Jura Augustinavicius

Association of caregiver quality of care with neurocognitive outcomes in HIV-affected children aged 2–5 years in Uganda

ABSTRACT Children affected by HIV are at increased risk of developmental and neuropsychological disturbances due to direct effects of HIV on the brain and direct effects associated with living in poverty. Caregivers can play an important role, through quality caregiving, in mitigating the negative effect of these stressors. This study used baseline data from an ongoing caregiver training intervention trial to evaluate the association between quality of caregiver–child interactions and neurocognitive outcomes in rural HIV-infected and HIV-exposed but uninfected children in Uganda. We also assessed the extent to which caregiver distress moderated this relationship. Data on 329 caregiver–child dyads were collected between March 2012 and July 2014, when the children were between 2 and 5 years of age. Child outcomes include the Mullen Scales of Early Learning to assess general cognitive ability and the Color Object Association Test to assess immediate memory and total recall. Caregiving quality was assessed using the Home Observation for the Measurement of the Environment (HOME) total and subscale scores. Caregiver distress was assessed using the Hopkins Symptom Checklist. General linear regression models assessed the association between the HOME total and subscale scores and child outcomes, with interaction terms used to test moderation by caregiver distress. Total HOME scores were positively and significantly associated with Mullen scores of cognitive ability; HOME acceptance subscale scores were positively and significantly associated with immediate recall scores. No other associations were statistically significant. As hypothesized, there is a strong association between the HOME and Mullen scores of cognitive ability in our study population, such that children who were assessed as living in environments with more stimulation also presented with a higher level of general neurocognitive development. Our results support the view of program guidance for HIV-affected children that suggest family-oriented care with emphasis on parent–child relationships for optimal child development.

Neighborhood physical disorder, social cohesion, and insomnia: Results from participants over age 50 in the Health and Retirement Study

ABSTRACT Background: We determined the association between neighborhood socio-environmental factors and insomnia symptoms in a nationally representative sample of US adults aged >50 years. Methods: Data were analyzed from two waves (2006 and 2010) of the Health and Retirement Study using 7,231 community-dwelling participants (3,054 men and 4,177 women) in the United States. Primary predictors were neighborhood physical disorder (e.g. vandalism/graffiti, feeling safe alone after dark, and cleanliness) and social cohesion (e.g. friendliness of people, availability of help when needed, etc.); outcomes were insomnia symptoms (trouble falling asleep, night awakenings, waking too early, and feeling unrested). Results: After adjustment for age, income, race, education, sex, chronic diseases, body mass index, depressive symptoms, smoking, and alcohol consumption, each one-unit increase in neighborhood physical disorder was associated with a greater odds of trouble falling asleep (odds ratio (OR) = 1.09, 95% confidence interval (CI): 1.04-1.14), waking too early (OR = 1.05, 95% CI: 1.00-1.10), and, in adults aged ≥69 years (adjusting for all variables above except age), feeling unrested in the morning (OR = 1.11, 95% CI: 1.02-1.22 in 2006). Each one-unit increase in lower social cohesion was associated with a greater odds of trouble falling asleep (OR = 1.06, 95% CI: 1.01-1.11) and feeling unrested (OR = 1.09, 95% CI: 1.04-1.15). Conclusions: Neighborhood-level factors of physical disorder and social cohesion are associated with insomnia symptoms in middle-aged and older adults. Neighborhood-level factors may affect sleep, and consequently health, in our aging population.

Challenges for the implementation of World Health Organization guidelines for acute stress, PTSD, and bereavement: a qualitative study in Uganda

BackgroundIn 2013, the World Health Organization (WHO) published new guidelines for the management of conditions specifically related to stress, including symptoms of acute stress, bereavement, and post-traumatic stress disorder (PTSD). It is important to evaluate potential challenges for the implementation of these guidelines in low-resource settings, however, there is a dearth of research in this area. The current qualitative study aimed to assess perspectives on the feasibility and acceptability of the new guidelines in four clinics that provide mental health services in post-conflict northern Uganda.MethodsIn-depth interviews were conducted with 19 mental health-care providers and program developers in northern Uganda to address three major research objectives: (1) describe the current standard practices and guidelines used for treating conditions related to stress in Uganda; (2) identify barriers and challenges associated with implementing the new WHO guidelines; and (3) identify and describe potential strategies for overcoming these barriers and challenges. An emergent thematic analysis was used to develop a coding scheme for the transcribed interviews.ResultsPractices for managing conditions related to stress included group psychological interventions, psychoeducation, and medication for clients with severe signs and symptoms. Several themes were identified from the interviews on barriers to guideline implementation. These included (1) a lack of trained and qualified mental health professionals to deliver WHO-recommended psychological interventions; (2) a perception that psychological interventions developed in high-income countries would not be culturally adaptable in Uganda; and (3) reluctance about blanket statements regarding medication for the management of acute stress symptoms and PTSD. Identified strategies for overcoming these barriers included (1) training and capacity building for current mental health staff; (2) a stepped care approach to mental health services; and (3) cultural modification of psychological interventions to improve treatment acceptability by clients.ConclusionsGuidelines were viewed positively by mental health professionals in Uganda, but barriers to implementation were expressed. Recommendations for implementation include (1) strengthening knowledge on effectiveness of existing cultural practices for improving mental health; (2) improving supervision capacity of current mental health staff to address shortage in human resources; and (3) increasing awareness of help-seeking clients on the potential effectiveness of psychological vs. pharmacological interventions.

Randomized controlled trial of caregiver training for HIV-infected child neurodevelopment and caregiver well-being

Objectives: HIV infection places children at neurodevelopmental risk; for young children in poverty, risk is compounded by compromised caregiving quality. The mediational intervention for sensitizing caregivers (MISC) program trained caregivers on fostering daily interactions with young children. We hypothesized that MISC could enhance neurodevelopment of rural Ugandan HIV-infected children and improve mental health outcomes of their caregivers, which might mediate improved caregiving quality. Design: A randomized trial of HIV-infected young children (ages 2–5 years) and their female caregivers; cluster randomization was to MISC or a nutrition curriculum. Setting: A total of 18 geographic clusters in rural Uganda. Study participants: Children and caregivers were evaluated at baseline, 6 months, 1 year, and 1-year post-training. Main outcome measures: Mullen Scales of Early Learning, the Color-Object Association Test for memory, the Early Childhood Vigilance Test of attention, and the Behavior Rating Inventory of Executive Function for the children. Caregivers completed measures of depression and anxiety symptoms and daily functioning. Results: MISC had a significant impact on postintervention receptive language (adjusted mean difference = 3.13, 95% confidence interval 0.08, 6.18) that persisted at 1-year follow-up. MISC caregivers reported significantly less functional impairment postprogram (adjusted mean difference = −0.15, 95% confidence interval −0.28, −0.01). Other outcomes were NS. Conclusion: Both intervention conditions resulted in improvements in the study children over time. MISC showed additional impacts on child language and caregiver well-being. Future directions that include assessing the extent enhanced language development resulting from improved caregiving may better prepare impoverished children for school.

The impact of Cognitive Processing Therapy on stigma among survivors of sexual violence in eastern Democratic Republic of Congo: results from a cluster randomized controlled trial

BackgroundSexual violence is associated with a multitude of poor physical, emotional, and social outcomes. Despite reports of stigma by sexual violence survivors, limited evidence exists on effective strategies to reduce stigma, particularly in conflict-affected settings. We sought to assess the effect of group Cognitive Processing Therapy (CPT) on stigma and the extent to which stigma might moderate the effectiveness of CPT in treating mental health problems among survivors of sexual violence in the Democratic Republic of Congo.MethodsData were drawn from 405 adult female survivors of sexual violence reporting mental distress and poor functioning in North and South Kivu. Women were recruited through organizations providing psychosocial support and then cluster randomized to group CPT or individual support. Women were assessed at baseline, the end of treatment, and again six months later. Assessors were masked to women’s treatment assignment. Linear mixed-effect regression models were used to estimate (1) the effect of CPT on feelings of perceived and internalized (felt) stigma, and (2) whether felt stigma and discrimination (enacted stigma) moderated the effects of CPT on combined depression and anxiety symptoms, posttraumatic stress, and functional impairment.ResultsParticipants receiving CPT experienced moderate reductions in felt stigma relative to those in individual support (Cohen’s D = 0.44, p = value = 0.02) following the end of treatment, though this difference was no longer significant six-months later (Cohen’s D = 0.45, p = value = 0.12). Neither felt nor enacted stigma significantly moderated the effect of CPT on mental health symptoms or functional impairment.ConclusionsGroup cognitive-behavioral based therapies may be an effective stigma reduction tool for survivors of sexual violence. Experiences and perceptions of stigma did not hinder therapeutic effects of group psychotherapy on survivors’ mental health.Trial registrationClinicalTrials.gov NCT01385163.

Association between coping strategies, social support, and depression and anxiety symptoms among rural Ugandan women living with HIV/AIDS

ABSTRACT Poor mental health detrimentally affects quality of life among women living with HIV/AIDS. An improved understanding of how coping and social support relate to depression and anxiety in this population can facilitate the design and implementation of appropriate mental health treatment and support services. Secondary analysis was conducted on baseline data from 288 HIV-positive women enrolled in a parenting intervention in Uganda. Depression and anxiety symptoms, social support, and coping were assessed with the Hopkins Symptom Checklist and adapted versions of the Multidimensional Scale for Perceived Social Support and Ways of Coping Questionnaire. General linear regression models were used to estimate associations between coping and mental health. Based on report of elevated symptoms, approximately 10% of women were categorized as having clinically-relevant depression or anxiety. Emotion-focused (EF: p < .001) and problem-focused (PF: p = .01) coping were associated with more depressive symptoms while greater family support (EF: p = .002; PF: p = .003) was associated with fewer depression symptoms. More anxiety symptoms were associated with reporting both coping strategies (EF: p < .001; PF: p = .02) and higher community support (EF&PF: p = .01). The cross-sectional nature of the study limits our ability to rule out the role of reverse causation in the significant relationship between coping and mental health. Findings do suggest that high family support can be protective against depression and anxiety symptoms among women living with HIV.

Feasibility of a guided self-help intervention to reduce psychological distress in South Sudanese refugee women in Uganda

Implementing evidence-based psychological interventions in low-resource refugee settings is challenging, because of the need for an extensive workforce of trainers, supervisors and facilitators. Self-Help Plus (SH1) was developed by the World Health Organization (WHO) as a tool potentially applicable in those settings. SH1 is a guided self-help intervention consisting of five audio-recorded sessions and an illustrated self-help manual. It can be provided to large groups (20 to 30 participants) and facilitated by lay helpers with minimal training. It aims to reduce psychological distress in people with a range of common mental disorders and subthreshold symptoms. It is based on acceptance and commitment therapy, a third wave cognitive behavioral therapy focused on enhancing psychological flexibility. We adapted SH1 for South Sudanese refugees and conducted a feasibility cluster randomized controlled trial of the intervention in Rhino Camp, a refugee settlement area in northern Uganda. Our focus in this study was on women, since prior intervention adaptation and piloting had shown the need for separate evaluation efforts with men and women. We randomly allocated one village to SH1 and one to enhanced usual care. Within each village, we randomly selected households and screened one Juba Arabic-speaking consenting woman (age 18 years) until 25 eligible women were identified per village. We screened for moderate psychological distress using the Kessler 6 (K6) (primary outcome, cut-off 5). We assessed exclusion criteria (imminent risk of suicide; observable signs of severe mental disorder; severe cognitive impairment) using structured questionnaires. With eligible and consenting women, we assessed secondary outcomes: disability (WHO Disability Assessment Schedule 2.0, WHODAS 2.0); self-defined psychosocial concerns (Psychological Outcome Profiles instrument, PSYCHLOPS); depression symptoms (Patient Health Questionnaire, PHQ-9); post-traumatic stress disorder (PTSD) symptoms (PTSD Checklist Civilian, PCL-6); hazardous alcohol use (two survey questions); feelings of anger (shortened explosive anger index); inter-ethnic relations (three survey questions); subjective wellbeing (WHO Wellbeing Index, WHO-5); psychological flexibility (Acceptance and Action Questionnaire, AAQII). We also assessed attendance, health service use, cost indicators, and exposure to potentially traumatic events. The SH1 workshops were facilitated by four Juba Arabicspeaking Ugandan women from the settlement area without prior mental health training. Facilitators were trained by international experts (KC, FB) over a four-day period and supervised weekly by a Ugandan social worker. Enhanced usual care consisted of one psychoeducation session focused on psychological distress delivered by a trained community health worker, which included information on where to access existing mental health services delivered by the implementing organization, the Peter C. Alderman Foundation. Assessors were blinded to allocation of villages to study condition, and conducted interviews one week preand post-intervention. All participants provided written or verbal informed consent. Ethical procedures were approved by the WHO Ethics Review Committee, the MildMay Uganda Research Ethics Commission, and the Uganda National Council for Science and Technology. We screened 50 women, all of whom were eligible and consented. Their mean age was 29.568.5 years and 68% of them were married. Half of participants were managing households; 60% had no schooling or completed primary school. Fidelity checks (clinical supervisor attending 10% of sessions) showed that all sections of the audio were delivered correctly at each session. Weekly supervision was provided to SH1 facilitators and covered reporting of any adverse events, requests for additional help from participants or problems in running the course. Few problems were reported and supervision was brief. Attendance was good (90% of women attended each session). We found that our research protocol was feasible. Randomization resulted in balanced groups at baseline despite the small sample. We did not find differences between groups at baseline on socio-demographic characteristics. There were larger mean post-intervention differences for the SH1 condition on all outcome measures. These were statistically significant for the K6 (p<0.05) and the WHO-5 (p<0.001). Blinding was maintained: assessors guessed correctly which participants were part of which study condition at chance level (50% of cases). Similarly, contamination did not appear to be a major concern: none of the participants in the control condition had seen the SH1 self-help book, attended workshops, nor heard about SH1. Only two women receiving enhanced usual care were lost to follow-up – an attrition of 4%. In conclusion, we found that the SH1 intervention and research protocols were feasible in Uganda among South Sudanese refugees, with promising results related to randomization, fidelity, adherence, contamination, blinding, and sensitivity to change. If efficacy is confirmed in a forthcoming larger fully-powered trial, SH1 will represent a promising and

Translation, adaptation, and pilot of a guided self-help intervention to reduce psychological distress in South Sudanese refugees in Uganda

Background. In this period of unprecedented levels of displacement, scalable interventions are needed to address mental health concerns of forced migrants in low-resource settings. This paper describes the adaptation and piloting of a guided, multi-media, self-help intervention, Self-Help Plus (SH+), which was developed to reduce psychological distress in large groups of people affected by adversity. Methods. Using a phased approach that included community consultations, cognitive interviewing, facilitator training, pilot implementation, and a qualitative process evaluation, we adapted SH+ for use among South Sudanese refugees in a refugee settlement in northern Uganda. Results. The SH+ materials, including audio-recorded sessions and an accompanying illustrated manual, were translated into Juba Arabic. Cognitive interviewing primarily resulted in adaptations to language with some minor adaptations to content. Facilitator training and supervision led to further suggested changes to delivery methods. An uncontrolled pilot study (n = 65) identified changes in the expected direction on measures of psychological distress, functional impairment, depression, wellbeing, and psychological flexibility. The process evaluation resulted in further adaptations to intervention materials and the decision to focus future effectiveness evaluations of the intervention in its current form on South Sudanese female refugees. Conclusions. We found that this potentially scalable, guided self-help intervention could be adapted for and feasibly implemented among female South Sudanese refugees in northern Uganda. These findings lay the groundwork for a future rigorous evaluation of SH+ in this context.

Self Help Plus: study protocol for a cluster-randomised controlled trial of guided self-help with South Sudanese refugee women in Uganda

Background. Exposure to armed conflict and forced displacement constitute significant risks for mental health. Existing evidence-based psychological interventions have limitations for scaling-up in low-resource humanitarian settings. The WHO has developed a guided self-help intervention, Self Help Plus (SH+), which is brief, implemented by non-specialists, and designed to be delivered to people with and without specific mental disorders. This paper outlines the study protocol for an evaluation of the SH+ intervention in northern Uganda, with South Sudanese refugee women. Methods. A two-arm, single-blind cluster-randomised controlled trial will be conducted in 14 villages in Rhino Camp refugee settlement, with at least 588 women experiencing psychological distress. Villages will be randomly assigned to receive either SH+ with enhanced usual care (EUC), or EUC alone. SH+ is a five-session guided self-help intervention delivered in workshops with audio-recorded materials and accompanying pictorial guide. The primary outcome is reduction in overall psychological distress over time, with 3 months post-treatment as the primary end-point. Secondary outcomes are self-defined psychosocial concerns, depression and post-traumatic stress disorder symptoms, hazardous alcohol use, feelings of anger, interethnic relations, psychological flexibility, functional impairment and subjective wellbeing. Psychological flexibility is a hypothesised mediator, and past trauma history and intervention attendance will be explored as potential moderators. Discussion. This trial will provide important information on the effectiveness of a scalable, guided self-help intervention for improving psychological health and wellbeing among people affected by adversity. Trial Registration: ISRCTN50148022; registered 13/03/2017.

Monitoring and evaluation of mental health and psychosocial support programs in humanitarian settings: a scoping review of terminology and focus

BackgroundMonitoring and evaluation of mental health and psychosocial support (MHPSS) programs is critical to facilitating learning and providing accountability to stakeholders. As part of an inter-agency effort to develop recommendations on MHPSS monitoring and evaluation, this scoping review aimed to identify the terminology and focus of monitoring and evaluation frameworks in this field.MethodsWe collected program documents (logical frameworks (logframes) and theories of change) from members of the Inter-Agency Standing Committee Reference Group on MHPSS, and systematically searched the peer-reviewed literature across five databases. We included program documents and academic articles that reported on monitoring and evaluation of MHPSS in low- and middle-income countries describing original data. Inclusion and data extraction were conducted in parallel by independent reviewers. Thematic analysis was used to identify common language in the description of practices and the focus of each monitoring and evaluation framework. Logframe outcomes were mapped to MHPSS activity categories.ResultsWe identified 38 program documents and 89 peer-reviewed articles, describing monitoring and evaluation of a wide range of MHPSS activities. In both program documents and peer-reviewed literature there was a lack of specificity and overlap in language used for goals and outcomes. Well-validated, reliable instruments were reported in the academic literature, but rarely used in monitoring and evaluation practices. We identified six themes in the terminology used to describe goals and outcomes. Logframe outcomes were more commonly mapped to generic program implementation activities (e.g. “capacity building”) and those related to family and community support, while outcomes from academic articles were most frequently mapped to specialized psychological treatments.ConclusionsInconsistencies between the language used in research and practice and discrepancies in measurement have broader implications for monitoring and evaluation in MHPSS programs in humanitarian settings within low- and middle-income countries. This scoping review of the terminology commonly used to describe monitoring and evaluation practices and their focus within MHPSS programming highlights areas of importance for the development of a more standardized approach to monitoring and evaluation.