Lauren C. Ng

Family-based prevention of mental health problems in children affected by HIV and AIDS: an open trial

Objective:The objective of this study is to assess the feasibility and acceptability of an intervention to reduce mental health problems and bolster resilience among children living in households affected by caregiver HIV in Rwanda. Design:Pre-post design, including 6-month follow-up. Methods:The Family Strengthening Intervention (FSI) aims to reduce mental health problems among HIV-affected children through improved child–caregiver relationships, family communication and parenting skills, HIV psychoeducation and connections to resources. Twenty families (N = 39 children) with at least one HIV-positive caregiver and one child 7–17 years old were enrolled in the FSI. Children and caregivers were administered locally adapted and validated measures of child mental health problems, as well as measures of protective processes and parenting. Assessments were administered at pre and postintervention, and 6-month follow-up. Multilevel models accounting for clustering by family tested changes in outcomes of interest. Qualitative interviews were completed to understand acceptability, feasibility and satisfaction with the FSI. Results:Families reported high satisfaction with the FSI. Caregiver-reported improvements in family connectedness, good parenting, social support and childrens pro-social behaviour (P < 0.05) were sustained and strengthened from postintervention to 6-month follow-up. Additional improvements in caregiver-reported child perseverance/self-esteem, depression, anxiety and irritability were seen at follow-up (P < .05). Significant decreases in child-reported harsh punishment were observed at postintervention and follow-up, and decreases in caregiver reported harsh punishment were also recorded on follow-up (P < 0.05). Conclusion:The FSI is a feasible and acceptable intervention that shows promise for improving mental health symptoms and strengthening protective factors among children and families affected by HIV in low-resource settings.

Posttraumatic stress disorder in the World Mental Health Surveys

BACKGROUND Traumatic events are common globally; however, comprehensive population-based cross-national data on the epidemiology of posttraumatic stress disorder (PTSD), the paradigmatic trauma-related mental disorder, are lacking. METHODS Data were analyzed from 26 population surveys in the World Health Organization World Mental Health Surveys. A total of 71 083 respondents ages 18+ participated. The Composite International Diagnostic Interview assessed exposure to traumatic events as well as 30-day, 12-month, and lifetime PTSD. Respondents were also assessed for treatment in the 12 months preceding the survey. Age of onset distributions were examined by country income level. Associations of PTSD were examined with country income, world region, and respondent demographics. RESULTS The cross-national lifetime prevalence of PTSD was 3.9% in the total sample and 5.6% among the trauma exposed. Half of respondents with PTSD reported persistent symptoms. Treatment seeking in high-income countries (53.5%) was roughly double that in low-lower middle income (22.8%) and upper-middle income (28.7%) countries. Social disadvantage, including younger age, female sex, being unmarried, being less educated, having lower household income, and being unemployed, was associated with increased risk of lifetime PTSD among the trauma exposed. CONCLUSIONS PTSD is prevalent cross-nationally, with half of all global cases being persistent. Only half of those with severe PTSD report receiving any treatment and only a minority receive specialty mental health care. Striking disparities in PTSD treatment exist by country income level. Increasing access to effective treatment, especially in low- and middle-income countries, remains critical for reducing the population burden of PTSD.

Developing and Validating the Youth Conduct Problems Scale-Rwanda: A Mixed Methods Approach

This study developed and validated the Youth Conduct Problems Scale-Rwanda (YCPS-R). Qualitative free listing (n = 74) and key informant interviews (n = 47) identified local conduct problems, which were compared to existing standardized conduct problem scales and used to develop the YCPS-R. The YCPS-R was cognitive tested by 12 youth and caregiver participants, and assessed for test-retest and inter-rater reliability in a sample of 64 youth. Finally, a purposive sample of 389 youth and their caregivers were enrolled in a validity study. Validity was assessed by comparing YCPS-R scores to conduct disorder, which was diagnosed with the Mini International Neuropsychiatric Interview for Children, and functional impairment scores on the World Health Organization Disability Assessment Schedule Child Version. ROC analyses assessed the YCPS-Rs ability to discriminate between youth with and without conduct disorder. Qualitative data identified a local presentation of youth conduct problems that did not match previously standardized measures. Therefore, the YCPS-R was developed solely from local conduct problems. Cognitive testing indicated that the YCPS-R was understandable and required little modification. The YCPS-R demonstrated good reliability, construct, criterion, and discriminant validity, and fair classification accuracy. The YCPS-R is a locally-derived measure of Rwandan youth conduct problems that demonstrated good psychometric properties and could be used for further research.

A mental health needs assessment of children and adolescents in post-conflict Liberia: results from a quantitative key-informant survey

Between 1989 and 2004, Liberia experienced a devastating civil war that resulted in widespread trauma with almost no mental health infrastructure to help citizens cope. In 2009, the Liberian Ministry of Health and Social Welfare collaborated with researchers from Massachusetts General Hospital to conduct a rapid needs assessment survey in Liberia with local key informants (n = 171) to examine the impact of war and post-war events on emotional and behavioral problems of, functional limitations of, and appropriate treatment settings for Liberian youth aged 5–22. War exposure and post-conflict sexual violence, poverty, infectious disease and parental death negatively impacted youth mental health. Key informants perceived that youth displayed internalizing and externalizing symptoms and mental health-related functional impairment at home, school, work and in relationships. Medical clinics were identified as the most appropriate setting for mental health services. Youth in Liberia continue to endure the harsh social, economic and material conditions of everyday life in a protracted post-conflict state, and have significant mental health needs. Their observed functional impairment due to mental health issues further limited their access to protective factors such as education, employment and positive social relationships. Results from this study informed Liberias first post-conflict mental health policy.

Risk and protective factors for suicidal ideation and behaviour in Rwandan children

BACKGROUND Suicide is a leading cause of death for young people. Children living in sub-Saharan Africa, where HIV rates are disproportionately high, may be at increased risk. AIMS To identify predictors, including HIV status, of suicidal ideation and behaviour in Rwandan children aged 10-17. METHOD Matched case-control study of 683 HIV-positive, HIV-affected (seronegative children with an HIV-positive caregiver), and unaffected children and their caregivers. RESULTS Over 20% of HIV-positive and affected children engaged in suicidal behaviour in the previous 6 months, compared with 13% of unaffected children. Children were at increased risk if they met criteria for depression, were at high-risk for conduct disorder, reported poor parenting or had caregivers with mental health problems. CONCLUSIONS Policies and programmes that address mental health concerns and support positive parenting may prevent suicidal ideation and behaviour in children at increased risk related to HIV.

Exploring the potential of a family-based prevention intervention to reduce alcohol use and violence within HIV-affected families in Rwanda

ABSTRACT HIV-affected families report higher rates of harmful alcohol use, intimate partner violence (IPV) and family conflict, which can have detrimental effects on children. Few evidence-based interventions exist to address these complex issues in Sub-Saharan Africa. This mixed methods study explores the potential of a family-based intervention to reduce IPV, family conflict and problems related to alcohol use to promote child mental health and family functioning within HIV-affected families in post-genocide Rwanda. A family home-visiting, evidence-based intervention designed to identify and enhance resilience and communication in families to promote mental health in children was adapted and developed for use in this context for families affected by caregiver HIV in Rwanda. The intervention was adapted and developed through a series of pilot study phases prior to being tested in open and randomized controlled trials (RCTs) in Rwanda for families affected by caregiver HIV. Quantitative and qualitative data from the RCT are explored here using a mixed methods approach to integrate findings. Reductions in alcohol use and IPV among caregivers are supported by qualitative reports of improved family functioning, lower levels of violence and problem drinking as well as improved child mental health, among the intervention group. This mixed methods analysis supports the potential of family-based interventions to reduce adverse caregiver behaviors as a major mechanism for improving child well-being. Further studies to examine these mechanisms in well-powered trials are needed to extend the evidence-base on the promise of family-based intervention for use in low- and middle-income countries.

Ethics in global health research: the need for balance

Global health research often needs collaboration between various organisations and oversight from many research ethics committees (RECs), including those from partner institutions, national committees, ministries of health, and funders, which increases administrative burden and time. Maintenance of the highest ethical standards in research is paramount; unfortunately ethics breaches are not uncommon.1 In view of the real possibility of ethical wrongdoing, worldwide health research must abide by transparent, rigorous, and eff ective procedures of ethics review. However, although oversight from many RECs might assist with maintenance of ethical principles, this process can result in delays and barriers to research.2 Usually each REC reviews protocols independently (either sequentially or in parallel), and will often only review protocols after the other committees have already approved them. Modifi cation requests can be quite different.2 Some RECs might request modifications to increase the cultural appropriateness, relevance of the research, and the availability of intervention during and after the project, whereas others might focus on letters of approval and complexity of consent forms.3 These competing priorities can mean that previously approved protocols require more amendments, but it is usually unclear which RECs feedback should take precedence. Having to seek various approvals, with no communication between RECs and no plan for which committees decisions take priority, can lead to research bottlenecks. Many RECs, particularly those in low-income and middle-income countries (LMICs), have long turnaround times, perhaps because of infrequent meetings, overworked members, and understaffed councils.2 These additional demands can make researchers who must show REC approval to apply for grants less competitive for funding. Moreover, the additional administrative burden research teams face to meet the requirements of several RECs might, paradoxically, reduce the time and attention given to the execution of research projects, weakening ethical oversight. One solution might be for RECs to learn about each others procedures, communicate about the proposals, and harmonise processes.4,5 If a REC could benefit from additional support and capacity building, then collaborating committees could provide this support. Ideally they could work together to ensure that partner RECs are meeting or exceeding international standards. Collaborative capacity building might be particularly useful for long-term institutional collaborations.4 If long-term partnership is not possible, communication between RECs regarding their updated guidelines, submission requirements, expected turnaround times, and agreement about the order of REC submissions might still be beneficial. To help efficient communication between these committees and researchers, we suggest that one REC coordinate feedback and respond to submissions on behalf of all RECs. Whenever possible, the lead REC should be an institutional review board from the country in which the research is being done. If the REC of the institution that is implementing the research is internationally accredited then the final word on approval of, or changes to, the research protocol might be advisably done by that REC. Another consequence of needing all RECs associated in multinational collaborations (even when research will only be done in one LMIC) to review studies is the reinforcement of the perception that RECs from LMIC do not meet international standards. Although some RECs in LMICs have historically had inadequate ethics training,6,7 over the past 20 years, the capacity of RECs from LMIC to do ethics reviews that meet or exceed international standards has been strengthened. Many members of these boards have received ethics training funded or provided by international organisations such as the UN and WHO,8,9 and many more are registered with the US Department of Health and Human Services Office for Human Research Protections.10 In 2000, 92% of interviewed researchers from LMIC believed that their countrys national guidelines for protecting patients involved in research were effective,3 a number that would be expected to have increased now because of the high standard of ethical training. Despite these achievements, RECs in LMICs are still sometimes undermined, or are perceived as inadequate or ineffective. The perception that local RECs are ill-equipped is particularly unfortunate because they might be the most appropriate REC to oversee research projects in their countries. Local RECs are most familiar with the research environment, participant population, and local strengths and challenges. They can also assist with ensuring that sustainable intervention is prioritised and institutional agreements regarding intellectual property rights, ownership of data and samples, and authorship are balanced and equitable. Additionally, some RECs in high-income countries have been perceived as insensitive to local context when reviewing protocols for research in LMICs.3 National ethics committees could also assist with overseeing, training, and monitoring the quality of local RECs to meet international standards. If the local RECs are allowed to coordinate all associated RECs and take responsibility for ensuring that all REC feedback is addressed, then the process might be more streamlined and efficient. Additionally, local RECs, which are best positioned to understand the unique contextual ethical challenges in their area, would be empowered to protect the interests of participants and researchers alike.

Ethics in Community-Based Research with Vulnerable Children: Perspectives from Rwanda.

A “risk of harm” protocol to identify youth in need of immediate emergency assistance in a study on mental health and HIV in Rwanda among 680 youth ages 10–17 is described. Cases are presented that describe the experience in using this protocol to ensure safety of participants, with ethical and logistical challenges considered. Among the population of the study, 3.2% were deemed “risk of harm.” The most prevalent presenting problem was non-fatal suicidal behavior (91% of risk of harm cases), with 36% having a history of a reported previous attempt. Challenges included: acute food insecurity/significant poverty; lack of support/adequate supervision from family members; family violence; alcohol abuse; and HIV-related stigma. Development of a “risk of harm” protocol and collaboration between study staff, community leadership, health authorities, and health workers are critical to ensuring participants’ safety in research among vulnerable populations.

Posttraumatic stress disorder symptoms and social and occupational functioning of people with schizophrenia

Abstract This study sought to clarify the contribution of posttraumatic stress disorder (PTSD) to interpersonal and occupational functioning in people with schizophrenia. Self-report questionnaires and semistructured interviews were used to evaluate PTSD and brain injury, positive symptoms, depression, substance abuse, occupational and social functioning, and intelligence. Multiple regressions assessed the relationship between predictors and functional impairment. Posttraumatic stress disorder symptoms were present in 76% of participants, with 12% of participants meeting diagnostic criteria for PTSD. Participants with PTSD had higher rates of depression and more severe positive symptoms. Results of multiple regressions indicated that PTSD symptoms were the only significant predictor of patient-rated interpersonal and occupational functioning. Posttraumatic stress disorder symptoms were not associated with interviewer-rated interpersonal or occupational functioning or employment. While more research is needed, screening and treatment for exposure to traumatic events and PTSD symptoms might be indicated for individuals with schizophrenia. Availability of PTSD assessment and evidence-based treatments for people with schizophrenia is a crucial and often unmet health service need.

Mental health care in post-genocide Rwanda: evaluation of a program specializing in posttraumatic stress disorder and substance abuse.

Background. Following the genocide, millions of Rwandans are likely living with posttraumatic stress disorder (PTSD). Le Centre Psychothérapeutique Icyizere provides the only specialized treatment for PTSD in the Rwandan healthcare system. Methods. Demographics, diagnosis, treatment, outcomes, and scores on assessments of functioning and PTSD were recorded from clinical charts of all patients receiving care between October 2013 and 2014. Descriptive statistics and within-group t tests comparing functional impairment and PTSD symptoms at intake to discharge and follow-up were calculated. Results. A total of 719 patients (55.08% male) received care. Patients were more educated, more likely to live in the capital, and less likely to be married than the general population. Patients reported high desire for, and strong satisfaction with, care. Most patients (55.60%) were still in care by the end of the program evaluation. Functioning improved from intake to discharge (p < 0.001), and improvements were sustained at follow-up (p < 0.001). Most adults were diagnosed with psychotic disorders, substance use disorders, or depression. Only 20 patients were diagnosed with PTSD, and symptoms were improved at discharge (p = 0.003). Conclusions. This program evaluation demonstrated the utility of a low-resource information management system to provide clarity about the patient population and outcomes. Results suggest that services are effective and sustainable, although people with PTSD were not the primary recipients of care. Disparities in care by diagnosis, education, marital status, and geography are discussed. Results have contributed to changes in service delivery and care and efforts to increase access to care.