Person:

Brennan, Robert

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.

HIV-affected families report higher rates of harmful alcohol use, intimate partner violence (IPV) and family conflict, which can have detrimental effects on children. Few evidence-based interventions exist to address these complex issues in Sub-Saharan Africa. This mixed methods study explores the potential of a family-based intervention to reduce IPV, family conflict and problems related to alcohol use to promote child mental health and family functioning within HIV-affected families in post-genocide Rwanda. A family home-visiting, evidence-based intervention designed to identify and enhance resilience and communication in families to promote mental health in children was adapted and developed for use in this context for families affected by caregiver HIV in Rwanda. The intervention was adapted and developed through a series of pilot study phases prior to being tested in open and randomized controlled trials (RCTs) in Rwanda for families affected by caregiver HIV. Quantitative and qualitative data from the RCT are explored here using a mixed methods approach to integrate findings. Reductions in alcohol use and IPV among caregivers are supported by qualitative reports of improved family functioning, lower levels of violence and problem drinking as well as improved child mental health, among the intervention group. This mixed methods analysis supports the potential of family-based interventions to reduce adverse caregiver behaviors as a major mechanism for improving child well-being. Further studies to examine these mechanisms in well-powered trials are needed to extend the evidence-base on the promise of family-based intervention for use in low- and middle-income countries.

Objective To investigate the longitudinal course of internalizing and externalizing problems and adaptive/prosocial behaviors among Sierra Leonean former child soldiers and whether post-conflict factors contribute to adverse or resilient mental health outcomes. Method Male and female former child soldiers (N=260, ages 10–17 at baseline) were recruited from the roster of an NGO-run Interim Care Center in Kono District and interviewed in 2002, 2004 and 2008. The retention rate was 69%. Linear growth models were used to investigate trends related to war and post-conflict experiences. Results The long-term mental health of former child soldiers was associated with war experiences and post-conflict risk factors, which were partly mitigated by post-conflict protective factors. Increases in externalizing behavior were associated with killing/injuring others during the war and post-conflict stigma while increased community acceptance was associated with decreases in externalizing problems (B=−1.09). High baseline levels of internalizing problems were associated with surviving rape while increases were associated with younger involvement in armed groups and social and economic hardships. Improvements in internalizing problems were associated with higher levels of community acceptance and increases in community acceptance (B=−0.86). Decreases in adaptive/prosocial behaviors were associated with killing/injuring others during the war and post-conflict stigma, but partially mitigated by social support, being in school and increased community acceptance (B=1.93). Conclusions Psychosocial interventions for former child soldiers may be more effective if they account for post-conflict factors in addition to war exposures. Youth with accumulated risk factors, lack of protective factors, and persistent distress should be identified; sustainable services to promote community acceptance, reduce stigma, and expand social supports and educational access are recommended.

This is the first prospective study to investigate psychosocial adjustment in male and female former child soldiers (n=156, 12% female). The study began in Sierra Leone in 2002 and was designed to examine both risk and protective factors in psychosocial adjustment. Over the two-year period of follow up, youth who had wounded or killed others during the war demonstrated increases in hostility. Youth who survived rape had higher levels of anxiety and hostility, but also demonstrated greater confidence and prosocial attitudes at follow up. Of the potential protective resources examined, improved community acceptance was associated with reduced depression at follow up and improved confidence and prosocial attitudes regardless of levels of violence exposure. Retention in school was also associated with greater prosocial attitudes.

Background: The child protection community is increasingly focused on developing tools to assess threats to child protection and the basic security needs and rights of children and families living in adverse circumstances. Although tremendous advances have been made to improve measurement of individual child health status or household functioning for use in low-resource settings, little attention has been paid to a more diverse array of settings in which many children in adversity spend time and how context contributes to threats to child protection. The SAFE model posits that insecurity in any of the following fundamental domains threatens security in the others: Safety/freedom from harm; Access to basic physiological needs and healthcare; Family and connection to others; Education and economic security. Site-level tools are needed in order to monitor the conditions that can dramatically undermine or support healthy child growth, development and emotional and behavioral health. From refugee camps and orphanages to schools and housing complexes, site-level threats exist that are not well captured by commonly used measures of child health and well-being or assessments of single households (e.g., SDQ, HOME). Methods: The present study presents a methodology and the development of a scale for assessing site-level child protection threats in various settings of adversity. A modified Delphi panel process was enhanced with two stages of expert review in core content areas as well as review by experts in instrument development, and field pilot testing. Results: Field testing in two diverse sites in India—a construction site and a railway station—revealed that the resulting SAFE instrument was sensitive to the differences between the sites from the standpoint of core child protection issues.

Introduction: Few evidence-based interventions exist to support parenting and child mental health during the process of caregiver HIV status disclosure in sub-Saharan Africa. A secondary analysis of a randomized-controlled trial was conducted to examine the role of family-based intervention versus usual social work care (care as usual) in supporting HIV status disclosure within families in Rwanda. Method: Approximately 40 households were randomized to family-based intervention and 40 households to care as usual. Parenting, family unity, and child mental health during the process of disclosure were studied using quantitative and qualitative research methods. Results: Many of the families had at least one caregiver who had not disclosed their HIV status at baseline. Immediately post-intervention, children reported lower parenting and family unity scores compared with those in the usual-care group. These changes resolved at 3-month follow-up. Qualitative reports from clinical counselor intervention sessions described supported parenting during disclosure. Overall findings suggest adjustments in parenting, family unity, and trust surrounding the disclosure process. Conclusion: Family-based intervention may support parenting and promote child mental health during adjustment to caregiver HIV status disclosure. Further investigation is required to examine the role of family-based intervention in supporting parenting and promoting child mental health in HIV status disclosure.

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.

Background: Little attention has been paid to potential relationships between mental health, trauma, and personal exposures to Ebola virus disease (EVD) and health behaviors in post-conflict West Africa. We tested a conceptual model linking mental health and trauma to EVD risk behaviors and EVD prevention behaviors. Methods and Findings: Using survey data from a representative sample in the Western Urban and Western Rural districts of Sierra Leone, this study examines associations between war exposures, post-traumatic stress disorder (PTSD) symptoms, depression, anxiety, and personal EVD exposure (e.g., having family members or friends diagnosed with EVD) and EVD-related health behaviors among 1,008 adults (98% response rate) from 63 census enumeration areas of the Western Rural and Western Urban districts randomly sampled at the height of the EVD epidemic (January–April 2015). Primary outcomes were EVD risk behaviors (14 items, Cronbach’s α = 0.84) and EVD prevention behaviors (16 items, Cronbach’s α = 0.88). Main predictors comprised war exposures (8 items, Cronbach’s α = 0.85), anxiety (10 items, Cronbach’s α = 0.93), depression (15 items, Cronbach’s α = 0.91), and PTSD symptoms (16 items, Cronbach’s α = 0.93). Data were analyzed using two-level, population-weighted hierarchical linear models with 20 multiply imputed datasets. EVD risk behaviors were associated with intensity of depression symptoms (b = 0.05; 95% CI 0.00, 0.10; p = 0.037), PTSD symptoms (b = 0.10; 95% CI 0.03, 0.17; p = 0.008), having a friend diagnosed with EVD (b = −0.04; 95% CI −0.08, −0.00; p = 0.036), and war exposures (b = −0.09; 95% CI −0.17, −0.02; p = 0.013). EVD prevention behaviors were associated with higher anxiety (b = 0.23; 95% CI 0.06, 0.40; p = 0.008), having a friend diagnosed with EVD (b = 0.15; 95% CI 0.04, 0.27; p = 0.011), and higher levels of war exposure (b = 0.45; 95% CI 0.16, 0.74; p = 0.003), independent of mental health. PTSD symptoms were associated with lower levels of EVD prevention behavior (b = −0.24; 95% CI −0.43, −0.06; p = 0.009). Conclusions: In post-conflict settings, past war trauma and mental health problems are associated with health behaviors related to combatting EVD. The associations between war trauma and both EVD risk behaviors and EVD prevention behaviors may be mediated through two key mental health variables: depression and PTSD symptoms. Considering the role of mental health in the prevention of disease transmission may help fight continuing and future Ebola outbreaks in post-conflict Sierra Leone. This sample is specific to Freetown and the Western Area and may not be representative of all of Sierra Leone. In addition, our main outcomes as well as personal EVD exposure, war exposures, and mental health predictors rely on self-report, and therefore raise the possibility of common methods bias. However, the findings of this study may be relevant for understanding dynamics related to EVD and mental health in other major capital cities in the EVD-affected countries of West Africa.

Background

Worldwide, over one billion children and adolescents live in war-affected settings. At present, only limited research has investigated linkages between disrupted social ecology and adverse mental health outcomes among war-affected youth. In this study, we examine three community-level characteristics—social disorder and collective efficacy within the community, as reported by caregivers, and perceived stigma as reported by youth—in relation to externalizing behaviors and internalizing symptoms among male and female former child soldiers in post-conflict Sierra Leone.

Methods

243 former child soldiers (30% female, mean age at baseline: 16.6 years) and their primary caregivers participated in interviews in 2004 and 2008, as part of a larger prospective cohort study of war-affected youth in Sierra Leone. Two-point growth models were estimated to examine the relationship between community-level characteristics and externalizing and internalizing outcomes across the time points.

Results

Both social disorder within the community, reported by caregivers, and perceived stigma, reported by youth, positively co-varied with youths’ externalizing and internalizing scores—indicating that higher levels of each at baseline and follow-up were associated with higher levels of mental health problems at both time points (p<0.05). The relationship between collective efficacy and mental health outcomes was non-significant (p>0.05).

Conclusions

This study offers a rare glimpse into the role that the post-conflict social context plays in shaping mental health among former child soldiers. Results indicate that both social disorder and perceived stigma within the community demonstrate an important relationship to externalizing and internalizing problems among adolescent ex-combatants. Moreover, these relationships persisted over a four-year period of follow up. These results underscore the importance of the post-conflict social environment and the need to develop post-conflict interventions that address community-level processes in addition to the needs of the individual.