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Steventon Roberts KJ, Du Toit S, Mawoyo T, Tomlinson M, Cluver LD, Skeen S, Laurenzi CA, Sherr L. Protocol for the OCAY study: a cohort study of orphanhood and caregiver loss in the COVID-19 era to explore the impact on children and adolescents. BMJ Open 2023; 13:e071023. [PMID: 37263702 DOI: 10.1136/bmjopen-2022-071023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/03/2023] Open
Abstract
INTRODUCTION Globally, no person has been untouched by the COVID-19 pandemic. Yet, little attention has been given to children and adolescents in policy, provision and services. Moreover, there is a dearth of knowledge regarding the impact of COVID-19-associated orphanhood and caregiver loss on children. This study aims to provide early insights into the mental health and well-being of children and adolescents experiencing orphanhood or caregiver loss in South Africa. METHODS AND ANALYSIS Data will be drawn from a quantitative longitudinal study in Cape Town, South Africa. A sample of children and adolescents between the ages of 9 and 18 years, experiencing parental or caregiver loss from COVID-19, will be recruited together with a comparison group of children in similar environments who did not experience loss. The study aims to recruit 500 children in both groups. Mental health and well-being among children will be explored through the use of validated and study-specific measures. Participants will be interviewed at two time points, with follow-up data being collected 12-18 months after baseline. A combination of analytical techniques (including descriptive statistics, regression modelling and structural equation modelling) will be used to understand the experience and inform future policy and service provision. ETHICS AND DISSEMINATION This study received ethical approval from the Health Research Ethics Committee at Stellenbosch University (N 22/04/040). Results will be disseminated via academic and policy publications, as well as national and international presentations including high-level meetings with technical experts. Findings will also be disseminated at a community level via various platforms.
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Affiliation(s)
- Kathryn J Steventon Roberts
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK
- Institute for Global Health, University College London, London, UK
| | - Stefani Du Toit
- Institute for Life Course Health Reseach, Department of Global Health, Stellenbosch Univeristy, Stellenbosch, South Africa
| | - Tatenda Mawoyo
- Institute for Life Course Health Reseach, Department of Global Health, Stellenbosch Univeristy, Stellenbosch, South Africa
| | - Mark Tomlinson
- Institute for Life Course Health Reseach, Department of Global Health, Stellenbosch Univeristy, Stellenbosch, South Africa
- School of Nursing & Midwifrey, Queens University, Belfast, UK
| | - Lucie D Cluver
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK
- Department of Psychiatry & Mental Health, Univeristy of Cape Town, Cape Town, South Africa
| | - Sarah Skeen
- Institute for Life Course Health Reseach, Department of Global Health, Stellenbosch Univeristy, Stellenbosch, South Africa
- Amsterdam Institute for Social Science Research, Faculty of Social & Behavioural Sciences, Univeristy of Amsterdam, Amsterdam, Netherlands
| | - Christina A Laurenzi
- Institute for Life Course Health Reseach, Department of Global Health, Stellenbosch Univeristy, Stellenbosch, South Africa
| | - Lorraine Sherr
- Institute for Global Health, University College London, London, UK
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Carlucci JG, De Schacht C, Graves E, González P, Bravo M, Yu Z, Amorim G, Arinze F, Silva W, Tique JA, Alvim MFS, Simione B, Fernando AN, Wester CW. CD4 Trends With Evolving Treatment Initiation Policies Among Children Living With HIV in Zambézia Province, Mozambique, 2012-2018. J Acquir Immune Defic Syndr 2022; 89:288-296. [PMID: 34840319 PMCID: PMC8826612 DOI: 10.1097/qai.0000000000002870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 08/02/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Historically, antiretroviral therapy (ART) initiation was based on CD4 criteria, but this has been replaced with "Test and Start" wherein all people living with HIV are offered ART. We describe the baseline immunologic status among children relative to evolving ART policies in Mozambique. METHODS This retrospective evaluation was performed using routinely collected data. Children living with HIV (CL aged 5-14 years) with CD4 data in the period of 2012-2018 were included. ART initiation "policy periods" corresponded to implementation of evolving guidelines: in period 1 (2012-2016), ART was recommended for CD4 <350 cells/mm3; during period 2 (2016-2017), the CD4 threshold increased to <500 cells/mm3; Test and Start was implemented in period 3 (2017-2018). We described temporal trends in the proportion of children with severe immunodeficiency (CD4 <200 cells/mm3) at enrollment and at ART initiation. Multivariable regression models were used to estimate associations with severe immunodeficiency. RESULTS The cohort included 1815 children with CD4 data at enrollment and 1922 at ART initiation. The proportion of children with severe immunodeficiency decreased over time: 20% at enrollment into care in period 1 vs. 16% in period 3 (P = 0.113) and 21% at ART initiation in period 1 vs. 15% in period 3 (P = 0.004). Children initiating ART in period 3 had lower odds of severe immunodeficiency at ART initiation compared with those in period 1 [adjusted odds ratio (aOR) = 0.67; 95% CI: 0.51 to 0.88]. Older age was associated with severe immunodeficiency at enrollment (aOR = 1.13; 95% CI: 1.06 to 1.20) and at ART initiation (aOR = 1.14; 95% CI: 1.08 to 1.21). CONCLUSIONS The proportion of children with severe immunodeficiency at ART initiation decreased alongside more inclusive ART initiation guidelines. Earlier treatment of children living with HIV is imperative.
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Affiliation(s)
- James G. Carlucci
- Vanderbilt University Medical Center, Department of Pediatrics, Division of Pediatric Infectious Diseases, Nashville, TN
- Vanderbilt University Medical Center, Institute for Global Health, Nashville, TN
| | | | - Erin Graves
- Vanderbilt University Medical Center, Institute for Global Health, Nashville, TN
| | | | | | - Zhihong Yu
- Vanderbilt University Medical Center, Department of Biostatistics, Nashville, TN;
| | - Gustavo Amorim
- Vanderbilt University Medical Center, Department of Biostatistics, Nashville, TN;
| | | | | | | | | | - Beatriz Simione
- Ministry of Health, National Directorate of Public Health, Maputo, Mozambique;
| | | | - C. William Wester
- Vanderbilt University Medical Center, Institute for Global Health, Nashville, TN
- Vanderbilt University Medical Center, Department of Medicine, Division of Infectious Diseases, Nashville, TN
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Effect of care environment on educational attainment among orphaned and separated children and adolescents in Western Kenya. BMC Public Health 2022; 22:123. [PMID: 35042503 PMCID: PMC8764770 DOI: 10.1186/s12889-022-12521-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 12/10/2021] [Indexed: 11/17/2022] Open
Abstract
Background There are approximately 140 million orphaned and separated children (OSCA) around the world. In Kenya, many of these children live with extended family while others live in institutions. Despite evidence that orphans are less likely to be enrolled in school than non-orphans, there is little evidence regarding the role of care environment. This evidence is vital for designing programs and policies that promote access to education for orphans, which is not only their human right but also an important social determinant of health. The purpose of this study was to compare educational attainment among OSCA living in Charitable Children’s Institutions and family-based settings in Uasin Gishu County, Kenya. Methods This study analyses follow up data from a cohort of OSCA living in 300 randomly selected households and 17 institutions. We used Poisson regression to estimate the effect of care environment on primary school completion among participants age ≥ 14 as well as full and partial secondary school completion among participants age ≥ 18. Risk ratios and 95% confidence intervals were estimated using a bootstrap method with 1000 replications. Results The analysis included 1406 participants (495 from institutions, 911 from family-based settings). At baseline, 50% were female, the average age was 9.5 years, 54% were double orphans, and 3% were HIV-positive. At follow-up, 76% of participants age ≥ 14 had completed primary school and 32% of participants age ≥ 18 had completed secondary school. Children living in institutions were significantly more likely to complete primary school (aRR: 1.18, 95% CI: 1.10–1.28) and at least 1 year of secondary school (aRR: 1.28, 95% CI: 1.18–1.39) than children in family-based settings. Children living in institutions were less likely to have completed all 4 years secondary school (aRR: 0.79, 95% CI: 0.43–1.18) than children in family-based settings. Conclusion Children living in institutional environments were more likely to complete primary school and some secondary school than children living in family-based care. Further support is needed for all orphans to improve primary and secondary school completion. Policies that require orphans to leave institution environments upon their eighteenth birthday may be preventing these youth from completing secondary school.
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Braitstein P, DeLong A, Ayuku D, Ott M, Atwoli L, Galárraga O, Sang E, Hogan J. Association of Care Environment With HIV Incidence and Death Among Orphaned, Separated, and Street-Connected Children and Adolescents in Western Kenya. JAMA Netw Open 2021; 4:e2125365. [PMID: 34529063 PMCID: PMC8446813 DOI: 10.1001/jamanetworkopen.2021.25365] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE In 2015, there were nearly 140 million orphaned children globally, particularly in low- and middle-income regions, and millions more for whom the street is central to their everyday lives. A total of 16.6 million children were orphaned because of deaths associated with HIV/AIDS, of whom 90% live in sub-Saharan Africa. Although most orphaned and separated children and adolescents in this region are cared for by extended family, the large number of children requiring care has produced a proliferation of institutional care. Few studies have investigated the association between care environment and physical health among orphaned and separated youths in sub-Saharan Africa. OBJECTIVE To examine the association of care environment with incident HIV and death among orphaned and separated children and adolescents who were living in charitable children's institutions, family-based settings, and street settings in western Kenya over almost 10 years. DESIGN, SETTING, AND PARTICIPANTS The Orphaned and Separated Children's Assessments Related to Their Health and Well-Being (OSCAR) project was an observational prospective cohort study conducted in Uasin Gishu County, Kenya. The cohort comprised 2551 orphaned, separated, and street-connected children from communities within 8 administrative locations, which included 300 randomly selected households (family-based settings) caring for children who were orphaned from all causes, 19 charitable children's institutions (institutional settings), and a convenience sample of 100 children who were practicing self-care on the streets (street settings). Participants were enrolled from May 31, 2010, to April 24, 2013, and were followed up until November 30, 2019. EXPOSURES Care environment (family-based, institutional, or street setting). MAIN OUTCOMES AND MEASURES Survival regression models were used to investigate the association between care environment and incident HIV, death, and time to incident HIV or death. RESULTS Among 2551 participants, 1230 youths were living in family-based settings, 1230 were living in institutional settings, and 91 were living in street settings. Overall, 1321 participants (51.8%) were male, with a mean (SD) age at baseline of 10.4 (4.8) years. Most participants who were living in institutional (1047 of 1230 youths [85.1%]) or street (71 of 91 youths [78.0%]) settings were double orphaned (ie, both parents had died). A total of 59 participants acquired HIV infection or died during the study period. After adjusting for sex, age, and baseline HIV status, living in a charitable children's institution was not associated with death (adjusted hazard ratio [AHR], 0.26; 95% CI, 0.07-1.02) or incident HIV (AHR, 1.49; 95% CI, 0.46-4.83). Compared with living in a family-based setting, living in a street setting was associated with death (AHR, 5.46; 95% CI, 2.30-12.94), incident HIV (AHR, 17.31; 95% CI, 5.85-51.25), and time to incident HIV or death (AHR, 7.82; 95% CI, 3.48-17.55). CONCLUSIONS AND RELEVANCE In this study, after adjusting for potential confounders, no association was found between care environment and HIV incidence or death among youths living in institutional vs family-based settings. However, living in a street setting vs a family-based setting was associated with both HIV incidence and death. This study's findings suggest that strengthening of child protection systems and greater investment in evidence-based family support systems that improve child and adolescent health and prevent youth migration to the street are needed for safe and beneficial deinstitutionalization to be implemented at scale.
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Affiliation(s)
- Paula Braitstein
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Department of Epidemiology and Medical Statistics, School of Public Health, College of Health Sciences, Moi University, Eldoret, Kenya
- Academic Model Providing Access to Healthcare (AMPATH) Program, Eldoret, Kenya
| | - Allison DeLong
- Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island
| | - David Ayuku
- Department of Mental Health and Behavioral Sciences, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Mary Ott
- Department of Pediatrics, Faculty of Medicine, Indiana University, Indianapolis
| | - Lukoye Atwoli
- Department of Mental Health and Behavioral Sciences, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
- Dean’s Office, Aga Khan University Medical College, East Africa, Nairobi, Kenya
| | - Omar Galárraga
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Edwin Sang
- Academic Model Providing Access to Healthcare (AMPATH) Program, Eldoret, Kenya
| | - Joseph Hogan
- Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island
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Vermund SH. Where Should Orphaned and Separated Children and Adolescents Live: Comparing Institutionalized- and Family-Based Venues in Kenya. JAMA Netw Open 2021; 4:e2125572. [PMID: 34529069 PMCID: PMC10773959 DOI: 10.1001/jamanetworkopen.2021.25572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Sten H Vermund
- Office of the Dean, Yale School of Public Health, New Haven, Connecticut
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Tumwesige W, Namatovu P, Bahar OS, Byansi W, McKay MM, Ssewamala FM. Engaging community and governmental partners in improving health and mental health outcomes for children and adolescents impacted by HIV/AIDS in Uganda. ACTA ACUST UNITED AC 2021; 4. [PMID: 34056575 PMCID: PMC8159177 DOI: 10.21037/pm-20-86] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The African region remains the world’s most affected region in the HIV epidemic. A related consequence of HIV/AIDS in sub-Saharan Africa (SSA), including in Uganda, is the high prevalence of children and adolescents who have lost one or both parents to this virus or who have been perinatally infected. Guided by the Practical, Robust Implementation and Sustainability (PRISM) framework, this paper describes the strategies by which we have engaged community and government partners in research using three NIH-funded randomized clinical trials testing an evidence-based combination intervention aimed at improving health and mental health outcomes among children and adolescents impacted by HIV/AIDS in Uganda. We specifically lay out four strategies that have been used to facilitate stakeholder engagement, namely consultative meetings, stakeholder accountability meetings, training of key players (task-shifting), and policymaker engagement. We emphasize that community collaborations and partnerships are especially critical when implementing combination interventions that require a high level of communication and coordination among multiple implementation partners. We underline that building and sustaining long-term relationships and communication with the stakeholders can allow the researchers to successfully design rigorous studies that are responsive to local needs and can make a difference especially in low-resource settings. Finally, we highlight that the process of engagement and collaboration can be guided by conceptual frameworks.
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Affiliation(s)
| | - Phionah Namatovu
- Brown School, Washington University in St. Louis, St. Louis, MO, USA
| | - Ozge Sensoy Bahar
- Brown School, Washington University in St. Louis, St. Louis, MO, USA
| | - William Byansi
- Brown School, Washington University in St. Louis, St. Louis, MO, USA
| | - Mary M McKay
- Brown School, Washington University in St. Louis, St. Louis, MO, USA
| | - Fred M Ssewamala
- Brown School, Washington University in St. Louis, St. Louis, MO, USA
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Sui X, Massar K, Ruiter RAC, Reddy PS. Violence typologies and sociodemographic correlates in South African adolescents: a three-wave cross-sectional study. BMC Public Health 2020; 20:221. [PMID: 32050945 PMCID: PMC7017509 DOI: 10.1186/s12889-020-8332-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 02/06/2020] [Indexed: 11/10/2022] Open
Abstract
Background Violence victimisation and violence perpetration may co-occur in adolescents. Understanding the sociodemographic correlates of the independent and joint profiles of victimisation and perpetration may inform preventive interventions. This study examined the associations of sociodemographic factors with four violence typologies, namely, 1) non-involvement in both victimisation and perpetration, 2) victims only, 3) perpetrators only, and 4) victim-perpetrators. Trends in the prevalence of the four violence typologies over the three survey years were also examined. Methods We used data from the three nationally representative South African Youth Risk Behaviour Surveys conducted in 2002, 2008, and 2011 and included a multi-ethnic sample of adolescents (n = 30,007; boy: 46.9%, girls: 53.1%; M age = 16 years, SD = .06). Results The sample consisted of 8030 (30.8%) adolescents who had non-involvement in both victimisation and perpetration, 8217 were victims only (29.8%), 2504 were perpetrators only (9.0%), and 7776 were victim-perpetrators (24.6%). Logistic regression analyses showed that being a girl increased the odds of non-involvement (OR: 1.47, 99% CI: 1.36–1.58) and being victims only (OR: 1.90, 99% CI: 1.76–2.05). Being a boy increased the odds of being perpetrators only (OR: 0.42, 99% CI: 0.37–0.47) and victim-perpetrators (OR: 0.51, 99% CI: 0.47–0.55). Adolescents who did not have an absent mother had higher odds of non-involvement (OR: 0.78, 99% CI: 0.62–0.97). Lower monthly allowance increased the odds of victimisation only (OR: 0.99, 99% CI: 0.97–1.00), whereas higher monthly allowance increased the odds of perpetration only (OR: 1.05, 99% CI: 1.03–1.08). Trend analysis showed that between 2002 to 2011, there was an increase in the prevalence of non-involvement in adolescents (p < .001), a decrease in the prevalence of victims only (p < .05) and victim-perpetrators (p < .001), and no changes in the prevalence of perpetrators only (p > .05). Conclusions Sociodemographic factors are uniquely associated with different violence typologies suggesting the need for tailored interventions to target adolescents with differed risks to violence victimisation and perpetration. Strengthening family relations, particularly between mother and child, may protect adolescents from the experiences of victimisation and perpetration.
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Affiliation(s)
- Xincheng Sui
- Department of Work and Social Psychology, Faculty of Psychology and Neuroscience, Maastricht University, P.O. Box 616, 6200, MD, Maastricht, The Netherlands.
| | - Karlijn Massar
- Department of Work and Social Psychology, Faculty of Psychology and Neuroscience, Maastricht University, P.O. Box 616, 6200, MD, Maastricht, The Netherlands
| | - Robert A C Ruiter
- Department of Work and Social Psychology, Faculty of Psychology and Neuroscience, Maastricht University, P.O. Box 616, 6200, MD, Maastricht, The Netherlands
| | - Priscilla S Reddy
- Human Sciences Research Council, Cape Town, 8001, South Africa.,Visiting Professor, Nelson Mandela University, Port Elizabeth, 6031, South Africa
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Tozan Y, Sun S, Capasso A, Shu-Huah Wang J, Neilands TB, Bahar OS, Damulira C, Ssewamala FM. Evaluation of a savings-led family-based economic empowerment intervention for AIDS-affected adolescents in Uganda: A four-year follow-up on efficacy and cost-effectiveness. PLoS One 2019; 14:e0226809. [PMID: 31891601 PMCID: PMC6938344 DOI: 10.1371/journal.pone.0226809] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 12/03/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Children who have lost a parent to HIV/AIDS, known as AIDS orphans, face multiple stressors affecting their health and development. Family economic empowerment (FEE) interventions have the potential to improve these outcomes and mitigate the risks they face. We present efficacy and cost-effectiveness analyses of the Bridges study, a savings-led FEE intervention among AIDS-orphaned adolescents in Uganda at four-year follow-up. METHODS Intent-to-treat analyses using multilevel models compared the effects of two savings-led treatment arms: Bridges (1:1 matched incentive) and BridgesPLUS (2:1 matched incentive) to a usual care control group on the following outcomes: self-rated health, sexual health, and mental health functioning. Total per-participant costs for each arm were calculated using the treatment-on-the-treated sample. Intervention effects and per-participant costs were used to calculate incremental cost-effectiveness ratios (ICERs). FINDINGS Among 1,383 participants, 55% were female, 20% were double orphans. Mean age was 12 years at baseline. At 48-months, BridgesPLUS significantly improved self-rated health, (0.25, 95% CI 0.06, 0.43), HIV knowledge (0.21, 95% CI 0.01, 0.41), self-concept (0.26, 95% CI 0.09, 0.44), and self-efficacy (0.26, 95% CI 0.09, 0.43) and lowered hopelessness (-0.28, 95% CI -0.43, -0.12); whereas Bridges improved self-rated health (0.26, 95% CI 0.08, 0.43) and HIV knowledge (0.22, 95% CI 0.05, 0.39). ICERs ranged from $224 for hopelessness to $298 for HIV knowledge per 0.2 standard deviation change. CONCLUSIONS Most intervention effects were sustained in both treatment arms at two years post-intervention. Higher matching incentives yielded a significant and lasting effect on a greater number of outcomes among adolescents compared to lower matching incentives at a similar incremental cost per unit effect. These findings contribute to the evidence supporting the incorporation of FEE interventions within national social protection frameworks.
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Affiliation(s)
- Yesim Tozan
- College of Global Public Health, New York University, New York, New York, United States of America
| | - Sicong Sun
- International Center for Child Health and Development, Brown School, Washington University in Saint Louis, Saint Louis, Missouri, United States of America
| | - Ariadna Capasso
- College of Global Public Health, New York University, New York, New York, United States of America
| | - Julia Shu-Huah Wang
- Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong SAR, China
| | - Torsten B. Neilands
- Center for AIDS Prevention Studies, School of Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Ozge Sensoy Bahar
- International Center for Child Health and Development, Brown School, Washington University in Saint Louis, Saint Louis, Missouri, United States of America
| | - Christopher Damulira
- International Center for Child Health and Development, Brown School, Washington University in Saint Louis, Saint Louis, Missouri, United States of America
| | - Fred M. Ssewamala
- International Center for Child Health and Development, Brown School, Washington University in Saint Louis, Saint Louis, Missouri, United States of America
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Ashaba S, Cooper-Vince C, Vořechovská D, Maling S, Rukundo GZ, Akena D, Tsai AC. Development and validation of a 20-item screening scale to detect major depressive disorder among adolescents with HIV in rural Uganda: A mixed-methods study. SSM Popul Health 2018; 7:100332. [PMID: 30560198 PMCID: PMC6289958 DOI: 10.1016/j.ssmph.2018.100332] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 10/31/2018] [Accepted: 11/25/2018] [Indexed: 12/27/2022] Open
Abstract
Background Depression is a major cause of disability among children and adolescents and is associated with elevated risks for substance abuse, HIV transmission risk behavior, and suicide. Among adolescents living with HIV (ALWH), depression undermines adherence to antiretroviral treatment, leading to poorer health outcomes. However, there are few instruments available for depression screening among ALWH in sub-Saharan Africa. Methods Using mixed methods we developed and validated a 20-item depression screening scale to be used among ALWH in rural Uganda. First, we conducted focus group discussions and in-depth interviews with adolescents and adult caregivers (n = 80) to elicit participant perspectives about mental health challenges facing HIV-affected children and adolescents. We generated an initial pool of 40 items, pilot tested it with ALWH and adolescents of unknown serostatus (n = 40), and then administered the items to a validation sample of ALWH (n = 224). Exploratory factor analysis was used to examine the factor structure of the scale. We evaluated the scale for its reliability, and validity. Results The mean age of the participants in the validation sample was 14.9 years (standard deviation [SD] 1.4), 131 (58%) were girls and 48 (21%) were orphans. Exploratory factor analysis revealed two factors related to affective and cognitive symptoms of depression. The 20-item depression scale was internally consistent (Cronbach’s alpha = 0.91) with moderate test-retest and inter-rater reliability. Construct validity was excellent, as demonstrated through correlation with related constructs like stigma (P< 0.001) and bullying (P< 0.001). At the optimized cutoff score, 64 (29%) participants screened positive for probable depression. Using the Mini-International Neuropsychiatric Interview for Children and Adolescents, we found that 37 participants (17%) were diagnosed with major depressive disorder. In reference to the criterion standard, the depression scale showed excellent discrimination (c-statistic = 0.84). Conclusion This new 20-item depression scale was reliable and valid for detecting major depressive disorder among ALWH in rural Uganda. There are few culturally- and age-appropriate screening scales for use among adolescents with HIV in sub-Saharan Africa. We used qualitative methods to generate new scale items, and adapted items from previously published depression screening scales. The items in the newly developed scale consist of well-known affective and cognitive symptoms of depression. The scale has adequate internal consistency, test-retest, and inter-rater reliability, and adequate evidence of construct and criterion-related validity.
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Affiliation(s)
| | - Christine Cooper-Vince
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | | | - Samuel Maling
- Mbarara University Science and Technology, Mbarara, Uganda
| | | | - Dickens Akena
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Alexander C Tsai
- Mbarara University Science and Technology, Mbarara, Uganda.,Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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