Routine outcome measurement in adolescents seeking mental health services: standardization of HoNOSCA in Kenyan sample

Abstract: Background The evaluation of treatment outcomes is important for service providers to assess if there is improvement or not. The Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) was developed for this use in child and adolescent mental health services. Outcome measurement in routine mental health services is limited. This paper evaluates the psychometric properties of the self and clinician rated versions of the HoNOSCA for routine use in child and adolescent mental health services in Kenya. Methods Using a prospective design, the clinician- and self-rated versions of the HoNOSCA and the Paediatric Symptom Checklist (PSC) were administered at the Youth Centre at the Kenyatta National Hospital in Nairobi. Initial ratings were obtained from adolescents 12-17 years (n = 201). A sample of 98 paired ratings with 2 follow-ups were examined for measurement of change over time. Results Our findings showed good reliability with the self-rated version of the HoNOSCA score, correlating well with the self-reported version of the PSC (r = .74, p \u3c .001). Both versions correlated well at follow-up and were sensitive to change. Using factor analysis, the maximum likelihood factoring and Promax rotation resulted in a four-factor structure, which with a Kaiser–Meyer–Olkin measure of sampling adequacy of 0.8 explained 54.74% of total variance. Conclusion The HoNOSCA appears to be of value, and easy to use in routine settings. Our findings suggest further investigation with a larger sample

Mapping services at two Nairobi County primary health facilities: identifying challenges and opportunities in integrated mental health care as a Universal Health Coverage (UHC) priority

Abstract: Introduction There is a need to scale-up mental health service provision in primary health care. The current extent of integration of mental health in primary care is pertinent to promoting and augmenting mental health at this level. We describe a facility mapping exercise conducted in two low-income/primary health facilities in Kenya to identify existing barriers and facilitators in the delivery of mental health services in general and specifically for peripartum adolescents in primary health care as well as available service resources, cadres, and developmental partners on the ground. Method and measures This study utilized a qualitative evidence synthesis through mapping facility-level services and key-stakeholder interviews. Services-related data were collected from two facility in-charges using the Nairobi City County Human Resource Health Strategy record forms. Additionally, we conducted 10 key informant interviews (KIIs) with clinical officers (Clinicians at diploma level), Nurses, Community Health Assistants (CHAs), Prevention of Mother-to-child Transmission of HIV Mentor Mothers (PMTCTMs), around both general and adolescent mental health as well as psychosocial services they offered. Using the World Health Organization Assessments Instrument for Mental Health Systems (WHO-AIMS) as a guideline for the interview, all KII questions were structured to identify the extent of mental health integration in primary health care services. Interview transcripts were then systematically analyzed for common themes and discussed by the first three authors to eliminate discrepancies. Results Our findings show that health care services centered around physical health were offered daily while the mental health services were still vertical, offered weekly through specialist services by the Ministry of Health directly or non-governmental partners. Despite health care workers being aware of the urgent need to integrate mental health services into routine care, they expressed limited knowledge about mental disorders and reported paucity of trained mental health personnel in these sites. Significantly, more funding and resources are needed to provide mental health services, as well as the need for training of general health care providers in the identification and treatment of mental disorders. Our stakeholders underscored the urgency of integrating mental health treatment, prevention, and well-being promotive activities targeting adolescents especially peripartum adolescent girls. Conclusion There is a need for further refining of the integrated care model in mental health services and targeted capacity-building for health care providers to deliver quality services

Validation of the English and Swahili Adaptation of the Patient Health Questionnaire–9 for Use Among Adolescents in Kenya

Purpose: Our study aimed to validate culturally adapted English and Swahili versions of the Patient Health Questionnairee9 (PHQ-9) for use with adolescents in Kenya. Criterion validity was determined with clinician-administered diagnostic interviews using the Kiddie Schedule of Affective Disorders and Schizophrenia. Methods: A total of 250 adolescents comprising 148 (59.2%) females and 102 (40.8%) males aged 10e19 years (mean ¼ 14.76; standard deviation ¼ 2.78) were recruited. The PHQ-9 was administered to all respondents concurrently in English and Swahili. Adolescents were later interviewed by clinicians using Kiddie Schedule of Affective Disorders and Schizophrenia to determine the presence or absence of current symptoms of major depressive disorder. Sensitivity specificity, positive predictive value (PPV) and negative predictive value (NPV), and likelihood ratios for various cut-off scores for PHQ-9 were analyzed using receiver operating characteristic curves. Results: The internal consistency (Cronbach’s a) for PHQ-9 was 0.862 for the English version and 0.834 for Swahili version. The area under the curve was 0.89 (95% confidence interval, 0.84e0.92) and 0.87 (95% confidence interval, 0.82e0.90) for English and Swahili version, respectively, on receiver operating characteristic analysis. A cut-off of 9 on the English-language version had a sensitivity of 95.0%, specificity of 73.0%, PPV of 0.23, and NPV of 0.99; a cut-off of 9 on the Swahili version yielded a sensitivity of 89.0%, specificity of 70.0%, PPV of 0.20, and NPV of 0.9

Prevalence and correlates of bacterial vaginosis in different sub-populations of women in Sub-Saharan Africa: a cross-sectional study

Background: Clinical development of vaginally applied products aimed at reducing the transmission of HIV and other sexually transmitted infections, has highlighted the need for a better characterisation of the vaginal environment. We set out to characterise the vaginal environment in women in different settings in sub-Saharan Africa. Methods: A longitudinal study was conducted in Kenya, Rwanda and South-Africa. Women were recruited into pre-defined study groups including adult, non-pregnant, HIV-negative women; pregnant women; adolescent girls; HIV-negative women engaging in vaginal practices; female sex workers; and HIV-positive women. Consenting women were interviewed and underwent a pelvic exam. Samples of vaginal fluid and a blood sample were taken and tested for bacterial vaginosis (BV), HIV and other reproductive tract infections (RTIs). This paper presents the cross-sectional analyses of BV Nugent scores and RTI prevalence and correlates at the screening and the enrolment visit. Results: At the screening visit 38% of women had BV defined as a Nugent score of 7-10, and 64% had more than one RTI (N. gonorrhoea, C. trachomatis, T. vaginalis, syphilis) and/or Candida. At screening the likelihood of BV was lower in women using progestin-only contraception and higher in women with more than one RTI. At enrolment, BV scores were significantly associated with the presence of prostate specific antigen (PSA) in the vaginal fluid and with being a self-acknowledged sex worker. Further, sex workers were more likely to have incident BV by Nugent score at enrolment. Conclusions: Our study confirmed some of the correlates of BV that have been previously reported but the most salient finding was the association between BV and the presence of PSA in the vaginal fluid which is suggestive of recent unprotected sexual intercourse

Mental Health and Psychosocial Support During COVID-19: A Review of Health Guidelines in Sub-Saharan Africa

The COVID-19 pandemic brought in its wake an unforeseen mental health crisis. The World Health Organization published a guideline as a way of supporting mental health and psychosocial well-being of different groups during this pandemic. The impact of the pandemic has pushed governments to put measures in place to curb not only the physical health of individuals but their mental health and psychosocial well-being as well. The aim of our paper was to review mental health guidelines of some Sub Saharan African (SSA) countries: (i) to assess their appropriateness for the immediate mental health needs at this time, (ii) to form as a basis for ongoing reflection as the current pandemic evolves. Guidelines were retrieved openly from internet search and some were requested from mental health practitioners in various SSA countries. The authors designed a semi structured questionnaire, as a self-interview guide to gain insight on the experience of COVID-19 from experts in the mental health sector in the various countries. While we used a document analysis approach to analyze the data, we made use of the Mental Health Preparedness and Action Framework to discuss our findings. We received health or mental health guidelines from 10 SSA countries. Cameroon, Kenya, South Africa, Tanzania, and Uganda all had mental health guidelines or mental health component in their health guidelines. Our experts highlight that the mental health needs of the people are of concern during this pandemic but have not been given priority. They go further to suggest that the mental health needs are slightly different during this time and requiring a different approach especially considering the measures taken to curb the spread of disease. We conclude that despite the provision of Mental Health and Psychosocial Support guidelines, gaps still exist making them inadequate to meet the mental health needs of their communities

Process and outcome of child psychotherapies offered in Kenya:a mixed methods study protocol on improving child mental health

Background: Child and adolescent mental health problems account for a significant proportion of the local and global burden of disease and is recognized as a growing public health concern in need of adequate services. Studies carried out in Kenya suggest a need for a robust service for the treatment, prevention, and promotion of child and adolescent mental health. Despite a few existing services to provide treatment and management of mental health disorders, we need more knowledge about their effectiveness in the management of these disorders. This paper describes a study protocol that aims to evaluate the process and outcomes of psychotherapies offered to children and adolescents seeking mental health services at the Kenyatta National Hospital in Kenya. Methods: This study will use a prospective cohort approach that will follow adolescent patients (12-17 years of age) receiving mental health services in the youth clinics at the Kenyatta National Hospital for a period of 12 months. During this time a mixed methods research will be carried out, focusing on treatment outcomes, therapeutic relationship, understanding of psychotherapy, and other mental health interventions offered to the young patients. In this proposed study, we define outcome as the alleviation of symptoms, which will be assessed quantitatively using longitudinal patient data collected session-wise. Process refers to the mechanisms identified to promote change in the adolescent. For example, individual participant or clinician characteristics, therapeutic alliance will be assessed both quantitatively and qualitatively. In each session, assessments will be used to reduce problems due to attrition and to enable calculation of longitudinal change trajectories using growth curve modeling. For this study, these will be referred to as session-wise assessments. Qualitative work will include interviews with adolescent patients, their caregivers as well as feedback from the mental health care providers on existing services and their barriers to providing care. Conclusion: This study aims to understand the mechanisms through which change takes place beyond the context of psychotherapy. What are the moderators and through which mechanisms do they operate to improve mental health outcomes in young people

Outcome evaluation of psychological interventions offered to adolescents seeking mental health services at the national referral and teaching hospital in Nairobi, Kenya

Background: Literature highlights that adolescent mental health problems are amenable to treatment, specifically to psychological interventions. Unfortunately, there is a dearth of evidence on the services available for their management especially in low-middle-income contexts. This study aimed to highlight psychological interventions available to adolescents seeking mental health services at the National referral hospital in Kenya and to understand their effectiveness in the management of child and adolescent mental disorders. Methods: Making use of a naturalistic, observational approach, we followed a cohort of adolescents (n ​= ​201) receiving talk therapy. Assessments were collected at the beginning and end of each session to assess patient outcomes and therapeutic alliance over the 12-month study period, with participants attending an average of three sessions. Analysis was carried out on the entire sample including descriptive and bivariate analyses, as well as analyses of clinical and reliable change. Sub-analysis was also carried out on a smaller sample who had a clinical diagnosis. Results: Scores on the Paediatric Symptom Checklist [M(SD) ​= ​51.1 (9.55)] showed our participants had high levels of impairment warranting further treatment. However, only 37.3% were assigned a clinical diagnosis. It was noted that the adolescents received multiple therapies. Our findings on outcome showed that there was statistically significant mean decrease in scores from intake to second follow-up on the self and clinician rated outcomes. Post hoc analysis with a Bonferroni adjustment revealed that outcome scores statistically significantly decreased from intake to second follow-up at 3.39 (95% CI, 1.61 to 5.17) on self-rated and 2.64 (95% CI, 1.38 to 3.9) on the clinician-rated scores. Conclusion: Our findings illustrate mental health services, specifically psychotherapies offered to adolescents seeking care in a public institution are associated with alleviation of adolescent distress over time

Understanding mental health difficulties and associated psychosocial outcomes in adolescents in the HIV clinic at Kenyatta National Hospital, Kenya

Abstract Background Globally adolescents continue to have an upward trend in HIV incidence and AIDS-related mortality. The interplay between the rapid physical growth, sexual maturation, and enormous albeit slow-evolving cognitive and psychological changes in adolescence may partly explain this trend. Our main purpose was to highlight key psychosocial characteristics of HIV-infected adolescents and explore if these characteristics are associated with depression symptoms. Methods From August to December 2016 after obtaining informed consent, adolescents living with HIV at Kenyatta National Hospital were interviewed using the Home environment, Education and Employment, Activity, Sexuality, Suicide and depression traits (HEADSS) tool combined with the Patient Health Questionnaire (PHQ-9) to elucidate which key symptoms of depression and link with psychosocial characteristics mapped on HEADSS. In order to determine which psychosocial characteristics were linked with risk of depression, the traits of adolescents who were symptomatic were compared to those who were not using univariate and multivariate regression analysis. Results All the 270 adolescents offered participation in the study accepted to enroll. The aged 10–19 years were recruited and mean age was 14.75 and 53.7% (n = 145) were males. Overall, 269 (99.9%) were still in school and 52.6% of the adolescents had symptoms of depression. The independent predictors of depression were being of ages 15–19 years [OR = 2.34 (95% CI 1.36, 4.04) P < 0.02], ever repeating classes [OR = 1.74 (95% CI 1.0–3.05) P = 0.05], ever being sent away from school due to lack of school fees [OR = 1.71 (95% CI 1.0–2.91) P = 0.05], and non-adherence to medication [OR = 1.84 (95% CI 1.08–3.14) P = 0.03. Missing of meals due to food insecurity was associated with an important trend towards increased risk of depression [OR = 2.42 (CI 0.96–6.14) P = 0.06]. Conclusion One in two of the adolescents interviewed had depression symptoms which were significantly associated with lack of school fees, missing meals, non-adherence to medication, and substance abuse

Attachment and Its Social Determinants, Kenyan Child and Adolescent Perspective from Two Informal Settlements in Nairobi: A Qualitative Study

Abstract: There has been a sustained interest in examining social determinants of health (SDH) for late childhood and adolescence to shift the focus from individual risk factors to social patterns, material conditions and to improve long-term health outcomes. This study offers an opportunity to look at the number of risk and protective factors associated with SDH using children\u27s narratives around their attachment relationships. The research was carried out in Kariobangi and Kangemi health centers of Nairobi County, Kenya. All 83 participants were recruited from the community with the assistance of community health workers. Fifty-seven percent of participants were girls; 65.1% of ages 12–14 and 34.9% of ages 8–11 years. Child Attachment Interview (Target et al., 2003) was used to study attachment security as well as adolescents’ understanding of their relational and social world. Inductive thematic analysis was informed by preexisting themes identified from the literature on “risk” and “protective” factors within different layers of SDH and focused on identifying children’s understanding and appraisals of those factors. Secure attachment with both parents had 37.3% of participants 33.7% had insecure attachment with one parent, and 28.9% had insecure attachment with both parents. The overarching themes included poverty, parenting, religion, and schooling. Some factors commonly classified as protective or risk factors were described and appraised by children as a more complex and multidimensional phenomenon. Apart from it, these factors appeared interconnected and interrelated with each other on different levels of SDH

Shifting parental roles, caregiving practices and the face of child development in low resource informal settlements of Nairobi: experiences of community health workers and school teachers

Abstract Approximately, 42% of the Kenyan population live below the poverty line. Rapid growth and urbanization of Kenya’s population have resulted in a changing poverty and food security environment in high-density urban areas. Lack of basic food needs in Kenya affects approximately 34.8% rural population and 7.6% of its urban population. Using multi-community stakeholders such as teachers and community health workers (CHWs), this paper examined food insecurity and its consequences on caregiving practices and child development. A qualitative study design was utilized. Key informant interviews and focused-group discussions with four primary school teachers and three CHWs and a nurse in-charge working within Kariobangi and Kangemi were applied to elicit various perspectives from family-, school- and community-level challenges that influence caregiving practices and child development. Grounded theory method was applied for qualitative data sifting and thematic analysis. Our findings exposed various challenges at the school, family and the community levels that affect caregiving practices and consequent child development. School-level challenges included lack of adequate amenities for effective learning, food insecurity, absenteeism and mental health challenges. Family-level barriers included lack of parenting skills, financial constraints, domestic violence and lack of social support, while community challenges such as unemployment, poor living conditions, cultural practices, lack of social support and poor community follow-up mechanisms contributed to poor parenting practices and child development. Parenting practices and holistic child development strategies in resource poor settings should focus on parenting skills, food security, quality education and addressing parents and children’s mental health challenges