Person:

Beardslee, William

In assessing the mental health of HIV/AIDS-affected children and adolescents in Sub-Saharan Africa, researchers often employ mental health measures developed in other settings. However, measures derived from standard Western psychiatric criteria are frequently based on conceptual models of illness or terminology that may or may not be an appropriate for diverse populations. Understanding local perceptions of mental health problems can aid in the selection or creation of appropriate measures. This study used qualitative methodologies (Free Listing [FL], Key Informant [KI] interviews, and Clinician Interviews [C-KIs]) to understand local perceptions of mental health problems facing HIV/AIDS-affected youth in Rwinkwavu, Rwanda. Several syndrome terms were identified by participants: agahinda kenshi, kwiheba, guhangayika, ihahamuka, umushiha and uburara. While these local syndromes share some similarities with Western mood, anxiety, and conduct disorders, they also contain important culture-specific features and gradations of severity. Our findings underscore the importance of understanding local manifestations of mental health syndromes when conducting mental health assessments and when planning interventions for HIV/AIDS-affected children and adolescents in diverse settings.

In Rwanda, the dual vectors of HIV and legacy of the 1994 genocide have had devastating consequences for children and families. In this and other low-resource settings, extreme poverty, poor access to services, family conflict, and other adversities put children and families affected by HIV/AIDS at increased risk of mental health problems. However, even in the face of tremendous hardship, many children and families demonstrate better than expected outcomes. To design interventions that harness these natural sources of resilience, greater knowledge of local protective processes is needed. This study used free listing exercises (N=68) and key informant interviews (N=58) with adults and children (ages 10-17) to investigate strengths and sources of resilience in Rwandan children and families at risk for psychosocial difficulties due to HIV/AIDS. Clinician key informants (N=10) were also interviewed. Five forms of protective resources emerged through this research: perseverance (kwihangana); self-esteem/self-confidence (kwigirira ikizere); family unity/trust (kwizerana); good parenting (kurera neza) and collective/communal support (ubufasha abaturage batanga). Operating within individual, family, and collective/community systems, these resources support children at multiple ecological levels. Study evidence suggests that these protective processes provide “leverage points” for strengths-based interventions designed to increase resilient outcomes and prevent mental health problems. This information on culturally-appropriate practices for building resilience, along with input from local community advisory boards and the government, has informed the development of a Family Strengthening Intervention, which has broad applications to many forms of adversity and trauma.

Objective

The objective of this study is to assess the feasibility and acceptability of an intervention to reduce mental health problems and bolster resilience among children living in households affected by caregiver HIV in Rwanda.

Design

Pre-post design, including 6-month follow-up.

Methods

The Family Strengthening Intervention (FSI) aims to reduce mental health problems among HIV-affected children through improved child–caregiver relationships, family communication and parenting skills, HIV psychoeducation and connections to resources. Twenty families (N=39 children) with at least one HIV-positive caregiver and one child 7–17 years old were enrolled in the FSI. Children and caregivers were administered locally adapted and validated measures of child mental health problems, as well as measures of protective processes and parenting. Assessments were administered at pre and postintervention, and 6-month follow-up. Multilevel models accounting for clustering by family tested changes in outcomes of interest. Qualitative interviews were completed to understand acceptability, feasibility and satisfaction with the FSI.

Results

Families reported high satisfaction with the FSI. Caregiver-reported improvements in family connectedness, good parenting, social support and children's pro-social behaviour (P<0.05) were sustained and strengthened from postintervention to 6-month follow-up. Additional improvements in caregiver-reported child perseverance/self-esteem, depression, anxiety and irritability were seen at follow-up (P<.05). Significant decreases in child-reported harsh punishment were observed at postintervention and follow-up, and decreases in caregiver reported harsh punishment were also recorded on follow-up (P<0.05).

Conclusion

The FSI is a feasible and acceptable intervention that shows promise for improving mental health symptoms and strengthening protective factors among children and families affected by HIV in low-resource settings.