Theoneste Rutayisire

The effect on mental health of a large scale psychosocial intervention for survivors of mass violence: A quasi-experimental study in Rwanda

Background War has serious and prolonged mental health consequences. It is argued that post-emergency mental health interventions should not only focus on psychological factors but also address the social environment. No controlled trials of such interventions exist. We studied the effect on mental health of a large scale psychosocial intervention primarily aimed at social bonding in post-genocide Rwanda. The programme is implemented at population level without diagnostic criteria for participation. It is open to any person older than 15 years, and enables participation of over 1500 individuals per year. We postulated that the mental health of programme participants would improve significantly relative to non-participants. Methods and Findings We used a prospective quasi-experimental study design with measurement points pre and post intervention and at 8 months follow-up. 100 adults from both sexes in the experimental condition entered the study; follow-up measurements were taken from 81. We selected a control group of 100 respondents with similar age, sex and symptom score distribution from a random community sample in the same region; of these, 73 completed the study. Mental health was assessed by use of the Self Reporting Questionnaire (SRQ-20), a twenty item instrument to detect common mental disorders in primary health care settings. Mean SRQ-20 scores decreased by 2.3 points in the experimental group and 0.8 in the control group (p = 0.033). Women in the experimental group scoring above cut-off at baseline improved with 4.8 points to below cut-off (p<0.001). Men scoring above cut-off at baseline showed a similar trend which was statistically non-significant. No adverse events were observed. Conclusions A large scale psychosocial intervention primarily aimed at social bonding caused a lasting improvement of mental health in survivors of mass violence in Rwanda. This approach may have a similar positive effect in other post-conflict settings. Trial Registration Nederlands Trial Register 1120

Psychometric properties and longitudinal validation of the self-reporting questionnaire (SRQ-20) in a Rwandan community setting: a validation study

BackgroundThis study took place to enable the measurement of the effects on mental health of a psychosocial intervention in Rwanda. It aimed to establish the capacities of the Self-Reporting Questionnaire (SRQ-20) to screen for mental disorder and to assess symptom change over time in a Rwandan community setting.MethodsThe SRQ-20 was translated into Kinyarwanda in a process of forward and back-translation. SRQ-20 data were collected in a Rwandan setting on 418 respondents; a random subsample of 230 respondents was assessed a second time with a three month time interval. Internal reliability was tested using Cronbachs alpha. The optimal cut-off point was determined by calculating Receiver Operating Curves, using semi-structured clinical interviews as standard in a random subsample of 99 respondents. Subsequently, predictive value, likelihood ratio, and interrater agreement were calculated. The factor structure of the SRQ-20 was determined through exploratory factor analysis. Factorial invariance over time was tested in a multigroup confirmatory factor analysis.ResultsThe reliability of the SRQ-20 in women (α = 0.85) and men (α = 0.81) could be considered good. The instrument performed moderately well in detecting common mental disorders, with an area under the curve (AUC) of 0.76 for women and 0.74 for men. Cut-off scores were different for women (10) and men (8). Factor analysis yielded five factors, explaining 38% of the total variance. The factor structure proved to be time invariant.ConclusionsThe SRQ-20 can be used as a screener to detect mental disorder in a Rwandan community setting, but cut-off scores need to be adjusted for women and men separately. The instrument also shows longitudinal factorial invariance, which is an important prerequisite for assessing changes in symptom severity. This is a significant finding as in non-western post-conflict settings the relevance of diagnostic categories is questionable. The use of the SRQ-20 can be considered an alternative option for measuring the effect of a psychosocial intervention on mental health.Trial registrationNederlands Trial Register NTR1120.

Intimate Partner Violence in Rwanda: The Mental Health of Victims and Perpetrators

Exposure to intimate partner violence (IPV) is a common feature of women living in low- and middle-income countries. Several studies have shown a significant association between IPV against women and mental health in both developed and in low- and middle-income countries. In postconflict settings, the relationship between IPV and mental health is likely more complex, given the high levels of violence experienced by the population as a whole. In this cross-sectional study the authors explore the association between IPV and common mental health disorders (CMD), and more specifically, suicidal ideation, among inhabitants of postgenocide Rwanda. The authors use the concept of “mutual partner violence,” thereby exploring the association between IPV and CMD in victims, perpetrators, and those who state they are both. Data of 241 married men and women were used. Symptoms suggestive of CMD were established by use of the Self-Reporting Questionnaire (SRQ-20), and physical intimate partner violence was measured using the Conflict Tactics Scale, Short Version (CTS2S). The authors applied multivariate logistic regressions with total SRQ-20 scores (above/below cutoff) and suicidal ideation as the outcome measures and corrected for age and gender. The study findings suggest that reported IPV is associated with CMD (odds ratio [OR] = 1.7, 95% confidence interval [95% CI] = 0.92-3.15) and suicidal ideation (OR = 1.6, 95% CI = 0.70-3.53). Those who state to be both victim and perpetrator (OR = 1.75, 95% CI = 0.82-3.72), or only perpetrator (OR = 3.13, 95% CI = 0.49-20.0), are more likely to report mental health problems than victims and people who do not report IPV. In a postconflict situation, perpetrators of IPV may suffer from mental health problems as much as, or even more than, victims. Longitudinal data are needed to clarify the complex relationship between CMD and IPV, especially if outcomes may also be related to other forms of violence experienced in the past.

Sexual transgression and social disconnection: healing through community-based sociotherapy in Rwanda

A distinguishing feature of the 1994 genocide against the Tutsi and the preceding 1990–1994 war in Rwanda was the social intimacy of the crimes committed. The legacy of this kind of violence includes distrust in social relations within communities and families, an increase of violence in everyday social interaction, transgressive sexual engagements, and a range of psychological problems. Many people feel nostalgia for their past social life, but are unable to change their current situation. In 2005, a community-based sociotherapy programme was introduced into this context of mental and social distress. The goal was to help people regain feelings of dignity and safety and to reduce distress. This paper is based on qualitative research, in particular, case studies. It explores how sociotherapy, as a specific form of peer group counselling, may facilitate the healing of suffering related to issues of sexuality, violence within the family and the breakdown of social connections on a community level.

The validation of a social functioning questionnaire in an African postconflict context

This study evaluated the reliability and criterion validity of the Byumba Social Functioning Questionnaire (BSFQ), an instrument to measure social functioning in Rwanda. The instrument was locally composed in concordance with a well-described method for culture-specific and sex-specific function assessment. Respondents in a Northern Province of Rwanda (N = 393) were assessed with the BSFQ and a 19-item scale (SF-19) drawn from the Medical Outcomes Study 36-Item Short-Form (SF-36). The BSFQ’s internal consistency was just acceptable for women but poor for men, while the SF-19 had good to excellent internal consisteny. BSFQ total scores showed a strong floor effect, while the SF-19 showed more variation in total score distribution. The BSFQ did not perform as well as we expected, and appears not to be suitable for measuring social functioning in the study context. This outcome seems to reflect the conceptualization of social functioning used in constructing the BSFQ. Implications for the development of culture-specific measures of functional status are discussed.

Before my time? Addressing the intergenerational legacies of the genocide against the Tutsi in Rwanda

This study aims to (i) understand how the legacies of the 1994 genocide against the Tutsi and its aftermath are transmitted to the next generation within Rwandan families and (ii) explore how institutional support plays a role in the pathways of intergenerational transmission. Through an in-depth analysis of qualitative interviews with 41 mothers and one of their adolescent children, we identified direct and indirect pathways through which the legacies of the genocide are transmitted to the second generation. Direct pathways concern the ways in which the genocide and its aftermath are reflected upon, reconstructed and explicitly communicated or silenced to the second generation. Indirect pathways are ways in which the genocide and its aftermath affect the life circumstances of the children, and through that, the child. Many of the included households had access to at least some kind of support. In general, our results indicate that organisations providing support to families and individuals in post-conflict settings might want to consider focusing explicitly on the identified pathways of intergenerational transmission to improve the living conditions of the next generation(s). Key implications for practice Development organisations that provide support to families in post-conflict settings could specifically address parenting, family relations and family communication and interactions to help participants secure a safe environment for the next generations to grow up in Development organisations in post-conflict settings could specifically facilitate and encourage the interactions of participants with the broader social environment and the community to stimulate cooperation and social support Stimulating the development of economic cooperation among the participants of support programmes in post-conflict settings as well as within their communities may be helpful in reducing intergenerational poverty.