one of the provinces, these pioneering female managers assumed role-modelling and mentoring roles and built strong networks of support for emerging managers. This was aided by an enabling, value-based, organisational culture. This study has implications for institutionalising personal and organisational development that recognise and appropriately advances women managers, paying attention to the intersections of gender, race and professional hierarchy. It is important in the context of national and global goals, in particular SDG 5, that women and in particular black women, are prioritised for training and capacity development and ensuring that transformative health system policies and practices recognise and adapt, supporting the multiple social and work roles that managers, in particular women, play.

Background: The persistence of high maternal mortality and consistent failure in low- and middle-income countries to achieve global targets such as Millennium Development Goal five (MDG 5) is usually explained from epidemiological, interventional and health systems perspectives. The role of policy elites and their interests remains inadequately explored in this debate. This study examined elites and how their interests drove maternal health policies and actions in ways that could explain policy failure for MDG 5 in Uganda. Methods: We conducted a retrospective qualitative study of Uganda’s maternal health policies from 2000 to 2015 (MDG period). Thirty key informant interviews and 2 focus group discussions (FGDs) were conducted with national policy-makers, who directly participated in the formulation of Uganda’s maternal health policies during the MDG period. We reviewed 9 National Maternal Health Policy documents. Data were analysed inductively using elite theory. Results: Maternal health policies were mainly driven by a small elite group comprised of Senior Ministry of Health (MoH) officials, some members of cabinet and health development partners (HDPs) who wielded more power than other actors. The resulting policies often appeared to be skewed towards elites’ personal political and economic interests, rather than maternal mortality reduction. For a few, however, interests aligned with reducing maternal mortality. Since complying with the government policy-making processes would have exposed elites’ personal interests, they mainly drafted policies as service standards and programme documents to bypass the formal policy process. Conclusion: Uganda’s maternal health policies were mainly influenced by the elites’ personal interests rather than by the goal of reducing maternal mortality. This was enabled by the formal guidance for policy-making which gives elites control over the policy process. Accelerating maternal mortality reduction will require re-engineering the policy process to prevent public officials from infusing policies with their interests, and enable percolation of ideas from the public and frontline.

From ‘stepchild of primary healthcare’ to priority programme: Lessons for the implementation of the National Integrated School Health Policy in South Africa

Physical inactivity is increasing in low- and middle-income countries (LMICs), where noncommunicable diseases (NCDs), urbanisation and sedentary living are rapidly growing in tandem. Increasing active living requires the participation of multiple sectors, yet it is unclear whether physical activity (PA)-relevant sectors in LMICs are prioritising PA. We investigated to what extent sectors that influence PA explicitly integrate it in their policies in an LMIC such as Cameroon. We systematically identified policy documents relevant to PA and NCD prevention in Cameroon; and using the Walt and Gilson policy triangle we described, analysed, and interpreted the policy contexts, contents, processes, and actors. We found 17 PA and NCD policy documents spanning from 1974 to 2019 across seven ministries. Thirteen (13/17) policies targeted infrastructure improvement, and four (4/17) targeted communication for behaviour change, all aiming to enhance leisure domain PA. Only the health sector explicitly acknowledged the role of PA in NCD prevention. Notably, no policy from the transport sector mentioned PA. Our findings highlight the need for intersectoral action to integrate PA into policies in all relevant sectors. These actions will need to encompass the breadth of PA domains, including transport, while emphasising the multiple health benefits of PA for the population.