Stigma, marginalization and psychosocial well-being of orphans in Rwanda: exploring the mediation role of social support

Study protocol for Sauti ya Vijana (The Voice of Youth): A hybrid-type 1 randomized trial to evaluate effectiveness and implementation of a mental health and life skills intervention to improve health outcomes for Tanzanian youth living with HIV

OBJECTIVE

Young people living with HIV (YPLWH) experience increased morbidity and mortality compared to all other age groups. Adolescence brings unique challenges related to sexual reproductive health, the elevated importance of peer groups, and often, emerging symptoms of emotional distress. Failure to address this unique life stage for YPLWH can lead to worse HIV and mental health outcomes. Herein lies the protocol for a hybrid-type-1 effectiveness-implementation trial designed to evaluate a mental health and life skills intervention that aims to address these needs for YPLWH in Tanzania.

METHODS

This is an individually randomized group-treatment trial designed to evaluate the effectiveness of Sauti ya Vijana (SYV: The Voice of Youth) toward improving viral suppression (HIV RNA <400 copies/mL) and mental health outcomes and to assess implementation including acceptability, feasibility, fidelity, and cost-effectiveness of the manualized intervention. The trial is being conducted across four geographically distinct regions of Tanzania. Peer group leaders (PGL) with lived HIV experience deliver the 10-session group-based intervention and two individual sessions during which participants describe their disclosure narrative (when they learned they live with HIV) and value-based goal setting. Caregiver or chosen supportive adults are encouraged to attend two specific group sessions with their youth. Participants are 10-24 years of age, prescribed antiretroviral therapy for at least 6 months, fully aware of their HIV status, able to commit to session attendance, and able to understand and meaningfully contribute to group sessions. Participant study visits occur at 5 time points for evaluation: baseline, 4-, 6-, 12-, and 18-months post baseline. A single booster session is conducted before the 12-month visit. Study visits evaluate mental health, adverse childhood events, interpersonal violence, resilience, stigma, HIV knowledge, substance use, sexual relationships, ART adherence, and HIV RNA. Implementation outcomes evaluate feasibility and acceptability through attendance, intervention session notes, focus discussion groups and qualitative interviews. Fidelity to the intervention is measured using fidelity checklists by a PGL observer at each group session. Cost effectiveness is calculated using an incremental cost-effectiveness ratio that utilizes a patient cost questionnaire and financial records of study costs.

SIGNIFICANCE

Few mental health interventions for YPLWH have demonstrated effectiveness. Results from this study will provide information about effectiveness and implementation of a peer-led intervention for delivering a mental health and life skills intervention in low-income settings.

TRIAL IDENTIFIER

This trial is registered at clinicaltrials.gov NCT05374109.

Enlisting in the army in the Jewish Ultraorthodox community and the consequences for wellbeing

Israeli law requires citizens to enlist in the army at 18 years old. However, the Jewish Ultraorthodox community has a longstanding agreement with the state that members of this community will not have to enlist in the army, given its spiritual leaders' strong opposition. Still, there are young men who go against the communal norms and enlist. In the current study we investigated these young men and the contribution of their self-esteem (a personal resource), their sense of community (a communal resource), and the community members' attitudes toward them (societal conditional regard, both positive and negative, and stigma) to their wellbeing. The current study consisted of 153 participants between the ages of 20 and 55 (M = 29.64, SD = 6.89). A path analysis model indicated the protective role played by self-esteem and sense of community in participants' wellbeing, and the risk factor posed by societal conditional negative regard and stigma. Moreover, self-esteem was found to mediate between income and wellbeing, whereas sense of community was found to mediate between societal conditional negative regard and wellbeing, and between stigma and wellbeing. The discussion highlights the complexity of the protective role played by sense of community against the risk of experiencing societal conditional negative regard and stigma. It also addresses the importance of promoting intervention programs during the army service of these young men, with a focus on promoting their self-esteem and on the presence of a spiritual leadership that legitimizes working, serving in the army, and yet still being part of the community.

Health-Related Stigma, Social Support, Self-Efficacy, and Self-Care Actions Among Adults With Sickle Cell Disease in Oman

Stigma contributes to the burden of individuals and families affected by Sickle cell disease (SCD) and causes delay in appropriate care seeking. The aim of this study is to examine the levels and associations between stigma, social support, self-efficacy, and self-care actions among adult patients with SCD in Oman using a cross-sectional, correlational design. Of the 264 participants, 56.1% (n = 148) were males, with mean age of 30.1 years (SD 7.7). Half of the participants were married, and 88.3% had no other associated diseases. The results demonstrate that patients in Oman suffer from health-related stigma. However, social support, self-efficacy, and self-care actions were reported to be high and correlated with several clinical and demographic variables. Based on the results, effective, low-cost interventions such as psycho-educational groups, individual counseling, or group therapies might be developed. They can promote belief in enhanced efficacy and improved SCD adaptation, thereby increasing patient, and provider satisfaction.

Social support, resilience, and self-esteem protect against common mental health problems in early adolescence: A nonrecursive analysis from a two-year longitudinal study

The aim of this study is to examine the mutual effects of self-esteem and common mental health problems (CMHPs) as well as the mutual effects of self-esteem and resilience in early adolescence. The recruited participants were 1015 adolescents aged 12.7 years (SD = 0.5 years) from two junior high schools. Data were repeatedly collected at five time points at 6-month intervals over 2-year years. The Social Support Rating Scale (SSRS), Block and Kremen's Ego-Resiliency Scale (ER89), Rosenberg Self-esteem Scale (RSES), and Mental Health Inventory of Middle School Students (MMHI-60) were used to measure social support, resilience, self-esteem, and CMHPs, respectively. Nonrecursive structural equation modeling (SEM) was performed to analyze the data.There were bivariate partial correlations among the five-time measurements for the SSRS, ER89, RSES, and MMHI-60 scores. Self-esteem negatively predicted CMHPs with a standardized direct effect of -0.276 (95% CI: -0.425 to -0.097), and the opposite effect was -0.227 (95% CI: -0.383 to -0.072). Self-esteem positively predicted resilience with the standardized direct effect of 0.279 (95% CI: 0.093-0.425), and the opposite effect was 0.221 (95% CI: 0.063-0.376). Social support was a protective factor for mental health status.The findings of mutual effects of self-esteem and CMHPs as well as self-esteem and resilience can provide researchers and practitioners with a conceptual framework that can help them build effective intervention methods to promote adolescent mental health status.

Marginalization: Conceptualizing patient vulnerabilities in the framework of social determinants of health-An integrative review

Scientific advances in health care have been disproportionately distributed across social strata. Disease burden is also disproportionately distributed, with marginalized groups having the highest risk of poor health outcomes. Social determinants are thought to influence health care delivery and the management of chronic diseases among marginalized groups, but the current conceptualization of social determinants lacks a critical focus on the experiences of people within their environment. The purpose of this article was to integrate the literature on marginalization and situate the concept in the framework of social determinants of health. We demonstrate that social position links marginalization and social determinants of health. This perspective provides a critical lens to assess the societal power dynamics that influence the construction of the socio-environmental factors affecting health. Linking marginalization with social determinants of health can improve our understanding of the inequities in health care delivery and the disparities in chronic disease burden among vulnerable groups.

The Relationships of Self-Esteem, Future Time Perspective, Positive Affect, Social Support, and Career Decision: A Longitudinal Multilevel Study

This study aimed, first, to determine whether the intra-individual variability in positive affect was related to the intra-individual variability in career decision-making self-efficacy, and career choice anxiety. The second objective was to examine whether social support moderates the relationship between affect and these outcome variables. The third objective was to find out how career decision-making self-efficacy and career choice anxiety change according to self-esteem and future time perspective. We conducted a study using the daily diary method in which participants were asked to rate their affect or attitudes for 21 consecutive days. In total, 128 university students participated in this study. The main results were as follows. First, positive affect was associated positively with career decision-making self-efficacy and negatively with career choice anxiety. Second, social support had a synergy effect with positive affect to influence career choice anxiety. Third, self-esteem was related positively to career decision-making self-efficacy and negatively to career choice anxiety. We discuss theoretical and practical implications.

Orphanhood and Self-Esteem: An 18-Year Longitudinal Study From an HIV-Affected Area in Tanzania

BACKGROUND

The HIV epidemic exacerbated the prevalence of prime-aged adult death in many parts of sub-Saharan Africa, resulting in increased rates of orphanhood. Little is known about whether this will coincide with adverse psychosocial well-being in adulthood for those who were orphaned at childhood.

METHODS

We studied a cohort of 1108 children from Kagera, a region of Tanzania that was heavily affected by HIV early in the epidemic. During the baseline data collection in 1991-1994, these children were aged 0-16 years and had both parents alive. We followed them roughly 16-19 years later in 2010, by which time 531 children (36%) had lost either one or both parents before their 19th birthday. We compared the 2010 10-item Rosenberg Self-Esteem Scale (RSES) score between children who lost a parent before the age of 19 and those who did not. We used the baseline data to control for preorphanhood confounders. This is important because we find that children who will lose their fathers in the future before age 19 came from somewhat lower socioeconomic backgrounds.

RESULTS

We found no correlation between maternal death and self-esteem measured through RSES. Paternal death was strongly correlated with lower levels of self-esteem (0.2 SDs lower RSES 95% confidence interval: 0.059 to 0.348), and the correlation was stronger when the death occurred during the child's teenage years. These effects are a net of socioeconomic differences that existed before the orphanhood event.

CONCLUSIONS

Our study supports the further development and piloting of programs that address psychosocial problems of orphans.