Browsing by Author "Puffer, Eve"
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Item Open Access A mixed-methods study to validate a measure of and explore influences on child mental health in Eldoret, Kenya(2017) Haynes, Taylor MargaretBackground: In Kenya, approximately 14.5% of children and youth meet criteria for a mental disorder. Despite this high burden, research is very limited related to mental health problems this population. Research is needed on the measurement of child mental health problems and on the risk and protective factors associated with these conditions.
Objectives: (1) Evaluate a set of survey items, chosen from both standardized measures and locally developed items, to identify those that that best differentiate between children with and without mental health problems. (2) Identify and explore important individual- and family-level influences on child mental health.
Methods: Individual surveys and semi-structured interviews were administered to members (1-2 caregivers, 1 child age 8-17) of 22 families living in Eldoret, Kenya. We evaluated differences in survey item endorsement between children with and without mental health problems to identify the best performing items. We used mixed-methods analysis of semi-structured interview transcripts and associated rating scores to explore differences between children with and without mental health problems on a variety of family-level variables.
Results: Following an extensive cultural adaptation process, fourteen of 26 survey items were successful in differentiating between children with and without mental health problems. Successful survey items were all drawn from standardized measures; no locally developed items were successful. All family-level variables (e.g., overall family functioning, couples’ relationship quality, parent-child relationship quality, and caregiver mental health) were strongly associated with child mental health outcomes, evidenced by large effect sizes ranging from 0.86 to 4.16. Subsequent qualitative analysis identified specific components of these variables likely contributing to the large numerical differences in scores.
Conclusions: The results of this study both suggest that standardized measures are appropriate for use in this population and highlight the importance of cultural adaptation before implementing standardized assessment tools. Additionally, the results indicate that the family environment is a promising target for interventions aiming to reduce mental health problems in Kenyan children.
Item Open Access A Qualitative Study of Contextual Factors’ Impact on the Adaptation of a Caregiver-mediated Early Autism Intervention in South Africa(2016) Guler, JessyBackground: Autism Spectrum Disorder (ASD) is a major global health challenge as the majority of individuals with ASD live in low- and middle-income countries (LMICs) and receive little to no services or support from health or social care systems. Despite this global crisis, the development and validation of ASD interventions has almost exclusively occurred in high-income countries, leaving many unanswered questions regarding what contextual factors would need to be considered to ensure the effectiveness of interventions in LMICs. This study sought to conduct explorative research on the contextual adaptation of a caregiver-mediated early ASD intervention for use in a low-resource setting in South Africa.
Methods: Participants included 22 caregivers of children with autism, including mothers (n=16), fathers (n=4), and grandmothers (n=2). Four focus groups discussions were conducted in Cape Town, South Africa with caregivers and lasted between 1.5-3.5 hours in length. Data was recorded, translated, and transcribed by research personnel. Data was then coded for emerging themes and analyzed using the NVivo qualitative data analysis software package.
Results: Nine contextual factors were reported to be important for the adaptation process including culture, language, location of treatment, cost of treatment, type of service provider, familial needs, length of treatment, support, and parenting practices. One contextual factor, evidence-based treatment, was reported to be both important and not important for adaptation by caregivers. The contextual factor of stigma was identified as an emerging theme and a specifically relevant challenge when developing an ASD intervention for use in a South African context.
Conclusions: Eleven contextual factors were discussed in detail by caregivers and examples were given regarding the challenges, sources, and preferences related to the contextual adaptation of a parent-mediated early ASD intervention in South Africa. Caregivers reported a preference for an affordable, in-home, individualized early ASD intervention, where they have an active voice in shaping treatment goals. Distrust of community-based nurses and health workers to deliver an early ASD intervention and challenges associated with ASD-based stigma were two unanticipated findings from this data set. Implications for practice and further research are discussed.
Item Embargo Adaptation and Evaluation of a Picture-Based Measure of Parent Discipline Preferences(2021) Quick, KaitlinBackground: Harsh parenting behaviors are some of the most commonly used discipline practices parents use in the United States but are often difficult to measure. Self-report instruments are the most used method of assessing parenting behaviors, but likely result in response biases due to their methodological shortcomings. This study aimed to provide a viable alternative to traditional self-report surveys used to evaluate parenting practices with lower social desirability and lower literacy requirements. Our primary objectives were to adapt the Harsh Discipline Preference Discrete Choice Experiment (HDP-DCE), a picture-based measure originally developed for Liberia, for use with an American population, and evaluate its psychometric evidence of reliability and validity. Methods: We first adapted items through an iterative process of collecting feedback from 97 parents and 10 experts through focus groups and surveys to generate clear and acceptable images to elicit preferences for discipline strategies. We then administered the measure to 439 parents to explore the internal structure of the measure and evaluate multiple indicators of reliability and validity. Results: An exploratory factor analysis resulted in three potential factor-solutions, with the three-factor solution explaining the most variance and being the most theoretically sound. Analyses also demonstrated that the HDP-DCE has excellent internal consistency, good test-retest reliability, as well as good convergent and discriminant validity. Given these results the HDP-DCE could be a useful alternative or complement to traditional self-report tools in research and clinical work.
Item Open Access Barriers and facilitators to treatment for alcohol use among fathers in Kenya: A qualitative study(2018) Patel, PujaIntroduction: Substance use disorders accounts for 9.6% of Disability-Adjusted Life Years worldwide. In Kenya, close to 3 million individuals are reported to abuse alcohol but a notable treatment gap persists. This problem is especially pronounced among men, leading to negative consequences at the individual and family levels. This study examines the perceptions of fathers in Kenya engaged in problem drinking and their families about previous experiences with receiving help related to alcohol use. The dynamics of the family as they pertain to these help-related experiences are also explored. Methods: Semi-structured qualitative interviews were conducted with 11 families in Eldoret, Kenya. Males exhibiting problem drinking, their spouse or partner, and one child were recruited from each family. Thematic content analysis was conducted. Results: Participants only reported informal help delivered by family and community members; they exhibited very little awareness of available formal treatment. Families were deeply affected by the alcohol use and very actively involved in seeking help. Results elucidated barriers and facilitators of fathers’ acceptance of help. Three main barriers to help acceptance included: fathers’ perceiving help strategies as negative or harsh; negative peer influence; and lack of desire to quit. Four facilitators to help acceptance were identified: fathers’ perceiving help to be positive and well-intentioned; financial motivation; perceived social-support for behavior change; and fathers’ motivation to decrease external stigma. Cultural factors, including religiosity and gender identities, emerged as strong influences on experiences of help. Overall, most help efforts were short-term and reported only to lead to very short-term behavior change. Conclusion and Implications: Families and communities are very active in help provision for men in Kenya, though results confirm the ongoing need for effective interventions. Future interventions could benefit from recognizing the role of the family in engaging men in treatment and attending to the identified barriers and facilitators in designing treatment strategies.
Item Open Access Chronic Interpersonal Trauma in Kenyan Adolescents: a Culturally Grounded Model(2014) Friis, ElsaThe exposure to chronic interpersonal trauma during developmentally critical periods can have pervasive impacts on social, psychological, biological and cognitive functioning. Interpersonal trauma has been associated with a complex range of risk factors at the individual, family, community, and societal levels. However, little research has focused on the interplay between culture and trauma, especially in low- and middle-income countries. The current study is a qualitative investigation to develop a culturally grounded model of interpersonal trauma in Kenyan adolescents. Fourteen focus groups were conducted in three ethnically diverse communities surrounding Eldoret, Kenya with adolescents ages 12 to 18 (n=67) and caregivers (n=54). Focus Group participants identified community leaders and providers and three additional focus groups were conducted with these key informants (n=28). A grounded theory approach was used for data collection and analysis. A culturally grounded model of interpersonal trauma exploring both exposure and symptomatic presentation is proposed. From this investigation, it is apparent that adolescents who experience chronic interpersonal trauma in these communities experience dysregulation symptoms similar to those described in complex trauma theory. However, poverty, martial conflict, caregiver stress, caregiver substance abuse and favoritism emerged as risk factors for interpersonal trauma and indicate measures and interventions developed for the assessment and treatment of symptoms resulting from interpersonal trauma must be adapted for use in this population.
Item Open Access Development and Evaluation of a Web Application to Support Remote Clinical Supervision of Lay Counselors in Kenya(2020) Friis, ElsaPsychological treatments delivered by lay counselors, individuals with little or no previous mental health training, have been shown to be effective in treating a range of mental health problems. However, in low resource settings, the dearth of available experts to train and supervise lay counselors is a key bottleneck in scaling up lay counselor delivered psychological treatments. Locally sustainable solutions that allow experts to train and supervise large volume of lay providers are needed. Two proposed solutions include the use of digital health strategies and peer supervision. In study one, we used a human-centered design approach to develop a web application to support asynchronous clinical supervision of lay counselors providing a family therapy program in Kenya. The development process engaged seven previously trained lay counselors and three prior supervisors in a phased design process which resulted in a final application prototype, “REACH”, that supported audio and text communication via a chat and a structured session report form. In study two, we conducted a feasibility study with 30 counselors with the aim of describing the capacity of REACH support supervision practices, exploring the feasibility and acceptability of REACH compared to peer group supervision, and describing the treatment fidelity and clinical competency of a small group of counselors using REACH. REACH was perceived as highly acceptable from both peers and supervisors and demonstrated promising impacts on counselor fidelity and clinical competency. Content analysis of correspondence between the counselors and the superior via the REACH indicated the supervisor was able to implement a wide range of evidence-based supervision strategies. Limitations of bi-directional communication on potential supervision effectiveness are discussed. Overall, this project suggests digital asynchronous clinical supervision holds promise as a scalable method of clinical supervision in low-resource contexts.
Item Embargo Development and Piloting of a Cognitive Behavioral Intervention for Gynecologic Cancer Survivors Undergoing Pelvic Exams(2023) Coleman, Jessica NRegular pelvic exams in the first two years after completing cancer treatment are critical for early detection of endometrial and cervical cancer recurrence. Gynecologic cancer survivors often report high levels of anxiety, pain and discomfort during this procedure. Despite increased attention to screening for distress during cancer treatment and follow up appointments, no interventions currently exist to support patients in coping with this recommended procedure. This dissertation aims to address this gap in health services research.The first study involved conducting in-depth individual interviews with gynecologic cancer patients (N=13) and interdisciplinary oncology providers (N=10) to explore patients’ experiences of distress associated with pelvic exams and intervention needs and preferences. The intervention development process is described including the development of a conceptual model, qualitative data collection and analysis, and the resulting content of each intervention session. Findings suggested that patients experience several types and sources of distress related to surveillance pelvic exams. Patients expressed interest in psychosocial support for managing anxiety related to pelvic exams. Patients and providers reported that a proposed brief telemedicine cognitive behavioral skills-based intervention targeting anxiety and pain related to pelvic exams would be acceptable and feasible. These findings informed the development of the PEACE intervention (Pelvic Examination and Anxiety Coping skills for Empowerment). The second study was a proof-of concept pilot study conducted with a quasi-experimental, within-subject design (N=16) to evaluate the acceptability and feasibility of the coping skills intervention and patterns of change in anxiety and pain symptoms. Mixed methods approaches were used. Participants (n=14) completed the 3-session telemedicine delivered coping skills intervention, completed assessments at baseline, post-intervention, and post pelvic exam, and completed a feedback interview. Findings suggested high overall acceptability and feasibility of PEACE. While the PEACE proof of concept trial was not powered to detect significant changes across time, patterns of change suggest promising results. While state anxiety during exams increased over time, the single-item measures of anxiety, fear and embarrassment indicated statistically significant decreases in distress over time. Participants demonstrated significant decreases in fear of recurrence after the intervention that were maintained after the follow up exam. Trends in patterns suggest that pain and discomfort severity decreased as well, though those changes were not significant. Self-efficacy for tension release and mindful attention significantly increased from pre- to post- intervention and generally remained high. Participants reported increased use of CBT skills and all reported they would use the skills in the future. Self-efficacy for communicating with providers and use of communication skills use did not follow a uniform pattern. Results suggest that a brief CBT intervention can reduce psychological distress, and may be suitable for implementation in collaborative care settings. Findings also indicate that patients with psychosocial stressors may benefit from flexible intervention delivery (i.e., phone sessions, booster sessions) and that adding a provider sensitive practice training component to PEACE may help strengthen the effects of the communication skill in particular. PEACE responds to a great need for evidence based, trauma-informed OB/GYN interventions and is well suited for further efficacy and implementation testing in the future.
Item Open Access Development and Piloting of an Intervention to Reduce Alcohol Use and Improve Family Engagement Among Fathers in Kenya(2020) Giusto, AliProblem drinking accounts for 9.6% of disability-adjusted life years worldwide, and disproportionally affects men with disabling physical, psychological, and behavioral consequences. These can lead to a cascade of negative effects on men’s families, with documented ties to intimate partner violence (IPV) and child maltreatment. These problems are often exacerbated where poverty rates are high, including low and middle-income countries (LMICs). To begin to address intersecting risks, two studies were completed. Study 1 aimed to develop an alcohol reduction and family engagement intervention for fathers with problem drinking in Kenya using a mixed-method, multi-step process, as well as evaluate its feasibility and acceptability among fathers and lay counselors using process data from the pilot trial. Study 2 aimed to pilot and examine the initial impact of the intervention on alcohol use and related problems in the family using a non-concurrent multiple baseline single case series design. Study 1 resulted in a 5-session family-focused intervention rooted in behavioral activation (BA), motivational interviewing (MI), and gender transformative strategies (GTS) modified for context-specific goal and streamlined for lay providers. Results indicated the treatment was feasible and acceptable to fathers with high attendance, high satisfaction, acceptance of implementation strategies, and perceived program helpfulness. Counselors with no prior formal training in mental health were able to recruited and trained as counselors and demonstrated reached high rates of intervention fidelity implemented with good quality and high general counselor competency. In Study 2, quantitative and qualitative findings demonstrated promising findings. Fathers who completed treatment (n=8) showed significant reductions in alcohol use during treatment and follow-up periods in comparison to the time prior to treatment. Improvements were also seen in alcohol-related conflict, drinking-related problems, father involvement, and missed family time due to drinking from the perspective of multiple reporters, as well as in secondary outcomes of individual mental health, couple relationship quality, and father-child relationship quality. Indicators of family violence did not show significant improvements, but trended in the expected direction. Results suggest that the developed treatment may be helpful for reducing men’s alcohol use and family outcomes.
Item Open Access Development and Piloting of an Intervention to Reduce Alcohol Use and Improve Family Engagement Among Fathers in Kenya(2020) Giusto, AliProblem drinking accounts for 9.6% of disability-adjusted life years worldwide, and disproportionally affects men with disabling physical, psychological, and behavioral consequences. These can lead to a cascade of negative effects on men’s families, with documented ties to intimate partner violence (IPV) and child maltreatment. These problems are often exacerbated where poverty rates are high, including low and middle-income countries (LMICs). To begin to address intersecting risks, two studies were completed. Study 1 aimed to develop an alcohol reduction and family engagement intervention for fathers with problem drinking in Kenya using a mixed-method, multi-step process, as well as evaluate its feasibility and acceptability among fathers and lay counselors using process data from the pilot trial. Study 2 aimed to pilot and examine the initial impact of the intervention on alcohol use and related problems in the family using a non-concurrent multiple baseline single case series design. Study 1 resulted in a 5-session family-focused intervention rooted in behavioral activation (BA), motivational interviewing (MI), and gender transformative strategies (GTS) modified for context-specific goal and streamlined for lay providers. Results indicated the treatment was feasible and acceptable to fathers with high attendance, high satisfaction, acceptance of implementation strategies, and perceived program helpfulness. Counselors with no prior formal training in mental health were able to recruited and trained as counselors and demonstrated reached high rates of intervention fidelity implemented with good quality and high general counselor competency. In Study 2, quantitative and qualitative findings demonstrated promising findings. Fathers who completed treatment (n=8) showed significant reductions in alcohol use during treatment and follow-up periods in comparison to the time prior to treatment. Improvements were also seen in alcohol-related conflict, drinking-related problems, father involvement, and missed family time due to drinking from the perspective of multiple reporters, as well as in secondary outcomes of individual mental health, couple relationship quality, and father-child relationship quality. Indicators of family violence did not show significant improvements, but trended in the expected direction. Results suggest that the developed treatment may be helpful for reducing men’s alcohol use and family outcomes.
Item Open Access Dietary Patterns, Nutritional Status, Prevalence and Risk Factors for Anemia among School Children in Naama Community, Uganda(2015) Zhao, YiBackground: The disease burden of malnutrition, anemia, malaria and helminth infections among school-aged children is rarely studied in low- and middle-income countries (LMICs) although these children are still at a high risk for these diseases compared with other more studied populations, such as pregnant women and children under 5 years old. Even in countries where the prevalence and trend of anemia and malnutrition are relatively well documented, few studies relate this to dietary factors, which are considered major contributors to anemia and malnutrition in most age groups. Aims: The aims of the study are (1) To determine the prevalence of anemia, malaria, helminth infections and malnutrition in a sample of 95 children, ages 6 to 14, attending primary schools in Naama Community, Uganda, and to observe and quantify school children's dietary patterns and daily nutrient intakes. (2) To find out the association between dietary factors and the risk of anemia and malnutrition. Methods: Measures included school-based, cross-sectional surveys, dietary assessments, anthropometric measurements and biological tests among school children. Photo-assisted 24-hour recall was used to collect daily nutrient intakes, combined with a Food Frequency Questionnaire (FFQ) to capture the dietary patterns. Anthropometrical and biochemical data was collected using standardized protocols. Socioeconomic data was obtained from parent surveys. Results: Ninety-five children in total were enrolled in all or some components of the study. The prevalence of anemia was low (3.2%), and all were mildly anemic. However, the prevalence of malaria and hookworm infections was relatively high, representing 12.9% and 24.4% of the studied population, respectively. In the studied children, 2.8% were underweight, 15.6% stunted and 1.3% thin, using criteria based on the WHO Growth reference. According to the WHO recommendations for nutrient intake, 80% of participants consumed inadequate energy from their daily diet, especially boys. Dietary fat intake was insufficient in 78% of the children. About 25% of the children had a low protein intake and 93% had low intakes of vitamin A. Calcium intake was low in school children's diet- 97.6% of children lacked of calcium. Inadequate vitamin C intake was less common, appearing in one out of three participants (29.1%). Matooke and posho, the most common local staple food, were the major sources for children's energy. Avocado, beans and matooke contributed to the highest fat, protein and vitamin A intake, respectively. Every participant reported consuming cereal/cereal products, roots/tubers/plantain, pulses/nuts, oil/oil-rich foods and fruits during the previous month, while almost one-fifth never consumed milk/dairy products. Vegetables were consumed by most of the respondents. Few (1.6%) of the respondents reported no animal source food in their diet. In general, children ate 3.81(SD: 0.99) out of all five meals in the area. Dinner was consumed by most of the participants (93.7%) while afternoon tea was the least consumed meal and was skipped by half of the childrenNo significant association between dietary factors and anemia were found, mainly due to the small sample size and low prevalence of disease. None of the dietary factors of primary interest were found to be associated with children's Hb concentration, but secondary analysis found the frequency of eating oranges was a protective factor for higher Hb concentration (P=0.015). The association between diet and stunting was not significant, except children who had low dietary fat intakes had a lower risk of being stunted compared with those had adequate fat consumption (OR=0.27, P=0.046). Conclusions: Malaria and helminth infections, but not anemia, in this cohort of school children is relatively high. Stunting was the most prevalent type of malnutrition. Most of the nutrients studied were not adequate in children's diets. The dietary pattern in this sample of children was primarily high in carbohydrates from staple foods and a minimal intake of fat and protein from animal sources. Children generally ate four meals per day. Dietary factors do not explain anemia and stunting in this population.
Item Open Access Experiences of Lay Counselors Providing a Family-Based Therapy in Kenya: A Focus on Identity, Stress, Burnout, Motivation, and Self-Efficacy(2019) Wall, Jonathan TaylorAs health systems continue to implement task shifting models to overcome health access barriers and inequity, it is critical to understand the experiences of lay individuals in these new roles. This is particularly true for lay counselors who provide mental health services. This study sought to understand lay counselor experiences through the lens of identity, stress, motivation, burnout, and self-efficacy. Semi-structured interviews and focus group discussions were conducted with three groups of lay counselors with varying levels of counseling experience from a family therapy program in Eldoret, Kenya. Using thematic analysis, emergent themes were explored to characterize counselor experiences and inform task shifting implementation improvements. Such research provides crucial insight so that future interventions can improve support of lay providers.
Item Open Access Explaining rural/non-rural disparities in physical health-related quality of life: a study of United Methodist clergy in North Carolina.(Qual Life Res, 2011-08) Miles, Andrew; Proescholdbell, Rae Jean; Puffer, EvePURPOSE: Researchers have documented lower health-related quality of life (HRQL) in rural areas. This study seeks to identify factors that can explain this disparity. METHODS: United Methodist clergy in North Carolina (N = 1,513) completed the SF-12 measure of HRQL and items on chronic disease diagnoses, health behaviors, and health care access from the Behavioral Risk Factor Surveillance Survey (BRFSS). Differences in HRQL between rural (N = 571) and non-rural clergy (N = 942) were examined using multiple regression analyses. RESULTS: Physical HRQL was significantly lower for rural clergy (-2.0; 95% CI: -2.9 to -1.1; P < 0.001). Income, body mass index, and joint disease partially accounted for the rural/non-rural difference, though a sizable disparity remained after controlling for these mediators (-1.02; 95% CI: -1.89 to -.15; P = 0.022). Mental HRQL did not differ significantly between rural and non-rural respondents (1.0, 95% CI: -0.1 to 2.1; P = 0.067). CONCLUSIONS: Rural/non-rural disparities in physical HRQL are partially explained by differences in income, obesity, and joint disease in rural areas. More research into the causes and prevention of these factors is needed. Researchers also should seek to identify variables that can explain the difference that remains after accounting for these variables.Item Open Access Exploring Machista Gender Roles and Psychosocial Well-being: An Exploratory Analysis in Camasca, Honduras(2019-04-20) Malo, VincenzoThere is a severe lack of mental health research in rural regions of Latin America like Camasca, Honduras, where typically there exists a societal construct of hypermasculinity and patriarchal authority termed machismo. Much of the current literature on psychosocial factors of mental health in settings with machismo report gender disparities with women experiencing worse outcomes. This study sought to characterize indicators of machismo through division of labor and perceived parental roles, and to then use these data to explore their interactions with psychosocial aspects of mental health. This study recruited 53 participants (41 female) from Camasca, Honduras to participate in orally-administered interviews. Three scales for resilience, general stress, and parental stress were administered in addition to open-ended questions to gauge satisfaction with and comfort discussing parental responsibilities across gender. Overall, the majority of participants reported there are gender differences in parental responsibilities with most explanations mentioning men working as a family’s economic provider and women taking on childcare responsibilities. There were trends towards men experiencing worse levels of general stress and parental stress, although there were no gender differences in resilience. These measurements did not vary by differences in perceived parental responsibilities. Most women reported being more comfortable discussing parental responsibilities with other women, while men typically reported no preference. In light of these results, machista societal organization creates a unique context in which to study psychosocial well-being and provides a useful lens for understanding health disparities in similar gender-rigid contexts. These results suggest that perhaps there is an internalization of traditional gender norms, such that men and women report stressors according to what is deemed stressful in their society, and that furthermore gender-disparate workforces may contribute to gender-specific experiences. Gender-specific differences may also emerge from the importance of agricultural industry, suggesting a possible factor perpetuating machista norms.Item Open Access Factors Impacting Grandparent and Grand Child Communication Across Sex- Related Topics in Kenya(2016) Thulin, Elyse JoanBackground: Although many studies have investigated sexual communication between parents and children in Kenya, none have focused singularly on grandparent and grandchild communication when grandparents are primary caregivers. Further, few studies have asked about specific topics related to sex, instead asking generally about “sex related topics” or focusing on HIV/AIDS. This research aims to investigate communication on ten specific sex- related topics between grandparents who are primary caregivers and their grandchildren. The primary research aim was to identify facilitators and barriers to grandparent-grandchild communication associated with frequency of communication. A secondary exploratory question was whether frequency of communication and youth satisfaction with communication were associated with youth’s desire for more communication in the future. Methods: The study was conducted in urban and peri-urban central Kenya. A convenience sample of 193 grandparents and 166 twelve to fifteen year old grandchildren were identified by community health workers. A cross sectional survey assessed nine potential barriers or facilitators to communication (e.g., frequency of communication, perceived grandparent knowledge, grandparent sense of responsibility to communication on a given topic) on ten specified sex- related topics (e.g., peer pressure on sex topics, romantic relationships, condoms). Bivariate and multivariable analyses identified significant associations between communication variables and the outcomes of interest. Results: Bivariate regression showed that higher grandchild age, grandchild gender, higher perceived grandparent knowledge, higher perceived grandparent comfort, higher grandparent-reported sense of responsibility, higher grandparent-reported belief that child should be aware of a given topic before initiating in sex, and higher youth’s own comfort during communication, were significantly associated with higher levels of communication frequency. In the multivariable model, higher grandchild age, gender, higher comfort during communication, and higher perceived grandparent knowledge remained significantly associated with higher levels communication frequency. For the secondary research question, higher communication frequency and higher levels of youth satisfaction were both significantly associated with higher levels of youth desire for more communication in bivariate regression, and higher levels of youth’s satisfaction with communication remained significantly associated with higher levels of youth’s desire for more in the adjusted analysis. Conclusions: This study found that several potential barriers and facilitators of communication are associated with both frequency of and youth’s desire for more communication. The association between grandchild age, gender and perceived grandparent knowledge and frequency of communication is similar to findings from other studies that have examined sex-related communication between parent primary caregivers and children. This finding has important implications for understanding grandparent and grandchild communication, and communication on specific topics in a population from Kenya. The positive association between youth satisfaction of and desire for more communication has important education policy and intervention implications, suggesting that if youth are satisfied with the communication with their caregivers, they may want to learn more.
Item Open Access “It must be in the thoughts”: A mixed-methods study to validate a mental health assessment and to identify family influences on mental health of Kenyan caregivers(2017) Watson, Leah KatarinaBackground: With the increasing burden of mental health disorders worldwide, strategies are needed to identify salient issues related to mental health and to locally validate mental health screening measures in order to ultimately inform and improve mental illness prevention and treatment. This is particularly the case in regions such as Sub-Saharan Africa, where the burden of illness caused by mental health and substance use disorders is putting increased pressure on an already severely under-resourced healthcare system with few mental health professionals. This study had two aims: (1) to validate items assessing general mental health distress in a Kenyan sample and (2) to identify salient family-level influences on caregiver mental health in Kenyan families.
Methods: This study used a mixed-methods approach with cross-sectional data collected from a sample of 33 caregivers from two communities in Kenya. Each caregiver participated in a survey and a semi-structured interview. Based on the interview data, presence of emotional problems in each study participant was determined such that each participant was designated a mental health “case” or “non-case.” For Aim 1, individual mental health survey items were evaluated for their ability to discriminate between mental health case status groups. For Aim 2, a mixed-methods approach was used to examine relationships between family functioning domains and individual mental health using survey and interview data.
Results: Survey items found to discriminate between individuals with and without emotional problems included 23 items adapted from existing measures of mental health, as well as 5 new items developed for the cultural context. Positively-worded items tended to have poor discrimination between individuals with and without emotional problems. Through examination of quantitative and qualitative data, both family functioning and couple functioning were found to be associated with individual mental health. Satisfaction with roles in terms of provision for family needs was a particularly salient issue affecting individual mental health, as corroborated by the qualitative data. Religiosity was also found to be an important factor in the population, with generally high religiosity among all participants and some differences in use of religion for coping with stressors between individuals with and without emotional problems.
Conclusions: Integration of both adapted and locally-developed mental health screening items should be considered to fully capture the construct of mental health in a given setting, and both content and structure of questions should be considered when developing measures. Both family functioning and couple functioning domains were found to be important, with implications for areas of focus for future research and interventions. Future contextually-sensitive research is needed to comprehensively validate measures of mental health and to further identify predictors of individual mental health in the Kenyan setting.
Item Open Access Psychosocial Burden of Childhood Sickle Cell Disease on Family Members and Caregivers, Homa Bay, Kenya.(2019) Kuerten, Bethany GraceObjective To characterize the types and magnitude of family burden present in caregivers and families who have a child with Sickle Cell Disease (SCD) in Kenya; to identify demographic and disease-specific predictors of caregiver burden. Methods Primary caregivers (N = 103) of children diagnosed with SCD completed surveys assessing multiple domains of caregiver quality of life, parental adjustment related to child illness, mental health, and financial burden. Descriptive statistics characterize caregiver burden and linear regressions models assess associations. Results On indicators of quality of life (QOL), caregivers report problems across most domains assessed included their daily activities and their physical, social, cognitive, and emotional well-being. Daily Activities emerged as most burdensome. On indicators of parental adjustment to chronic illness, guilt and worry emerged as the largest concern, though they also experience long-term uncertainty and sorrow and anger; they reported relatively high levels of emotional resources. Financial burden was high; caregivers reported moderate to major loss in revenue and financial benefits due to the time spent caring for the child. Linear regression analyses revealed that financial burden was a significant predictor of all negative outcomes. Conclusions Results provide preliminary evidence that Kenyan caregivers of children with SCD experience difficulties across multiple domains of functioning and that financial struggles are associated with most psychosocial outcomes. Results can begin to guide intervention needs and opportunities.
Item Open Access The Influence of Race and Ethnicity in Psychiatric Emergency Services(2017-05-03) Triplett, NoahThe present study examined the distribution of psychiatric diagnoses across black, white, and Hispanic or Latino children and adolescents that presented for psychiatric emergency care at the Duke University Hospital Emergency Department. In concordance with existing literature, it was hypothesized that the distribution of diagnoses would differ significantly among Hispanic or Latino patients and their non-Hispanic or Latino counterparts. Emergency department records from 442 pediatric patients were analyzed. Two sample t-tests were completed to test for significant differences in the proportion of each sample diagnosed with a pre-defined category of mental or behavioral illness. Hispanic or Latino children and adolescents had significantly higher proportions or anxiety and substance use disorders than non-Hispanic or Latino black children and adolescents. Hispanic or Latino children and adolescents also had significantly lower proportions of behavioral and emotional disorders than non-Hispanic or Latino black children and adolescents. These findings may invite more directed research into ethnic differences in care seeking, care provision, and prevalence.Item Open Access Understanding Community-Sourced Practices Used by Lay Counselors in a Family Therapy Intervention in Eldoret, Kenya(2018) Kaufman, JuliaThe large global burden of mental health disorders calls for the development and implementation of contextually-appropriate mental health interventions that improve the wellbeing of children and families in low-resource settings. Tuko Pamoja is a family therapy intervention designed for delivery by lay providers in low-resource settings and pilot tested in Eldoret, Kenya. Improving the effectiveness of evidence-based interventions like Tuko Pamoja requires cultural and contextual sensitivity in implementation. One important step towards contextual sensitivity is gaining an understanding of the community-sourced practices used in interventions. Community-sourced practices refer to the ways in which counselors draw upon their own local understandings and norms to discuss and incorporate different supports, lessons, and explanatory models into the intervention. This paper identifies and describes the community-sourced practices utilized by lay counselors delivering Tuko Pamoja. Results include six primary community-sourced practices used by lay counselors: 1) providing metaphors and proverbs, 2) incorporating religion, 3) self-disclosure, 4) using examples and role models, 5) discussing interpersonal relationships outside of the family, and 6) referring to community dynamics and resources. The community-sourced practices described in this thesis can be used to inform and develop context-specific implementation guidelines and a comprehensive implementation model for scale up, improving the intervention’s effectiveness in positively impacting child and family outcomes.Item Open Access Validity of 24-Hour Dietary Recall in Children Age 8 to 16 in Western Kenya(2013) Sable, Sylvia KrivanekObjective: The primary objective of this study is to test the validity of 24-hour dietary recall methods compared to the gold standard of measured portions and observed food intake in the study population for improvement of this assessment in similar low-resource settings.
Study Population:Located in Western Kenya in Nyanza Province, Migori County is the setting for this research. Children were recruited from two out of four primary schools taking part in a larger study. Children ranged in age from eight to sixteen, an age range within which accuracy of diet recall has been found to increase as children age.
Methods: Thirty-eight children were observed eating a measured meal at their school. Thus, for our study sample we know exactly what children consumed at this meal. The next day, the selected children were invited back to complete an interviewer-assisted 24-hour dietary recall using methods adapted for use in the study population. Single sample t-tests were conducted in order to test the validity of the dietary recall methods by comparing recalled food amounts with the gold standard of measured portions and observed food intake. Finally, two-sample t-tests were conducted in order to compare differences across age, sex, standard and school.
Results:The dietary recall methods used to obtain recalled food amounts do not appear to be a valid method for obtaining detailed information about children's food intake in our study population. For the large majority of food volume and macro- and micro-nutrient categories, the mean deviation for recalled values and those measured and observed was statistically different from 0 (p<.05). However, results appear to have been largely influenced by serving methodology, a potential confounder in this study, suggesting that the dietary recall method may in fact be valid after accounting for serving methodology.
Conclusions and Implications: Although the small sample size limits firm conclusions, the results provide evidence-based direction for future food intake validation studies and improvement of this assessment in similar low-resource settings. Future studies should increase the sample size in order to reach more robust conclusions and carefully consider approaches to improve the validity of this assessment in low-resource populations.