Person:

Betancourt, Theresa

As one article in an ongoing series on Global Mental Health Practice, Etheldreda Nakimuli-Mpungu and colleagues describe a private-public partnership that implemented and scaled psycho-trauma centers in Northern Uganda.

Overview: The World Health Organization Disability Assessment Schedule for children (WHODAS-Child) is a disability assessment instrument based on the WHO's International Classification of Functioning, Disability and Health for children and youth. It is modified from the original adult version specifically for use with children. The aim of this study was to assess the WHODAS-Child structure and metric properties in a community sample of children with and without reported psychosocial problems in rural Rwanda. Methods: The WHODAS-Child was first translated into Kinyarwanda through a detailed committee translation process and back-translation. Cognitive interviewing was used to assess the comprehension of the translated items. Test-retest reliability was assessed in a group of 64 children. The translated WHODAS-Child was then administered to a final sample of 367 children in southern Kayonza district in rural southeastern Rwanda within a larger psychosocial assessment battery. The latent structure was assessed through confirmatory factor analysis. Reliability was evaluated in terms of internal consistency (Cronbach's alpha) and test-retest reliability (Pearson's correlation coefficient). Construct validity was explored by examining convergence between WHODAS-Child scores and mental disorder status, and divergence of WHODAS-Child scores with protective factors and prosocial behaviors. Concordance between parent and child scores was also assessed. Results: The six-factor structure of the WHODAS-Child was confirmed in a population sample of Rwandan children. Test-retest and inter-rater reliability were high (r = .83 and ICC = .88). WHODAS-Child scores were moderately positively correlated with presence of depression (r = .42, p<.001) and post-traumatic stress disorder (r = .31, p<.001) and moderately negatively correlated with prosocial behaviors (r = .47, p<.001). The Kinyarwanda version of the WHODAS-Child was found to be a reliable and acceptable self-report tool for assessment of functional impairment among children largely referred for psychosocial problems in the study district in rural Rwanda. Further research in low-resource settings and with more general populations is recommended.

Background: The conflict in eastern Democratic Republic of the Congo (DRC) is the deadliest since World War II. Over a decade of fighting amongst an array of armed groups has resulted in extensive human rights abuses, particularly the widespread use of sexual violence against women. Methods: Using a mixed-methods approach, we surveyed a non-random sample of 255 women attending a referral hospital and two local non-governmental organizations to characterize their experiences of sexual and gender-based violence (SGBV). We then conducted focus groups of 48 women survivors of SGBV to elaborate on survey findings. Quantitative and qualitative data underwent thematic and statistical analysis respectively. Findings: Of the women surveyed, 193 (75.7%) experienced rape. Twenty-nine percent of raped women were rejected by their families and 6% by their communities. Thirteen percent of women had a child from rape. Widowhood, husband abandonment, gang rape, and having a child from rape were significant risk factors for social rejection. Mixed methods findings show rape survivors were seen as "contaminated" with HIV, contributing to their isolation and over 95% could not access prophylactic care in time. Receiving support from their husbands after rape was protective against survivors' feelings of shame and social isolation. Interpretation: Rape results not only in physical and psychological trauma, but can destroy family and community structures. Women face significant obstacles in seeking services after rape. Interventions offering long-term solutions for hyper-vulnerable women are vital, but lacking; reintegration programs on SGBV for women, men, and communities are also needed.

Background: Neuropsychiatric conditions comprise 14% of the global burden of disease and 30% of all noncommunicable disease. Despite the existence of cost-effective interventions, including administration of psychotropic medicines, the number of persons who remain untreated is as high as 85% in low- and middle-income countries (LAMICs). While access to psychotropic medicines varies substantially across countries, no studies to date have empirically investigated potential health systems factors underlying this issue. Methods and findings: This study uses a cross-sectional sample of 63 LAMICs and country regions to identify key health systems components associated with access to psychotropic medicines. Data from countries that completed the World Health Organization Assessment Instrument for Mental Health Systems (WHO-AIMS) were included in multiple regression analyses to investigate the role of five major mental health systems domains in shaping medicine availability and affordability. These domains are: mental health legislation, human rights implementations, mental health care financing, human resources, and the role of advocacy groups. Availability of psychotropic medicines was associated with features of all five mental health systems domains. Most notably, within the domain of mental health legislation, a comprehensive national mental health plan was associated with 15% greater availability; and in terms of advocacy groups, the participation of family-based organizations in the development of mental health legislation was associated with 17% greater availability. Only three measures were related with affordability of medicines to consumers: level of human resources, percentage of countries' health budget dedicated to mental health, and availability of mental health care in prisons. Controlling for country development, as measured by the Human Development Index, health systems features were associated with medicine availability but not affordability. Conclusions: Results suggest that strengthening particular facets of mental health systems might improve availability of psychotropic medicines and that overall country development is associated with affordability.

Abstract Objective: To measure the benefits to household caregivers of a psychotherapeutic intervention for adolescents and young adults living in a war-affected area. Methods: Between July 2012 and July 2013, we carried out a randomized controlled trial of the Youth Readiness Intervention – a cognitive–behavioural intervention for war-affected young people who exhibit depressive and anxiety symptoms and conduct problems – in Freetown, Sierra Leone. Overall, 436 participants aged 15–24 years were randomized to receive the intervention (n = 222) or care as usual (n = 214). Household caregivers for the participants in the intervention arm (n = 101) or control arm (n = 103) were interviewed during a baseline survey and again, if available (n = 155), 12 weeks later in a follow-up survey. We used a burden assessment scale to evaluate the burden of care placed on caregivers in terms of emotional distress and functional impairment. The caregivers’ mental health – i.e. internalizing, externalizing and prosocial behaviour – was evaluated using the Oxford Measure of Psychosocial Adjustment. Difference-in-differences multiple regression analyses were used, within an intention-to-treat framework, to estimate the treatment effects. Findings: Compared with the caregivers of participants of the control group, the caregivers of participants of the intervention group reported greater reductions in emotional distress (scale difference: 0.252; 95% confidence interval, CI: 0.026–0.4782) and greater improvements in prosocial behaviour (scale difference: 0.249; 95% CI: 0.012–0.486) between the two surveys. Conclusion: A psychotherapeutic intervention for war-affected young people can improve the mental health of their caregivers.

Purpose: To examine associations between war experiences, mental health, and gender in a sample of male and female Sierra Leonean former child soldiers. Methods: A total of 273 former child soldiers (29% females) were assessed for depression and anxiety by using the Hopkins Symptoms Checklist, and for hostility, confidence, and prosocial attitudes by using an instrument developed for use with Sierra Leonean child soldiers. Results: The former child soldiers had witnessed and perpetrated violence at largely comparable rates, although females experienced higher rates of rape (p.0001). More females scored within clinical ranges for depression (p .008) and anxiety (p.0001). In multiple regression analyses, female gender was a significant predictor of lower levels of confidence but not of mental health problems. Children who perpetrated injury or killing reported greater levels of depression (p.0001), anxiety (p.0001), and hostility (p.0001). Surviving rape was associated with increased anxiety (p.05) and hostility (p.05), in males. Surviving rape was also related to higher confidence levels (p.05) and prosocial attitudes (p.05). Male former child soldiers who lost caregivers were also more vulnerable to depression (p.05) and anxiety (p.05), strong and significant effects noted among male child soldiers. Conclusions: In our sample, female and male child soldiers experienced comparable levels of most war exposures. Female soldiers reported higher rates of rape and lower levels of adaptive outcomes. Toxic forms of violence (killing or injuring; rape) were associated with particularly poor outcomes. Although all boys and girls who experience rape and loss of caregivers are generally at risk for mental health problems, boys in our sample demonstrated increased vulnerability; these findings indicate a need for more inclusive mental health services.

Three waves of data from a prospective longitudinal study in Sierra Leone were used to examine internalizing trajectories in 529 war-affected youth (ages 10–17 at baseline; 25% female). Latent class growth analyses identified 4 trajectories: A large majority of youth maintained lower levels of internalizing problems (41.4%) or significantly improved over time (47.6%) despite very limited access to care, but smaller proportions continued to report severe difficulties 6 years postwar (4.5%) or their symptoms worsened (6.4%). Continued internalizing problems were associated with loss of a caregiver, family abuse and neglect, and community stigma. Despite the comparative resilience of most war-affected youth in the face of extreme adversity, there remains a compelling need for interventions that address family- and community-level stressors.

Objectives: To compare the risks of admission to hospital for any type of psychiatric disorder and for four specific psychiatric disorders among adults who as children were evacuated to Swedish foster families during the second world war and their non-evacuated siblings, and to evaluate whether these risks differ between the sexes. Design: Cohort study. Setting: National child evacuation scheme in Finland during the second world war. Participants: Children born in Finland between 1933 and 1944 who were later included in a 10% sample of the 1950 Finnish census ascertained in 1997 (n=45 463; women: n=22 021; men: n=23 442). Evacuees in the sample were identified from war time government records. Main outcome measure Adults admitted to hospital for psychiatric disorders recorded between 1971 and 2011 in the Finnish hospital discharge register. Methods: We used Cox proportional hazards models to estimate the association between evacuation to temporary foster care in Sweden during the second world war and admission to hospital for a psychiatric disorder between ages 38 and 78 years. Fixed effects methods were employed to control for all unobserved social and genetic characteristics shared among siblings. Results: Among men and women combined, the risk of admission to hospital for a psychiatric disorder did not differ between Finnish adults evacuated to Swedish foster families and their non-evacuated siblings (hazard ratio 0.89, 95% confidence interval 0.64 to 1.26). Evidence suggested a lower risk of admission for any mental disorder (0.67, 0.44 to 1.03) among evacuated men, whereas for women there was no association between evacuation and the overall risk of admission for a psychiatric disorder (1.21, 0.80 to 1.83). When admissions for individual psychiatric disorders were analyzed, evacuated girls were significantly more likely than their non-evacuated sisters to be admitted to hospital for a mood disorder as an adult (2.19, 1.10 to 4.33). Conclusions: The Finnish evacuation policy was not associated with an increased overall risk of admission to hospital for a psychiatric disorder in adulthood among former evacuees. In fact, evacuation was associated with a marginally reduced risk of admission for any psychiatric disorder among men. Among women who had been evacuated, however, the risk of being admitted to hospital for a mood disorder was increased.

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.

Civil war broke out in Sierra Leone in 1991 and lasted more than a decade. During the conflict, both the national army and the Revolutionary United Front (RUF), a rebel group responsible for some of the worst atrocities during the conflict, abducted children from the villages they attacked and occupied. An estimated 15,000–22,000 children of all ages were taken from their families and forced to serve the military groups in a number of ways, from performing domestic chores and other military support roles to committing acts of violence (McKay and Mazurana 2004). Many were sexually abused and forced to use alcohol and drugs. At the end of the conflict, short-term disarmament, demobilization, and reintegration (DDR) programs targeting children formerly associated with fighting and armed groups attempted to prepare children to return to their homes. In the medium to long term, however, true reintegration depends on former child soldiers having access to educational and training opportunities that will support them to achieve greater self-sufficiency and increased productivity within their communities. A number of studies have explored aspects of education relating to the reintegration of former child soldiers into their communities (Verhey 2001; Annan et al. 2006; Wessells 2006a). In particular, researchers have shown the negative effects of child soldiering on the educational and economic outcomes of former child soldiers. A few studies have discussed the relative benefits of education for war-affected youth during the postconflict phase (Santacruz and Arana 2002; Annan et al. 2006; Wessells 2006a). In Sierra Leone, available research focuses on the DDR process (Humphreys and Weinstein 2004, 2007) and has explored the relationship between DDR program participation and outcomes such as income-earning capacity, confidence in the democratic process, and acceptance within a sample of mainly adults (mean age of 31 years). Although the large survey sample included some youth as young as 14, educational opportunities and issues facing children and adolescents were not specifically examined. The complexity of providing education to former child soldiers in Sierra Leone and the potential challenges that may be associated with their return to school remain unexplored in the research. This study aims to fill this gap and presents the perspectives of former child soldiers in Sierra Leone, their caregivers, and community members speaking to the role of education in their psychosocial adjustment and community reintegration following the end of the civil war. In this article we first examine the state of the Sierra Leonean educational system before and after the war and its role in the reintegration of former child soldiers. Next, we present the perspectives of former child soldiers, their caregivers, and community members on the role of education in reintegrating former child soldiers into society. We also examine the barriers they described in accessing educational and other training opportunities and in achieving their future goals.