Cardiovascular risk profile of adults with psychotic disorders in Eldoret, Kenya

Introduction: Cardiovascular disorders contribute significantly to mortality and morbidity amongst patient's psychotic disorders such as schizophrenia and bipolar mood disorders. In addition to conventional risk factors for cardiovascular disorders (smoking, alcohol use, inadequate physical activity, hypertension, diabetes, dyslipidaemia, obesity and metabolic syndrome, and non-modifiable factors such as sex, age and social-economic status) exposure to potentially traumatic events, psychological distress, comorbidity of other medical conditions, and use of antipsychotics may also increase cardiovascular risk in patients with psychosis. There is also evidence to suggest that intervention to mitigate such cardiovascular risk factors are suboptimal, hence contributing to poor outcomes. Despite growing interest in cardiovascular health, there remains a paucity of data on the prevalence of the various cardiovascular risk factors among patients with psychosis in low resource settings such as Sub-Saharan Africa. This is likely to differ from high resource contexts given social-cultural and economic differences as well as differences in the health systems. In order to design contextually relevant cardiovascular risk screening, treatment and prevention guidelines that can be integrated into routine care of the mentally ill patients in low- and middle-income countries (LMICs), further work in this setting is warranted. Objectives: The aim of this thesis was to establish the cardiovascular risk profile among patients treated for psychotic disorders at Moi Teaching and Referral Hospital (MTRH) in Eldoret, Western Kenya. Specific objectives were as follows: 1. To conduct a literature review on the burden and etiological mechanisms of cardiovascular risk in patients with psychosis, with a focus on LMIC. 2. To compare the prevalence, as well as sociodemographic and clinical correlates, of conventional cardiovascular risk factors (smoking, alcohol intake, poor diet, and lack of exercise, diabetes mellitus, hypertension, obesity, dyslipidaemia and metabolic syndrome) in patients with psychosis versus matched controls. 3. To establish the prevalence and correlates of non-conventional risk factors; psychological distress, traumatic events (lifetime and childhood trauma) and comorbid medical disorders in patients with psychosis and controls, and to delineate how these risk factors contribute to the overall cardiovascular risk. 4. To describe current psychopharmacological treatments and explore potential associations with cardiovascular risk among patients with psychosis. 5. To explore the overall 10-year cardiovascular disease risk, as well as the social demographic and clinical correlates among patients and controls. 6 .To determine the proportion of untreated metabolic disorders (hypertension, diabetes mellitus, and dyslipidaemia) in patients with psychotic disorders and matched controls. Methods: This was a cross-sectional descriptive survey comparing 300 patients with psychosis and 300 controls at Moi Teaching and Referral Hospital, Western Kenya. A paper based researcher-administered questionnaire was used to collect data on demographic variables (age, sex, education level, and marital status), and risk factors (smoking, alcohol intake, diet, physical activity). We used the Composite International Diagnostic Interview (CIDI) to assess for presence of other chronic medical disorders. Data on childhood trauma were obtained using the Childhood Trauma Questionnaire (CTQ) while the Life Events Checklist (LEC) was used to obtain data on lifetime exposure to potentially traumatic events. Data on psychological distress among controls were obtained using the Kessler-10 questionnaire. Measurements of weight, height, abdominal circumference and blood pressure were taken from each of the participants. Blood was drawn for measurement of glucose level and lipid profile. Data analysis was undertaken using Stata version 15. T-tests were used to compare continuous variables while Pearson chi-squared tests was used for categorical variables. Regression modelling was undertaken to assess associations between sociodemographic and clinical predictor variables and the cardiovascular risk factors. Results: Data collection took place between July 2018 and March 2019. The mean age of patients was 33 years and of controls was 35 years. Compared to controls, patients were more likely to be unmarried (46% vs 33% p< 0.001), and were reduced among females (OR 0.41 p20). The estimated 10 year cardiovascular risk was significantly associated with female Sex (p=0.007), age (p <0.001), current tobacco smoking (p <0.001) and metabolic syndrome (P<0.001). Among the patients, 280 (94.3%) patients were on antipsychotics with the majority (86.5%) being treated with olanzapine. Of all the participants with diabetes 60% among patients and 22% among controls were not on treatment. Of the total number of participants with hypertension, 65% of patients and 47% controls were not on treatment. Conclusion: In the study setting of Eldoret, Western Kenya, patients with psychosis were found to have high levels of lifestyle cardiovascular risk factors such as smoking, inadequate intake of fruits and vegetables and inadequate physical activity. They were also found to have high rates of metabolic disorders such as hypertension, obesity, metabolic syndrome and dyslipidaemia. There was no evidence of increased cardiovascular risk among participants exposed to traumatic life events, with those experiencing psychological distress or those with other chronic medical disorders. The use of olanzapine was not significantly associated with increased cardiovascular risk in this setting. There was an identifiable gap in the treatment of cardiovascular risk factors in this setting. Given these findings, we recommend efforts to address these risk factors by development of protocols to ensure screening for these risk factors, adequate documentation and appropriate treatment

“Association between Traumatic Life Events and Psychosis: A case-control study in western Kenya

Globally close to 70% of the general population has experienced at least one traumatic life event (TLE). Although child and adulthood exposure to TLEs is considered a risk factor for the subsequent development of psychosis, few studies have examined the association between trauma and psychosis in the African population. We sought to explore the association between TLEs and psychosis in patients with psychotic disorders (N = 254) and individuals without (N = 254). The participants were matched by age and sex. The study was conducted at a national referral hospital, the Life Events Checklist for DSM-5 (LEC-5) was used to obtain data on TLEs, and ethical approval was obtained from the ethics committee. The proportion of those who experienced TLEs was equal among the cases and controls at about 80%. However, more cases reported that the TLEs happened to them (cases 60.3, p = 0.004). After multivariate analysis, the following specific TLEs remained statistically significant.: Physical assault (aOR = 3.66, 95% CI 2.28–5.48), assaults with a weapon (aOR = 5.26, 95% CI 2.15–10.48), sexual assault (aOR = 4.55, 95% CI 1.08–10.48). The sudden death of a loved one (aOR = 2.33, 95% CI 1.15–4.70) and serious injury/harm to others (aOR = 10.53, 95% CI 1.47–89.37)

Mental Disorders Among Health Care Workers at the Early Phase of COVID-19 Pandemic in Kenya; Findings of an Online Descriptive Survey

Background: Healthcare workers responding to the Corona Virus Pandemic (COVID-19) are at risk of mental illness. Data is scanty on the burden of mental disorders among Kenyan healthcare workers responding to the pandemic that can inform mental health and psychosocial support. The purpose of this study was to establish the frequency and associated factors of worry, generalized anxiety disorder, depression, posttraumatic stress disorder and poor quality of sleep among Kenyan health care workers at the beginning of COVID-19 pandemic. Methods: We conducted an online survey among 1,259 health care workers in Kenya. A researcher developed social demographic questionnaire and several standardized tools were used for data collection. Standardized tools were programmed into Redcap, (Research Electronic Data Capture) and data analysis was performed using R Core Team. In all analysis a p-value \u3c 0.05 was considered significant. Results: 66% of the participants reported experiencing worry related to COVID-19. 32.1% had depression, 36% had generalized anxiety, 24.2% had insomnia and 64.7% scored positively for probable Post Traumatic Stress Disorder (PTSD). Depression was higher among females compared to men (36.5 vs. 26.9%, p = 0.003), workers \u3c35 years old compared to older ones (38.1 vs. 26.4%, p \u3c 0.001), and those who were not married compared to those who were married (40.6 vs. 27.6%, p \u3c 0.001). Generalized anxiety was commoner among workers aged \u3c35 years (43.5 vs. 29.3%, p \u3c 0.001), females (41.7 vs. 29.2%, p \u3c 0.001), those who mere not married compared to the married (45.2 vs. 31.2%, p \u3c 0.001) and those with \u3c10 years working experience (41.6 to 20.5%, p \u3c 0.001). Younger health care professional had a higher proportion of insomnia compared to the older ones (30.3 vs. 18.6%, p \u3c 0.001). Insomnia was higher among those with \u3c10 years\u27 experience compared to those with more than 20 years\u27 experience(27.3 vs. 17.6%, p = 0.043) Conclusion: Many Kenyan healthcare workers in the early phase of COVID-19 pandemic suffered from various common mental disorders with young, female professionals who are not married bearing the bigger burden. This data is useful in informing interventions to promote mental and psychosocial wellbeing among Kenyan healthcare workers responding to the pandemic

A systematic review of substance use and substance use disorder research in Kenya

Objectives: The burden of substance use in Kenya is significant. The objective of this study was to systematically summarize existing literature on substance use in Kenya, identify research gaps, and provide directions for future research. Methods: This systematic review was conducted in line with the PRISMA guidelines. We conducted a search of 5 bibliographic databases (PubMed, PsychINFO, Web of Science, Cumulative Index of Nursing and Allied Professionals (CINAHL) and Cochrane Library) from inception until 20 August 2020. In addition, we searched all the volumes of the official journal of the National Authority for the Campaign Against Alcohol & Drug Abuse (the African Journal of Alcohol and Drug Abuse). The results of eligible studies have been summarized descriptively and organized by three broad categories including: studies evaluating the epidemiology of substance use, studies evaluating interventions and programs, and qualitative studies exploring various themes on substance use other than interventions. The quality of the included studies was assessed with the Quality Assessment Tool for Studies with Diverse Designs. Results: Of the 185 studies that were eligible for inclusion, 144 investigated the epidemiology of substance use, 23 qualitatively explored various substance use related themes, and 18 evaluated substance use interventions and programs. Key evidence gaps emerged. Few studies had explored the epidemiology of hallucinogen, prescription medication, ecstasy, injecting drug use, and emerging substance use. Vulnerable populations such as pregnant women, and persons with physical disability had been under-represented within the epidemiological and qualitative work. No intervention study had been conducted among children and adolescents. Most interventions had focused on alcohol to the exclusion of other prevalent substances such as tobacco and cannabis. Little had been done to evaluate digital and population-level interventions. Conclusion: The results of this systematic review provide important directions for future substance use research in Kenya

Harmful Alcohol Use Among Healthcare Workers at the Beginning of the COVID-19 Pandemic in Kenya

Background: Healthcare workers play a key role in responding to pandemics like the on-going COVID-19 one. Harmful alcohol use among them could result in inefficiencies in health service delivery. This is particularly concerning in sub-Saharan Africa where the health workforce is already constrained. The aim of this study is to document the burden and correlates of harmful alcohol use among healthcare workers at the beginning of the COVID-19 pandemic in Kenya with the aim of informing policy and practice. Methods: This study was a cross-sectional analysis of data obtained from a parent online survey that investigated the burden and factors associated with mental disorders among healthcare workers during the COVID-19 pandemic in Kenya. We analyzed data obtained from a sub-population of 887 participants who completed the Alcohol Use Disorder Identification Test questionnaire. We used descriptive statistics to summarize the socio-demographic characteristics of the participants and multivariate analysis to determine the factors associated with harmful alcohol use. Results: Three hundred and eighty nine (43.9%) participants reported harmful alcohol use. The factors significantly associated with increased odds of endorsing harmful alcohol use were: being male (AOR = 1.56; 95% CI = 1.14, 2.14; p = 0.006), being unmarried (AOR = 2.06; 95% CI = 1.48, 2.89; p \u3c 0.001), having 11-20 years of experience as compared to having 20+ years of experience (AOR = 1.91; 95% CI = 1.18, 3.12; p = 0.009), and being a specialist (AOR = 2.78; CI = 1.64, 4.78; p = \u3c0.001) or doctor (AOR = 2.82; 95% CI = 1.74, 4.63; p \u3c 0.001) as compared to being a nurse. Conclusions: A high proportion of healthcare workers reported harmful alcohol use at the beginning of the COVID-19 pandemic in Kenya. Males, the unmarried, those with 11–20 years of experience in the health field, doctors and specialists, were more likely to report harmful alcohol use. These findings highlight the need to institute interventions for harmful alcohol use targeting these groups of healthcare workers in Kenya during the COVID-19 pandemic in order to optimize functioning of the available workforce

Adaptation of the client diagnostic questionnaire for East Africa

Research increasingly involves cross-cultural work with non-English-speaking populations, necessitating translation and cultural validation of research tools. This paper describes the process of translating and criterion validation of the Client Diagnostic Questionnaire (CDQ) for use in a multisite study in Kenya and Uganda. The English CDQ was translated into Swahili, Dholuo (Kenya) and Runyankole/Rukiga (Uganda) by expert translators. The translated documents underwent face validation by a bilingual committee, who resolved unclear statements, agreed on final translations and reviewed back translations to English. A diagnostic interview by a mental health specialist was used for criterion validation, and Kappa statistics assessed the strength of agreement between non-specialist scores and mental health professionals’ diagnoses. Achieving semantic equivalence between translations was a challenge. Validation analysis was done with 30 participants at each site (median age 32.3 years (IQR = (26.5, 36.3)); 58 (64.4%) female). The sensitivity was 86.7%, specificity 64.4%, positive predictive value 70.9% and negative predictive value 82.9%. Diagnostic accuracy by the non-specialist was 75.6%. Agreement was substantial for major depressive episode and positive alcohol (past 6 months) and alcohol abuse (past 30 days). Agreement was moderate for other depressive disorders, panic disorder and psychosis screen; fair for generalized anxiety, drug abuse (past 6 months) and Post Traumatic Stress Disorder (PTSD); and poor for drug abuse (past 30 days). Variability of agreement between sites was seen for drug use (past 6 months) and PTSD. Our study successfully adapted the CDQ for use among people living with HIV in East Africa. We established that trained non-specialists can use the CDQ to screen for common mental health and substance use disorders with reasonable accuracy. Its use has the potential to increase case identification, improve linkage to mental healthcare, and improve outcomes. We recommend further studies to establish the psychometric properties of the translated tool

Exploring user experiences of a text message-delivered intervention among individuals on opioid use disorder treatment in Kenya: A qualitative study.

Opioid use disorder causes significant burden of disease and treatment comprises pharmacotherapy and psychosocial treatment. Cognitive behavioral therapy is an effective psychosocial intervention used in substance use disorders treatment and can be delivered using digital approach. There is limited use of digital treatment among individuals with opioid use disorder in Kenya. This study aimed to describe the experiences and feedback from participants with opioid use disorder enrolled in a text-message intervention in Kenya. Qualitative data was collected from participants in the intervention arm of a feasibility trial testing a text-message intervention based on cognitive behavioral therapy. Data was collected using open-ended questions in a questionnaire and structured in-depth interviews amongst those who received the intervention. Framework method was applied for analysis. Twenty-four participants (83.3% males) were enrolled with a mean age of 32.5 years (SD9.5). Five themes were identified namely: (1) Gain of cognitive behavioral therapy skills which included: identification and change of substance use patterns; drug refusal skills; coping with craving and self-efficacy; (2) Therapeutic alliance which included: development of a bond and agreement on treatment goals; (3) Feedback on intervention components and delivery such as: frequency, and duration of the text message intervention; (4) Challenges experienced during the intervention such as: technical problems with phones; and barriers related to intervention delivery; (5) Recommendations for improvement of intervention in future implementations. The findings demonstrated participants' satisfaction with intervention, gain of skills to change substance use patterns, highlighted challenges experienced and suggestions on improving the intervention among individuals with opioid use disorder. The feedback and recommendations provided by the participants can guide implementation of such interventions to allow acceptability, effectiveness and sustainability. Trial registration: This study was part of a randomized feasibility trial. Clinical trial registration: Pan African Clinical Trial Registry: Registration number: PACTR202201736072847. Date of registration: 10th January 2022

Mental healthcare services in Kenyan counties: a descriptive survey of four counties in Western Kenya

Abstract Background The government of Kenya has made progressive efforts towards improving mental health services in the country. However there is little documentation of mental health services in the counties that would support actualization of the legislative frameworks in the context of a devolved healthcare system. This study sought to document existing mental health services within 4 counties in Western Kenya. Methods We conducted a cross sectional descriptive survey of four counties using the World Health Organization, Assessment Instrument for Mental Health Systems (WHO-AIMS). Data was collected in 2021, with 2020 being the year of reference. We collected data from the facilities offering mental healthcare within the counties as well as from County health policy makers and leaders. Results Mental healthcare was provided at higher level facilities within the counties, with minimal structures at primary care facilities. No county had a stand-alone policy on mental health services or dedicated budget for mental healthcare. The national referral hospital, within Uasin-Gishu county, had a clear mental health budget for mental health. The national facility in the region had a dedicated inpatient unit while the other three counties admitted patients in general medical wards but had mental health outpatient clinics. The national hospital had a variety of medication for mental health care while the rest of the counties had very few options with antipsychotics being the most available. All the four counties reported submitting data on mental health to Kenya health information system (KHIS). There were no clearly defined mental healthcare structures in the primary care level except for funded projects under the National referral hospital and the referral mechanism was not well defined. There was no established mental health research in the counties except that which was affiliated to the national referral hospital. Conclusion In the four counties in Western Kenya, the mental health systems are limited and not well structured, are faced with limited human and financial resources and there is lack of county specific legistrative frameworks to support mental healthcare. We recommend that counties invest in structures to support provision of quality mental healthcare to the people they serve

Adapting a substance use screening and brief intervention for peer-delivery and for youth in Kenya

Background: Substance use is a major problem among youth in sub-Saharan Africa, yet interventions that address this problem are scarce within the region. Screening and brief intervention is a cost-effective, efficacious, and easy to scale public health approach to addressing substance use problems. We conducted a pilot study to evaluate the feasibility of implementing a peer delivered screening and brief intervention program for youth in Kenya. The goal of this paper is to report on the process of adapting the Alcohol Smoking and Substance Involvement Screening Test for Youth-linked Brief Intervention (ASSIST-Y-linked BI) program for peer delivery and for the Kenyan context prior to the pilot. Methods: The adaptation process was led by a multi-disciplinary team comprised of psychiatrists, pediatricians, and psychologists. We utilized the ADAPT-ITT framework to adapt the ASSIST-Y-linked BI. The ADAPT-ITT framework consists of 8 phases including Assessment, Decision making, Adaptation, Production, Topical Experts, Integration, Training, and Testing the evidence-based intervention. Here, we report on phases 1–7 of the framework. The results of the pilot testing will be out in 2023. Results: Overall, we made surface level adaptations to the ASSIST-Y-linked BI program such as simplifying the language to enhance understandability. We maintained the core components of the program i.e., Feedback, Responsibility, Advice, Menu of Options, Empathy, Self-efficacy (FRAMES). Conclusions: Our paper provides information which other stakeholders planning to implement the ASSIST-Y-linked BI for youth in sub-Saharan Africa, could use to adapt the intervention

Social support and the effects of the COVID-19 pandemic among a cohort of people living with HIV (PLWH) in Western Kenya

As coronavirus disease (COVID-19) was declared a pandemic in 2020, countries around the world implemented various prevention strategies, such as banning of public and social gatherings, restriction in movement, etc. These efforts may have had a deleterious effect on already vulnerable populations, including people living with HIV (PLWH). PLWH were concerned about contracting COVID-19, the impact of COVID-19 on their social networks that provide social support, and the continued availability of antiretroviral medications during the pandemic. In addition, their mental health may have been exacerbated by the pandemic. The purpose of this study was to explore pandemic-related concerns among a cohort of PLWH in Kenya and investigate social support factors associated with symptoms of depression and anxiety. This study is part of a larger cohort study that recruited from two clinics in Western Kenya. Data are drawn from 130 PLWH who participated in two phone surveys about experiences during the pandemic in 2020 and 2021. Participants reported a variety of concerns over the course of the pandemic and we documented statistically significant increases in symptoms of depression and anxiety over time, which affected some participants’ ability to adhere to their antiretroviral medication. However, a small but statistically significant group of participants reached out to expand their networks and mobilize support in the context of experiencing mental health and adherence challenges, speaking to the importance of social support as a coping strategy during times of stress. Our findings call for holistic approaches to HIV care that consider the broader political, economic, and social contexts that shape its effectiveness