Child and adolescent mental health in sub-Saharan Africa: a perspective from clinicians and researchers

Gene-environment interplays between family chaos and emotional problems among Nigerian adolescents: A twin study

Gene-environment correlations and interactions for the relationship between emotional problems (EP) and family environment in adolescents in low- to middle-income countries (LMIC) have been rarely investigated. In total, 3207 adolescent twins aged 12-18 (Mean = 14.6 ± 1.73) years attending public schools in Lagos State in Nigeria completed measures of EP and Family Chaos (FC). Model-fitting analyses suggested that genetic and non-shared environmental influences on EP were 21% and 71%, respectively, and the corresponding estimates were 23% and 71% for FC. Shared environmental influences were not significant (8% and 6% respectively). Phenotypic correlation between EP and FC was .30 (95% CI = .27-.34), which was significantly influenced by genetic (A - 49%, 95% CI: 0.01-0.97) and non-shared environmental factors (E - 32%, 95% CI: 0.10-0.54). Shared environmental influences were not significant (C - 19%, 95% CI: -0.13 to 0.50). Moderation effects were significant whereby as FC increased, A on EP decreased (βA = -0.07, 95% CI: -0.12 to -0.02) while E increased (βE = 0.06, 95% CI: 0.03-0.09). Our findings indicate that genetic and non-shared environmental risk factors may mediate the relationship between EP and FC, and that as FC increases, protective genetic influences on EP may be attenuated, whereas environmental influences may become stronger in adolescents in LMIC.

The Challenges and Opportunities for Mental Health Twin Research in Nigeria

The recent interest in increasing diversity in genetic research can be useful in uncovering novel insights into the genetic architecture of mental health disorders - globally and in previously unexplored settings such as low- and middle-income settings like Nigeria. Genetic research into mental health is potentially promising in Nigeria and we reflect on the challenges and opportunities for twin research which may be particularly suited to Nigeria. The higher rates of twinning in Africa and Nigeria specifically, make the twin design an affordable and readily maintainable approach for genetic research in the country. Despite potential challenges with recruitment, data collection, data analysis and dissemination; the success of current efforts suggest that the twin design can tapped even further for greater impact in the country. We highlight some ways in which the scope of twin research can be increased and suggest some ways in which existing challenges can be overcome including recent Patient Participant Involve and Engagement activities.

The significance of feeling safe for resilience of adolescents in sub-Saharan Africa

Introduction

Adolescents in sub-Saharan Africa (SSA) are exposed to several challenges and risk factors, linked to historical legacies. Sub-Saharan Africa has one of the highest rates of poverty and inequality in the world, is one of the regions most negatively affected by climate change, performs poorly on many health measures, and has high rates of different forms of violence, especially gender-based violence. These contextual challenges impact adolescent mental health outcomes, preventing them to access resilience-enabling pathways that support positive outcomes despite adversity. This study aimed to contribute to knowledge generation on resilience of young people in the understudied SSA region by investigating which variables directly (or indirectly) affect the resilience of adolescents.

Methods

Purposive sampling was used to collect quantitative survey data from 3,312 adolescents (females = 1,818; males = 1,494) between the ages of 12 and 20 years, participating in interventions implemented by a non-governmental organization, the Regional Psychosocial Support Initiative. Data were collected in Angola (385, 11.6%), Eswatini (128, 3.9%), Kenya (390, 11.8%), Lesotho (349, 10.5%), Mozambique (478, 14.4%), Namibia (296, 8.9%), South Africa (771, 23.3%), Uganda (201, 6.1%), and Zambia (314, 9.5%). The survey collected data on socio-demographic status, resilience (CYRM-R), depression (PHQ-9), self-esteem (Rosenberg Self-Esteem Scale) and feelings of safety (self-developed scale). Mental health was defined as lower levels of depression, higher levels of self-esteem and higher levels of feeling safe. A mediation analysis was conducted to investigate the relationship between the predictors (the socio-demographic variables) and the output (resilience), with the mediators being depression, self-esteem and feeling safe (which all link to mental health).

Results

This study contributes to a gap in knowledge on country-level comparative evidence on significant predictors that impact resilience outcomes (directly or indirectly) for adolescents in sub-Saharan African countries. The results indicate that, when considering all countries collectively, feeling safe is the only predictor that has a significant direct effect on overall resilience and personal resilience, but not on caregiver resilience. When considering each country separately, feeling safe has a direct effect on overall, personal and caregiver resilience for all countries; but not for South Africa and Mozambique.

Discussion

The results provide evidence on which to craft youth development interventions by measuring mediators (depression, self-esteem and feeling safe) and resilience for adolescents in sub-Saharan Africa. The overall results of the present paper point toward a contextually relevant pathway to supporting their resilience, namely, the need to systemically target the creation and/or strengthening of structures that enable adolescents to feel safe.

Short-Term Impact of "Amaka Amasanyufu" Multiple Family Group Intervention on Mental Health Functioning of Children With Disruptive Behavior Disorders in Uganda

OBJECTIVE

We evaluate the mid-intervention (8 weeks) and short-term (16 weeks) impact of a culturally adapted multiple family group (MFG) intervention, "Amaka Amasanyufu," on the mental health of children with disruptive behavior disorders (DBDs) and primary caregivers in Uganda.

METHOD

We analyzed data from the Strengthening mental health and research training in Sub-Saharan Africa (SMART) Africa-Uganda study. Schools were randomized to the following: a control group; an MFG facilitated by parent peers (MFG-PP); or an MFG facilitated by community health workers (MFG:CHW). All participants were blinded to interventions provided to other participants and study hypotheses. At 8 weeks and 16 weeks, we evaluated differences in depressive symptoms and self-concept among children and in mental health and caregiving-related stress among caregivers. Three-level linear mixed-effects models were fitted. Pairwise comparisons of post-baseline group means were performed using the Sidak adjustment for multiple comparisons and standardized mean differences. Data from 636 children with DBDs and caregivers (controls: n = 243, n = 10 schools; MFG-PP: n = 194, n = 8 schools; MFG-CHW: n = 199, n = 8 schools) were analyzed.

RESULTS

There were significant group-by-time interactions for all outcomes, and differences were observed mid-intervention, with short-term effects at 16 weeks (end-intervention). MFG-PP and MFG-CHW children had significantly lower depressive symptoms and higher self-concept, whereas caregivers had significantly lower caregiving-related stress and fewer mental health problems, than controls. There was no difference between intervention groups.

CONCLUSION

Amaka Amasanyufu MFG intervention is effective for reducing depressive symptoms and improving self-concept among children with DBDs while reducing parental stress and mental health problems among caregivers. Given the paucity of culturally adapted mental health interventions, this provides support for adaptation and scale-up in Uganda and other low-resource settings.

CLINICAL TRIAL REGISTRATION INFORMATION

SMART Africa (Strengthening Mental Health Research and Training); https://clinicaltrials.gov/: NCT03081195.

Urban-Rural Differences in Depression Literacy Among High School Teachers in the Kingdom of Eswatini

BACKGROUND

Concerns have been raised over teachers' mental health literacy in low-income countries and lower- and middle-income countries wherein pediatric mental health resources are limited. This study aims to investigate adolescent depression literacy among teachers in Eswatini and to explore the role of urbanicity.

METHODS

We conducted a cross-sectional survey in 59 public high schools in Eswatini in 2019-2020. Data were collected by a paper-and-pencil questionnaire; depression literacy was assessed by the 17-item Adolescent Depression Knowledge Questionnaire.

RESULTS

Teachers' adolescent depression literacy item-level correct rates fell between 27 and 80%. Although the multivariate response models indicated that teaching in urban areas was slightly associated with having higher depression literacy in general (adjusted odds ratio [aOR] = 1.46; 95% confidence interval = 1.00-2.12), such urban-rural differences did not manifest homogeneously across all items: urban teaching was significantly linked with reduced correct responses toward certain items concerning depression etiology and treatment, including "depression runs in some families," "major stress as a necessary cause," and "a curable illness" (aOR = 0.57 ∼ 0.68).

CONCLUSION

Urban-rural differences in teachers' depression literacy were manifested at both scale- and item-levels. A critical need exists for urban/rural areas-tailored intervention on teachers' literacy toward mental disorders in the resource-limited regions to better improve health and developmental outcomes of students.

Voices from the Youth in Kenya Addressing Mental Health Gaps and Recommendations

Studies including adolescents and young people (AYP) enhance the relevance of research results, benefit stakeholders, and inform future research. There exists a mental health gap in services for AYP living in low and middle-income countries. This study aims to identify mental health challenges faced by adolescents and young people in Kenya, develop practical recommendations to mitigate these issues, and reduce the mental health burden among this population. We convened an AYP-led meeting that involved 41 participants. The meeting objectives were to (1) identify efforts to support existing national and regional strategic priorities and review goals for addressing mental health needs among AYPs, (2) develop immediate action plans for strengthened mental health services, (3) review and strengthen country-level coordination mechanisms, and (4) identify how participating county experiences can inform mental health services in Kenya. Ministry of Health (MoH) officials from national and county levels, academic experts, and implementing partner agencies involved in mental health services participated in the meeting. The team, including AYP representatives, identified various mental health challenges among the AYA and recommended interventions aimed towards improving their mental health situation in the country. The challenges were clustered into three themes and comprehensively reviewed to establish the precipitating factors to mental health outcomes among AYPs in Kenya and provide recommendations. The themes included (1) legislative, (2) service provider/Ministry of Health, and (3) adolescent/individual-level factors. To bridge the mental health gap in the country and scale up mental health outcomes, the stakeholders recommended interventions within the context of the three clusters. The key suggestions included an increase in insurance financing, acceleration of community health interventions, the establishment of adolescent-friendly spaces, the training of adolescent youth champions, interactive service provision models, implementation of the existing mental health policies and structures, the development of comprehensive assessment tools, well equipped mental health departments in health facilities, the enhancement of telehealth services and digital villages, the mobilization of a functional mental health response team, and the development of a mental health database.

Associations between mild depression and anxiety and physical inactivity among school-going Ugandan adolescents aged 14 to 17 years

Objective: The aim of this cross-sectional study was to investigate associations between physical activity levels and emotional and behavioural problems in school-going adolescents aged 14 to 17 years in Uganda.Methods: Two-hundred and five adolescents [median (interquartile range) age = 16.0 (1.0) years; female = 61.9%] completed the interviewer-administered Strengths and Difficulties Questionnaire (SDQ), Patient Health Questionnaire-9 (PHQ-9), the Generalised Anxiety Disorder-7 questionnaire (GAD-7), and the Physical Activity Vital Sign (PAVS) measure. Spearman's rho correlations and Mann-Whitney U-tests were applied.Results: Among 205 adolescents, 97.1% were physically inactive (PAVS < 420min/week), while 64.4% reported either mild depressive (PHQ-9 ≥ 5) or anxiety (GAD-7 ≥ 5) symptoms. Higher PAVS scores correlated significantly with lower SDQ emotional problems (ρ = -0.23, p < 0.001), lower PHQ-9 (ρ = -0.26, p < 0.001), and lower GAD-7 (ρ = -0.22, p < 0.001) scores. Those with emotional problems (SDQ ≥ 5) (n = 86) were significantly less physically active than those without (n = 119) [30.0 (62.5) versus 60.0 (105.0) min/week, p < 0.001]. Those with depressive symptoms (PHQ-9 ≥ 5) were significantly less physically active than those without [35.0 (70.0) versus 60.0 (120.0) min/week, p < 0.001].Conclusion: Physical inactivity and mental health problems are related important public health concerns in school-going adolescents in low-income countries such as Uganda. The efficacy and effectiveness of school-based mental health literacy programs, including physical activity promotion, should be explored in these low-resource settings.

Accelerating ontological security for South African adolescents living in high HIV-prevalence areas: a longitudinal study

Ontological security is the personal need to build fundamental certainty about the continuity of life events. It is central to long-term human development, particularly among adolescents in highly vulnerable communities in South Africa. We examined the cumulative effects of eight hypothesised provisions (development accelerators) in reducing the risks of ontological insecurity outcomes aligned with Sustainable Development Goals (SDGs) targets. Three waves of survey data from adolescents living in high HIV prevalence areas in South Africa were analysed. We used standardised tools to measure twelve outcomes linked to two dimensions of ontological security: mental health and violence. Sustained receipt (at baseline and follow-ups) of eight hypothesised accelerators were examined: emotional and social support, parental/caregiver monitoring, food sufficiency, accessible health care, government cash transfers to households, basic economic security, positive parenting/caregiving, and participation in extramural activities. Associations of all accelerators with outcomes were evaluated using multivariable regressions controlling for age, sex, orphanhood and HIV status, rural/urban location, and informal housing. Cumulative effects were tested using marginal effects modelling. Of 1,519 adolescents interviewed at baseline, 1,353 (89%) completed the interviews at two follow-ups. Mean age was 13.8 at baseline; 56.6% were female. Four provisions were associated with reductions in twelve outcomes. Combinations of accelerators resulted in a percentage reduction risk in individual indicators up to 18.3%. Emotional and social support, parental/caregiver monitoring, food sufficiency and accessible health care by themselves and in combination showed cumulative reductions across twelve outcomes. These results deepen an essential understanding of the long-term effects of consistent exposure to accelerators on multi-dimensional human development. They could be directly implemented by existing evidence-based interventions such as peer-based psychosocial support, parenting programmes, adolescent-responsive healthcare and food support, providing safer and healthier environments for South African adolescents to thrive.

Accelerating Sustainable Development Goals for South African adolescents from high HIV prevalence areas: a longitudinal path analysis

BACKGROUND

Adolescents experience a multitude of vulnerabilities which need to be addressed in order to achieve the Sustainable Development Goals (SDGs). In sub-Saharan Africa, adolescents experience high burden of HIV, violence exposure, poverty, and poor mental and physical health. This study aimed to identify interventions and circumstances associated with three or more targets ("accelerators") within multiple SDGs relating to HIV-affected adolescents and examine cumulative effects on outcomes.

METHODS

Prospective longitudinal data from 3401 adolescents from randomly selected census enumeration areas in two provinces with > 30% HIV prevalence carried out in 2010/11 and 2011/12 were used to examine six hypothesized accelerators (positive parenting, parental monitoring, free schooling, teacher support, food sufficiency and HIV-negative/asymptomatic caregiver) targeting twelve outcomes across four SDGs, using a multivariate (multiple outcome) path model with correlated outcomes controlling for outcome at baseline and socio-demographics. The study corrected for multiple-hypothesis testing and tested measurement invariance across sex. Percentage predicted probabilities of occurrence of the outcome in the presence of the significant accelerators were also calculated.

RESULTS

Sample mean age was 13.7 years at baseline, 56.6% were female. Positive parenting, parental monitoring, food sufficiency and AIDS-free caregiver were variously associated with reductions on ten outcomes. The model was gender invariant. AIDS-free caregiver was associated with the largest reductions. Combinations of accelerators resulted in a percentage reduction of risk of up to 40%.

CONCLUSION

Positive parenting, parental monitoring, food sufficiency and AIDS-free caregivers by themselves and in combination improve adolescent outcomes across ten SDG targets. These could translate to the corresponding real-world interventions parenting programmes, cash transfers and universal access to antiretroviral treatment, which when provided together, may help governments in sub-Saharan Africa more economically to reach their SDG targets.

Multisystemic enablers of sub-Saharan child and youth resilience to maltreatment

BACKGROUND

The resilience of sub-Saharan children and youth to abuse and neglect is under-researched. In particular, the multisystemic and contextually sensitive nature of their resilience is under-appreciated.

PURPOSE

In response we conceptualized a discussion paper. Its intention is to make a case for a contextually relevant, multisystemic understanding of the resilience of sub-Saharan children and youth with exposure to maltreatment.

METHOD

This discussion paper draws on a critical analysis of pertinent peer-reviewed publications. It also draws on our lifelong residence in sub-Saharan Africa and related insight into this region's situational and cultural dynamics.

RESULTS

We advance three assertions regarding the multisystemic nature of sub-Saharan young people's resilience to abuse and neglect : (i) family↔communities are pivotal to sub-Saharan child and youth resilience to maltreatment; (ii) institutional supports matter too, particularly when multiple systems interact to provide networks of institutional support; and (iii) the resilience-enabling potential of built and natural environments is yet to be fully harnessed.

CONCLUSION

Interacting social and ecological system factors and processes matter for the resilience of sub-Saharan children and youth who experience abuse and neglect. Appreciation for their complexity and contextual fit are crucial to practice and policy efforts to advance the protection and wellbeing of sub-Saharan young people.

Child and adolescent mental health services in Uganda

INTRODUCTION

Worldwide, one in five children and adolescents suffer from mental health disorders, while facing limited opportunities for treatment and recovery. Growing up, they face multiple challenges that might contribute to the development of mental disorders. Uganda is a developing country with a history of prolonged civil and regional wars associated with child soldiers, large numbers of refugees and internally displaced people due to natural disasters and unrests, and a large infectious disease burden mainly due to acute respiratory tract infections, malaria and HIV/AIDS.

OBJECTIVE

This paper aims to examine the current status of child and adolescent mental health services in Uganda.

METHODOLOGY

A scoping review approach was used to select studies on child and adolescent mental health services (CAMHS) in Uganda. A search of MEDLINE, Wiley and PubMed databases was conducted using eligibility criteria. The papers were summarized in tables and then synthesized using the Frameworks for monitoring health systems performance designed by the World Health Organisation (WHO). This was done according to the Preferred Reporting Items for Systematic Review and M-Analyses Extension for Scoping Review (PRISMA-ScR) guidelines.

RESULTS

Twelve studies were identified; five of them used qualitative methods and focused mostly on the current limitations and strengths of CAMHS in Uganda, while six quantitative studies investigated the effects of new interventions. One study used a mixed-methods approach. In summary, the papers outlined a need for collaboration with the primary health sector and traditional healers to ensure additional human resources, as well as the need to focus on groups such as orphans, HIV/AIDS-affected youth, former child soldiers and refugees.

CONCLUSION

Relatively few studies have been conducted on CAMHS in Uganda, and most of those that exist are part of larger studies involving multiple countries. CAMHS in Uganda require improvement and needs to focus especially on vulnerable groups such as orphans, HIV/AIDS-affected youth and former child soldiers.

Development and external validation of a risk calculator to predict internalising symptoms among Ugandan youths affected by HIV

The aim of the study was to develop and externally validate a model to predict individualized risk of internalizing symptoms among AIDS-affected youths in low-resource settings in sub-Saharan Africa. Longitudinal data from 558 Ugandan adolescents orphaned by AIDS was used to develop our predictive model. Least Absolute Shrinkage and Selection Operator logistic regression was used to select the best subset of predictors using 10-fold cross-validation. External validation of the final model was conducted in a sample of 372 adolescents living with HIV in Uganda. Best predictors for internalizing symptoms were gender, family cohesion, social support, asset ownership, recent sexually transmitted infection (STI) diagnosis, physical health self-rating, and previous poor mental health; area under the curve (AUC)  = 72.2; 95% CI  = 67.9-76.5. For adolescents without history of internalizing symptoms, the AUC = 69.0, 95% CI = 63.4-74.6, and was best predicted by gender, drug use, social support, asset ownership, recent STI diagnosis, and physical health self-rating. Both models were well calibrated. External validation in adolescents living with HIV sample was similar, AUC = 69.7; 95% CI = 64.1-75.2. The model predicted internalizing symptoms among African AIDS-affected youth reasonably well and showed good generalizability. The model offers opportunities for the design of public health interventions addressing poor mental health among youth affected by HIV/AIDS.

[Training of higher qualification Specialists in children and adolescent psychiatry in Russia and other countries]

Most mental disorders occur before the age of 25 years, and if left without intervention, they can transform into more severe mental disorders. Despite the great need to protect the mental health of children and adolescents, in Russia and most countries of the world, there is a shortage of qualified personnel in this area. The article presents data on the availability of personnel in different countries of the world, including Russia. The issues of organizing the training of child and adolescent psychiatrists in Russia and various countries are examined, and the available data on training programs are analyzed. Educational opportunities for child and adolescent psychiatry in Russia are examined in detail.

Suicidal behaviours among deaf adolescents in Ghana: a cross-sectional study

Background

A growing global concern is that suicide research has paid little attention to young people with disabilities, particularly, in low- and middle-income countries (LAMICs). We aimed to estimate the 12-month prevalence of suicidal ideation and attempt and describe some associations among deaf adolescents in Ghana.

Methods

This is a cross-sectional anonymous self-report survey involving a nationally representative random sample of 450 school-going deaf adolescents. Data analysis included bivariate and multivariable approaches.

Results

The overall 12-month prevalence of suicidal ideation was 19·3% (95% confidence interval [CI] = 15·8–23·3) and suicidal attempt was 15·6% (95% CI = 12·3–19·2). Although alcohol use and parental divorce were strongly associated with increased odds of both suicidal ideation and attempt, high subjective mental well-being was associated with reduced odds of both suicidal ideation and attempt. Living with no parents and being a final year student were associated with suicidal ideation, while male gender was associated with suicidal attempt.

Conclusions

The prevalence of suicidal behaviours among school-going deaf adolescents in this study compares with estimates among in-school non-deaf adolescents in Ghana and other LAMICs in Africa, and also highlights the need for prevention efforts against the onset of suicidal ideation and possible transition to attempt and suicide among deaf adolescents.

Engaging community and governmental partners in improving health and mental health outcomes for children and adolescents impacted by HIV/AIDS in Uganda

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.

Prevalence and correlates of depressive symptoms among high school adolescent girls in southern Uganda

Background

In sub-Saharan Africa (SSA), adolescent girls and young women are three times more likely than boys to have depressive disorders. Understanding adolescents’ unique and common vulnerabilities and protective factors is essential for the development of appropriate interventions and programming focused on child and adolescent mental health. This paper examines the prevalence and predictors of depressive symptoms among high school adolescent girls in southern Uganda.

Methods

Baseline data from a longitudinal cluster randomized study involving 1260 adolescent girls (14–17 years), recruited from 47 secondary schools were utilized. Depressive symptoms were estimated using the 21-item Beck’s Depression Inventory. Hierarchical linear regression modelling was utilized to estimate key predictors of depressive symptoms among adolescent girls.

Results

Of the total sample, 16.35% (n = 206) reported severe depressive symptoms and almost one in every three adolescent girls interviewed (29.68%, n = 374) reported moderate symptoms. These symptoms were more prevalent among older adolescents (16 years and above). In addition, family relationships, social support, as well as measures of psychological wellbeing (self-concept and self-esteem) were all associated with lower levels of depressive symptoms. Hopelessness was associated with higher levels of depressive symptoms among adolescent girls.

Conclusion

Findings from this study indicate a high prevalence of depressive symptoms, especially among older adolescent girls. In addition, family support factors and adolescents’ psychological wellbeing were associated with low levels of depressive symptoms –pointing to the need to strengthen family functioning and adolescent’s psychological wellbeing to mitigate risks. Taken together, findings support increasing calls for early screening and detection of depressive symptoms to facilitate timely referral to care and treatment. Findings may also inform the development and incorporation of gender-specific mental health components in programming targeting adolescent girls, in low-resource communities in SSA.

Trial registration

This trial was prospectively registered with ClinicalTrials.gov (registration number: NCT03307226) on 11 October 2017.

CARTA fellows' scientific contribution to the African public and population Health Research agenda (2011 to 2018)

BACKGROUND

Since its inception in 2009, the Consortium for Advanced Research Training in Africa (CARTA) program has focused on strengthening the capacity of nine African universities and four research centres to produce skilled researchers and scholars able to improve public and population health on the continent. This study describes the alignment between CARTA-supported doctoral topics and publications with the priorities articulated by the African public and population health research agenda.

METHODS

We reviewed the output from CARTA PhD fellows between 2011 and 2018 to establish the volume and scope of the publications, and the degree to which the research focus coincided with the SDGs, World Bank, and African Development Bank research priority areas. We identified nine key priority areas into which the topics were classified.

RESULTS

In total, 140 CARTA fellows published 806 articles in peer-reviewed journals over the 8 years up to 2018. All the publications considered in this paper had authors affiliated with African universities, 90% of the publications had an African university first author and 41% of the papers have CARTA fellows as the first author. The publications are available in over 6300 online versions and have been cited in over 5500 other publications. About 69% of the published papers addressed the nine African public and population health research agenda and SDG priority areas. Infectious diseases topped the list of publications (26.8%), followed by the health system and policy research (17.6%), maternal and child health (14.7%), sexual and reproductive health (14.3%).

CONCLUSIONS

Investments by CARTA in supporting doctoral studies provides fellows with sufficient training and skills to publish their research in fields of public and population health. The number of publications is understandably uneven across Africa's public and population priority areas. Even while low in number, fellows are publishing in areas such as non-communicable disease, health financing, neglected tropical diseases and environmental health. Violence and injury is perhaps underrepresented. There is need to keep developing research capacity in partner institutions with low research output by training more PhDs in such institutions and by facilitating enabling environments for research.

Process and outcome of child psychotherapies offered in Kenya: a mixed methods study protocol on improving child mental health

BACKGROUND

Child and adolescent mental health problems account for a significant proportion of the local and global burden of disease and is recognized as a growing public health concern in need of adequate services. Studies carried out in Kenya suggest a need for a robust service for the treatment, prevention, and promotion of child and adolescent mental health. Despite a few existing services to provide treatment and management of mental health disorders, we need more knowledge about their effectiveness in the management of these disorders. This paper describes a study protocol that aims to evaluate the process and outcomes of psychotherapies offered to children and adolescents seeking mental health services at the Kenyatta National Hospital in Kenya.

METHODS

This study will use a prospective cohort approach that will follow adolescent patients (12-17 years of age) receiving mental health services in the youth clinics at the Kenyatta National Hospital for a period of 12 months. During this time a mixed methods research will be carried out, focusing on treatment outcomes, therapeutic relationship, understanding of psychotherapy, and other mental health interventions offered to the young patients. In this proposed study, we define outcome as the alleviation of symptoms, which will be assessed quantitatively using longitudinal patient data collected session-wise. Process refers to the mechanisms identified to promote change in the adolescent. For example, individual participant or clinician characteristics, therapeutic alliance will be assessed both quantitatively and qualitatively. In each session, assessments will be used to reduce problems due to attrition and to enable calculation of longitudinal change trajectories using growth curve modeling. For this study, these will be referred to as session-wise assessments. Qualitative work will include interviews with adolescent patients, their caregivers as well as feedback from the mental health care providers on existing services and their barriers to providing care.

CONCLUSION

This study aims to understand the mechanisms through which change takes place beyond the context of psychotherapy. What are the moderators and through which mechanisms do they operate to improve mental health outcomes in young people?

Impact of Extreme Weather Events on Sub-Saharan African Child and Adolescent Mental Health: A Protocol for a Systematic Review

Sub-Saharan Africa (SSA) has been identified by the Intergovernmental Panel on Climate Change (IPCC) as being the most vulnerable region to climate change impacts. A major concern is the increase in extreme weather events (EWE) such as storms, floods, droughts, heatwaves, wildfires, and landslides in SSA and their potential to affect the health and well-being of children and adolescents. The objective of this systematic review is to examine the direct and indirect impacts of EWE on the mental health of children and adolescents living in SSA, in order to inform protective adaptation strategies and promote resilience. A meta-analysis will not be possible, since the assumption is that limited studies have been published on the EWE-associated mental health impacts on children and adolescents living in SSA and that those studies that are available are heterogenous. There is acknowledgement in the global literature of the need to highlight child and adolescent mental health more prominently in climate change health strategies and policies. It is vital that adaptation strategies are informed by research on risk prevention and promotion of resilience to ensure the mental health of children and adolescents is protected.

The prevalence of mental health problems in sub-Saharan adolescents living with HIV: a systematic review

Despite the progress made in HIV treatment and prevention, HIV remains a major cause of adolescent morbidity and mortality in sub-Saharan Africa. As perinatally infected children increasingly survive into adulthood, the quality of life and mental health of this population has increased in importance. This review provides a synthesis of the prevalence of mental health problems in this population and explores associated factors. A systematic database search (Medline, PsycINFO, Scopus) with an additional hand search was conducted. Peer-reviewed studies on adolescents (aged 10-19), published between 2008 and 2019, assessing mental health symptoms or psychiatric disorders, either by standardized questionnaires or by diagnostic interviews, were included. The search identified 1461 articles, of which 301 were eligible for full-text analysis. Fourteen of these, concerning HIV-positive adolescents, met the inclusion criteria and were critically appraised. Mental health problems were highly prevalent among this group, with around 25% scoring positive for any psychiatric disorder and 30-50% showing emotional or behavioral difficulties or significant psychological distress. Associated factors found by regression analysis were older age, not being in school, impaired family functioning, HIV-related stigma and bullying, and poverty. Social support and parental competence were protective factors. Mental health problems among HIV-positive adolescents are highly prevalent and should be addressed as part of regular HIV care.

Generalised anxiety disorder in adolescents in Ghana: Examination of the psychometric properties of the Generalised Anxiety Disorder-7 scale

The Generalised Anxiety Disorder-7 (GAD-7) is a self-report scale used to assess general anxiety symptoms. Although the GAD-7 has been found to be a valid scale among adults, studies examining its psychometric properties among adolescents in high-income countries are notably limited and particularly non-existent in low- and middle-income countries. The current study addresses this lacuna by investigating the factorial validity, construct validity, internal consistency and discriminant accuracy of the GAD-7. Data were collected from 553 adolescents (boys = 231; average age = 16.85) recruited from a senior high school in Ghana, a sub-Saharan African country, using cross-sectional self-report methodology. The result supports a unidimensional structure of the GAD-7 that was invariant across gender. The GAD-7 correlates significantly with measures of anxiety, suicidal tendencies and mental well-being, suggesting construct validity. The internal consistency of the GAD-7, based on the mean inter-item correlation value of 0.24 and Cronbach’s a = 0.69, is adequate. The GAD-7 similarly discriminated between individuals at high risk of suicidal tendencies and depression from those with low or no risk, with area under curve values of 0.71 and 0.70, respectively. The GAD-7 is a reliable and valid measure to screen for generalised anxiety disorder among adolescents in Ghana.

Prevalence, correlates for early neurological disorders and association with functioning among children and adolescents with HIV/AIDS in Uganda

BACKGROUND

The aim of this study was to determine the prevalence of neurological disorders and their associated correlates and relations with clinical and behavioural problems among children and adolescents with HIV/AIDS (CA-HIV).

METHODS

This study involved a sample of 1070 CA-HIV/caregiver dyads who were evaluated at their 6-month follow-up visit as part of their participation in the longitudinal study, 'Mental health among HIV infected CHildren and Adolescents in KAmpala and Masaka, Uganda (the CHAKA study)'. Participants completed an extensive battery of measures that included a standardized DSM-5- referenced rating scale, the parent version (5-18 years) of the Child and Adolescent Symptom Inventory-5 (CASI-5). Using logistic regression, we estimated the prevalence of neurological disorders and characterised their associations with negative clinical and behavioural factors.

RESULTS

The overall prevalence of at least one neurological disorders was 18.5% (n = 198; 95% CI, 16.2-20.8). Enuresis / encopresis was the most common (10%), followed by motor/vocal tics (5.3%); probable epilepsy was the least prevalent (4%). Correlates associated with neurological disorders were in two domains: socio-demographic factors (age, ethnicity and staying in rural areas) and HIV-related factors (baseline viral load suppression). Enuresis/encopresis was associated with psychiatric comorbidity. Neurological disorders were associated with earlier onset of sexual intercourse (adjusted OR 4.06, 95% CI 1.26-13.1, P = 0.02).

CONCLUSIONS

Neurological disorders impact lives of many children and adolescents with HIV/AIDS. There is an urgent need to integrate the delivery of mental and neurological health services into routine clinical care for children and adolescents with HIV/AIDS in sub-Saharan Africa.