Linnet Ongeri

Translation of EPDS Questionnaire into Kiswahili: Understanding the Cross-Cultural and Translation Issues in Mental Health Research

The need for a suitable tool for assessing postpartum depression in Kenya led to the process of translation of the 10 items Edinburgh Postnatal Scale into Kiswahili. The idea was to seek semantic, conceptual as well as normative equivalence in this translation. The paper discusses issues and the process of translation and provides in depth discussions around translation from the point of view of cross-cultural mental health research and practice. The English version of the EPDS screening tool was finally successfully translated into Kiswahili and the translated version is attached with this paper.

Interpersonal psychotherapy for depression and posttraumatic stress disorder among HIV-positive women in Kisumu, Kenya: study protocol for a randomized controlled trial.

BackgroundMental disorders are the leading global cause of years lived with disability; the majority of this burden exists in low and middle income countries (LMICs). Over half of mental illness is attributable to depression and anxiety disorders, both of which have known treatments. While the scarcity of mental health care providers is recognized as a major contributor to the magnitude of untreated disorders in LMICs, studies in LMICs find that evidence-based treatments for depression and anxiety disorders, such as brief, structured psychotherapies, are feasible, acceptable and have strong efficacy when delivered by local non-specialist personnel. However, most mental health treatment studies using non-specialist providers in LMICs deploy traditional efficacy designs (T1) without the benefit of integrated mental health treatment models shown to succeed over vertical interventions or methods derived from new implementation science to speed policy change. Here, we describe an effectiveness-implementation hybrid study that evaluates non-specialist delivery of mental health treatment within an HIV clinic for HIV-positive (HIV+) women affected by gender- based violence (GBV) (HIV+ GBV+) in the Nyanza region of Kenya.Methods/DesignIn this effectiveness-implementation hybrid type I design, 200 HIV+ women with major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) who are receiving care at a Family AIDS Care Education and Services (FACES)-supported clinic in Kisumu, Kenya will be randomized to: (1) interpersonal psychotherapy (IPT) + treatment as usual (TAU) or (2) TAU, both delivered within the HIV clinic. IPT will consist of 12 weekly 60-minute individual IPT sessions, delivered by non-specialists trained to provide IPT. Primary effectiveness outcomes will include MDD and PTSD diagnosis on the Mini International Diagnostic Interview (MINI). Primary implementation outcomes will include treatment cost-benefit, acceptability, appropriateness, feasibility and fidelity of the IPT delivery within an HIV clinic.DiscussionThis trial leverages newly defined effectiveness-implementation hybrid designs to gather data on mental health treatment implementation within an HIV care clinic, while testing the effectiveness of an evidence-based treatment for use with a large underserved population (HIV+ GBV+ women) in Kenya.Trial registrationClinical Trials Identifier: NCT02320799, registered on 9 September 2014.

Antepartum Risk Factors for Postpartum Depression: A Follow up Study amongUrban Women Living in Nairobi, Kenya

Introduction: Longitudinal studies that assess antepartum risk factors and outcome in the postpartum period can help provide a wealth of information in understanding maternal depression. In addition to collecting information on prevalence and correlates of antepartum depression, such studies reveal postpartum outcomes of depression as well as its risk factors while avoiding recall bias, a limitation frequently seen in cross sectional postpartum studies. Methodology: We consecutively recruited 188 adult women residing in an urban, resource poor setting and attending maternal and child health clinics in 2 major public hospitals in Nairobi, Kenya. A translated Kiswahili EPDS was used to screen for depressive symptoms at baseline assessment in the 3rd trimester and a follow up assessment at 6-10 weeks post-partum. A different questionnaire was administered at baseline to collect information on potential socio demographic and clinical antepartum risk variables. Study results: At a cut off of 13 or more on the EPDS, our study found a prevalence of 18% for antepartum depression. Associated correlates of antepartum depression were partner current alcohol use and partner wanting current pregnancy. Out of the 171 women we followed up at 6-12 weeks postpartum, 21% were found to have postpartum depression. Antenatal depression and conflict with partner were the strongest independent predictors of postpartum depression. In the adjusted analysis, the risk of having postpartum depression is increased six-fold in the presence of antepartum depression and ten times in the presence of conflict with partner. Conclusion: High rates of perinatal depression among women residing in Africa underscore the need for addressing this public health burden. Despite the comparably little emphasis on antenatal depression, antenatal depressive symptoms appear to be as common as postnatal depressive symptoms. Depression screening and psychosocial support that especially addresses conflict resolution during pregnancy should therefore be targeted for future interventions.

Adult Psychotic Symptoms, Their Associated Risk Factors and Changes in Prevalence in Men and Women Over a Decade in a Poor Rural District of Kenya

There have been no repeat surveys of psychotic symptoms in Kenya or indeed subSaharan Africa. A mental health epidemiological survey was therefore conducted in a demographic surveillance site of a Kenyan household population in 2013 to test the hypothesis that the prevalence of psychotic symptoms would be similar to that found in an earlier sample drawn from the same sample frame in 2004, using the same overall methodology and instruments. This 2013 study found that the prevalence of one or more psychotic symptoms was 13.9% with one or more symptoms and 3.8% with two or more symptoms, while the 2004 study had found that the prevalence of single psychotic symptoms in rural Kenya was 8% of the adult population, but only 0.6% had two symptoms and none had three or more psychotic symptoms. This change was accounted for by a striking increase in psychotic symptoms in women (17.8% in 2013 compared with 6.9% in 2004, p < 0.001), whereas there was no significant change in men (10.6% in 2013 compared with 9.4% in 2004, p = 0.582). Potential reasons for this increase in rate of psychotic symptoms in women are explored.

Brief Report: Sexual Violence Against HIV-Positive Women in the Nyanza Region of Kenya: Is Condom Negotiation an Instigator?

Abstract: For people living with HIV, exposure to sexual violence (SV) is associated with decreased adherence to antiretroviral medication, a primary predictor of their survival. Identification of risk factors for SV is a pressing issue in sub-Saharan Africa, where the global majority of HIV-positive women live and the prevalence of SV against women is high. We used qualitative data to examine SV against HIV-positive women enrolled in HIV care in Kenya. Respondents identified husbands as perpetrators of SV in the context of womens efforts to use condoms as directed by HIV care providers.

Probable Post Traumatic Stress Disorder in Kenya and Its Associated Risk Factors: A Cross-Sectional Household Survey

This study aimed to assess the prevalence of probable post-traumatic stress disorder (PTSD), and its associated risk factors in a general household population in Kenya. Data were drawn from a cross-sectional household survey of mental disorders and their associated risk factors. The participants received a structured epidemiological assessment of common mental disorders, and symptoms of PTSD, accompanied by additional sections on socio-demographic data, life events, social networks, social supports, disability/activities of daily living, quality of life, use of health services, and service use. The study found that 48% had experienced a severe trauma, and an overall prevalence rate of 10.6% of probable PTSD, defined as a score of six or more on the trauma screening questionnaire (TSQ). The conditional probability of PTSD was 0.26. Risk factors include being female, single, self-employed, having experienced recent life events, having a common mental disorder (CMD)and living in an institution before age 16. The study indicates that probable PTSD is prevalent in this rural area of Kenya. The findings are relevant for the training of front line health workers, their support and supervision, for health management information systems, and for mental health promotion in state boarding schools.

Malaria and mental disorder: a population study in an area endemic for malaria in Kenya

Malaria, a disease transmitted by blood borne plasmodium parasites from mosquito bites, is still a key contributor to morbidity and mortality in parts of sub-Saharan Africa. However, to our knowledge, there have been no previous epidemiological or clinical studies of the relationship between this disease and mental disorders. The potential links between malaria and mental disorders are complex. Malaria, as a debilitating physical illness, may predispose to depression, while depression may predispose to malaria by affecting immunity and by altering behaviour. Depression may hinder treatment and recovery from malaria, and vice versa. African clinicians are known to often misdiagnose complaints of fatigue and general malaise as malaria when in fact the person has no parasitaemia but suffers from depression. Such misdiagnosis may lead to erroneous prescriptions of antimalarials, which may clear protective low-grade parasitaemia. Meanwhile the individual remains with undiagnosed and untreated depression, which may predispose to malaria and also discourage personal preventive action on malaria. We conducted a household survey in an area of Kenya endemic for malaria in order to examine the associations between malaria and mental disorders. The detailed methods of the survey have been reported elsewhere. To summarize, we drew a random sample of households from a rural health and demographic surveillance site of over 70,000 population near Kisumu, Lake Victoria, Kenya, and selected one adult aged 16 or over at random from each household. Research nurses undertook standardized clinical interviews and blood tests for malaria parasites, which were analyzed at the Kenya Medical Research Institute. The clinical interviews included a systematic assessment of socio-demographic variables. Moreover, we administered the Clinical Interview Schedule-Revised, which appraises the presence of depression, obsessive-compulsive disorder, panic disorder, phobic disorder, generalized anxiety disorder and mixed anxiety-depressive disorder by measuring the presence of 14 symptoms in the preceding month and the frequency, duration and severity of each symptom in the past week, and combining the symptom scores with diagnostic algorithms based on ICD-10. Alternatively, a score of 12 or more across the 14 sections of the interview is considered an indication of the presence of “any common mental disorder (CMD)”. Further assessment instruments included the Psychosis Screening Questionnaire, which measures psychotic symptoms; the WHO Adult ADHD Self-Report Scale Screener, which appraises symptoms of attention-deficit/hyperactivity disorder (ADHD); the Trauma Screening Questionnaire, which appraises symptoms of post-traumatic stress disorder (PTSD); and the Alcohol Use Disorders Identification Test for Consumption (AUDIT), which assesses hazardous drinking. We also asked questions about suicidal thoughts and attempts (last week, last year, and lifetime), and the quantity and frequency of alcohol use. Ethical approval was granted by the King’s College London and Kenya Medical Research Institute Boards of Research Ethics. Informed written and witnessed consent was asked of heads of sampled households, and then of sampled participants, to take part in the study. 1,158 subjects consented to the study, while 32 refused to participate and 149 refused to give a blood sample, thus giving an overall response rate of 91.4%. Malaria parasites were present in 28% of participants, CMD in 10.3%, one or more psychotic symptoms in 13.9%, PTSD in 10.6%, lifetime suicidal thoughts in 7.9%, suicidal attempts in 1.9%, and hazardous drinking in 6.4%. We conducted bivariate and multivariate analyses on the association of malaria with the various mental disorders identified by the assessment instruments, and found that the presence of malaria parasitaemia was associated at the bivariate level with increased rates of CMD (OR 1.7, p50.014), but not with increased rates of psychotic symptoms, ADHD, PTSD, alcohol use, hazardous drinking, or suicidal ideation or attempts. When adjusted for other variables including gender, the association between malaria and CMD remained significant (OR 1.6, p50.05), indicating that the risk of malaria was 60% higher in those with any CMD. This association did not arise from shared method variance due to measurement of symptoms of malaise and fatigue, because – although CMD caseness was identified by the occurrence of 14 different psychological symptoms including fatigue and excessive concern about bodily symptoms – malaria parasitaemia was ascertained by the presence of actual malaria parasites rather than of symptoms per se. The fact that we did not find an association between malaria and psychotic symptoms is interesting but not surprising, as cerebral malaria, which may present with visual hallucinations, necessitates urgent hospital admission, while our sample included all ambulant adults living at home. The key strength of this study is the use of a large representative sample of adults in a health and demographic surveillance site, with a high response rate. Limitations included practical difficulties of collecting blood samples in the field, and getting them safely to the laboratory. The relatively high prevalence rates of both malaria and mental disorders, and the association of malaria parasitaemia with common mental disorder, indicate the importance of strengthening the competence of front line health workers and the ability of health management information systems to record the presence of specific mental disorders as well as of comorbidity between physical and mental disorders. A biopsychosocial approach to training, supervision and health man-

Collaborative interpersonal psychotherapy for HIV-positive women in Kenya: a case study from the Mental Health, HIV and Domestic Violence (MIND) Study

We examine the efficacy of nonspecialists delivering interpersonal psychotherapy (IPT) to HIV-positive (HIV+) women. We describe a case in which local personnel without prior mental health training delivered IPT for the treatment of depression and posttraumatic stress disorder in an HIV+ woman who reported experiencing gender-based violence and was enrolled in HIV care at the Family AIDS, Care, Education and Services program in Kisumu, Kenya.

Sexual violence against HIV-positive women in the Nyanza region of Kenya: Is condom negotiation an instigator?

Abstract: For people living with HIV, exposure to sexual violence (SV) is associated with decreased adherence to antiretroviral medication, a primary predictor of their survival. Identification of risk factors for SV is a pressing issue in sub-Saharan Africa, where the global majority of HIV-positive women live and the prevalence of SV against women is high. We used qualitative data to examine SV against HIV-positive women enrolled in HIV care in Kenya. Respondents identified husbands as perpetrators of SV in the context of womens efforts to use condoms as directed by HIV care providers.

Attention deficit hyperactivity disorder symptom self-report in adults in Kenya and its associated risk factors, an analysis from a household survey in a demographic surveillance site

Background. There have been no household surveys of adult attention deficit and hyperactivity disorder (ADHD) in Kenya, and only one in sub-Saharan Africa. Methods. Data on ADHD was used from a household survey of mental disorders and their associated risk factors conducted in Maseno area (population 70 805), near Lake Victoria in Kenya, using a demographic surveillance site as the sample frame, as part of a wider survey of mental health, malaria and immunity A total of 1190 households were selected, and 1158 adult participants consented to the study while 32 refused to participate in the study interviews, giving a response rate of 97.3%. ADHD symptoms were assessed with the WHO Adult ADHD Self-Report Scale (ASRS) Screener. Results. This survey found that the overall prevalence of ADHD using the ASRS was 13.1%. This suggests a high level of ADHD in the Kenyan population which needs to be further investigated for its impact on adult mental health. In the adjusted analysis, increased odds ratios (ORs) were found in those with higher assets (OR 1.7, p = 0.023), those with life events (OR 2.4, p = 0.001 for those with 2–3 life events and OR 2.6, p < 0.001 for those with 4 or more life events), and those with common mental disorders (OR 2.3, p = 0.001). Conclusion. The study demonstrates the magnitude of ADHD symptoms as a public health issue, relevant for health worker training, and the importance of further research into its prevalence in adults and associated risk factors.