Methods and associations of suicidality in Kenyan high school students: clinical and public health implications

BACKGROUND

Most evidence on suicidal thoughts, plans and attempts comes from Western countries; prevalence rates may differ in other parts of the world.

AIMS

This study determined the prevalence of suicidal thoughts, plans and attempts in high school students in three different regional settings in Kenya.

METHOD

This was a cross-sectional study of 2652 high school students. We asked structured questions to determine the prevalence of various types of suicidality, the methods planned or effected, and participants' gender, age and form (grade level). We provided descriptive statistics, testing significant differences by chi-squared and Fisher's exact tests, and used logistic regression to identify relationships among different variables and their associations with suicidality.

RESULTS

The prevalence rates of suicidal thoughts, plans and attempts were 26.8, 14.9 and 15.7%, respectively. These rates are higher than those reported for Western countries. Some 6.7% of suicide attempts were not associated with plans. The most common method used in suicide attempts was drinking chemicals/poison (18.8%). Rates of suicidal thoughts and plans were higher for older students and students in urban rather than rural locations, and attempts were associated with female gender and higher grade level - especially the final year of high school, when exam performance affects future education and career prospects.

CONCLUSION

Suicidal thoughts, plans and attempts are prevalent in Kenyan high school students. There is a need for future studies to determine the different starting points to suicidal attempts, particularly for the significant number whose attempts are not preceded by thoughts and plans.

Face-to-face bullying in and outside of schools and cyberbullying are associated with suicidality in Kenyan high school students: a public health issue

BACKGROUND

Childhood bullying has been classified as a major public health concern by WHO, with negative effects on the health education and social outcomes of both bullies and victims. There is no current Kenyan data on the prevalence of face-to-face bullying and cyberbullying co-occurring in the same cohort of youth and how they are associated with different aspects of suicidality and socio-demographic characteristics. This study aims to fill these gaps in the Kenyan situation so as to inform current policy and practice.

METHODOLOGY

This cross-sectional study involved 2,652 students from ten secondary schools in Kenya, selected from three regions representing different levels of public funded schools and socioeconomic spaces. The outcome variable was derived from the questionnaire which asked students questions related to self-harm, suicide thoughts, plans, and attempts. Predictor variables were based on response on experience of bullying in school, out of school, at home, and cyberbullying. Other variables such as gender, age, family background, and class were also collected from the self-reported questions. Data were analyzed using SPSS version 25, with descriptive summary statistics and chi-square tests used to examine variables, and logistic regression analysis used to determine the associations between suicidality and experience of bullying.

RESULTS

The mean age was 16.13 years. More than half of the participants were male, with the largest proportion living in rural areas. Face-to-face bullying was more prevalent than cyberbullying, with 82% of participants experiencing bullying and 68% experiencing it almost daily in the past six months. Both face-to-face bullying and cyberbullying were associated with suicidal thoughts, plans, and attempts. Predictors of suicidal attempts included being bullied outside of school and being a victim of group bullying, while being bullied every day and being bullied by adult men were predictors of suicidal attempts in cyberbullying.

CONCLUSION

There is a high prevalence of face-to-face bullying both in and outside schools. There is also a high prevalence of cyberbullying. Both face-to-face and cyberbullying are associated with suicidality in Kenyan high school students.

The perceived impact of climate change on mental health and suicidality in Kenyan high school students

BACKGROUND

Climate change has psychological impacts but most of the attention has been focused on the physical impact. This study was aimed at determining the association of climate change with adolescent mental health and suicidality as reported by Kenyan high school students.

METHODS

This was a cross sectional study with a sample size of 2,652. The participants were high school students selected from 10 schools in 3 regions of Kenya. A questionnaire was used to assess climate change experiences, mental health problems, and suicidality of the youth. Data were analyzed descriptively and with logistic regression to determine various associations of the different variables and the predictors of the various scores of SDQ and suicidality at 95% CI.

RESULTS

Significant differences were observed between gender and two of the threats of climate change - worry and being afraid as subjectively experienced by the participants. Females were more worried and afraid of climate change than males. On univariate and multivariate logistic regression, we found that various experiences of climate change were significantly associated with various scores of SDQ and much fewer of the experiences predicted SDQ scores. The same pattern was reflected in suicidality.

CONCLUSION

Climate change appears to be associated with mental health concerns and suicidality according to Kenyan high school students' reports with gender differences in some associations.

The feasibility of using life skills training in primary schools to improve mental health and academic performance: a pilot study in Kenya

BACKGROUND

There is no Kenyan evidence on the relationship between mental illness and academic performance. We aimed to determine the effect of life skills training on mental health and academic performance.

METHODS

We administered to 1848 primary school children a researcher designed socio-demographic questionnaire, and the Youth Self Report (YSR) and Child Behavior Checklist (CBCL) to their parents, followed by eight sessions of life skills training. We extracted data from the individual records of each child on overall performance pre and post training separated by one year. We conducted descriptive statistics, paired sample t-tests, multivariate linear regression analysis and linear mixed model analysis to assess changing patterns of academic performance and any predictive characteristics.

RESULTS

There was significant (p < 0.05) improvement in overall academic performance (aggregate marks and all individual subjects) for both lower primary and upper primary classes after the life-skills training intervention. For lower classes (2-4 grades) increase in academic performance was significantly associated with fathers and mothers education levels, region and class. For upper classes, (5-7 grades) increase in academic performance was associated with region, class and age.

CONCLUSIONS

Life skills training is recommended as it could improve academic performance, but predicted by socio-demographic factors.

Digital Tools to Support Family-Based Weight Management for Children: Mixed Methods Pilot and Feasibility Study

BACKGROUND

Family-based behavioral therapy is an efficacious approach to deliver weight management counseling to children and their parents. However, most families do not have access to in-person, evidence-based treatment. We previously developed and tested DRIVE (Developing Relationships that Include Values of Eating and Exercise), a home-based parent training program to maintain body weight among children at risk for obesity, with the intent to eventually disseminate it nationally alongside SafeCare, a parent support program that focuses on parent-child interactions. Currently the DRIVE program has only been tested independently of SafeCare. This study created the "mHealth DRIVE" program by further adapting DRIVE to incorporate digital and mobile health tools, including remotely delivered sessions, a wireless scale that enabled a child-tailored weight graph, and a pedometer. Telehealth delivery via mHealth platforms and other digital tools can improve program cost-effectiveness, deliver long-term care, and directly support both families and care providers.

OBJECTIVE

The objective of this study was to examine preliminary acceptability and effectiveness of the mHealth DRIVE program among children and parents who received it and among SafeCare providers who potentially could deliver it.

METHODS

Study 1 was a 13-week pilot study of a remotely delivered mHealth family-based weight management program. Satisfaction surveys were administered, and height and weight were measured pre- and post-study. Study 2 was a feasibility/acceptability survey administered to SafeCare providers.

RESULTS

Parental and child satisfaction (mean of 4.9/6.0 and 3.8/5.0, respectively) were high, and children's (N=10) BMI z-scores significantly decreased (mean -0.14, SD 0.17; P=.025). Over 90% of SafeCare providers (N=74) indicated that SafeCare families would benefit from learning how to eat healthily and be more active, and 80% of providers reported that they and the families would benefit from digital tools to support child weight management.

CONCLUSIONS

Pediatric mHealth weight management interventions show promise for effectiveness and acceptability by families and providers.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03297541, https://clinicaltrials.gov/ct2/show/NCT03297541.

Engaging community voices to assess Kenya's strengths and limitations to support a child maltreatment prevention program

BACKGROUND

Preventing child maltreatment is a global mission of numerous international organizations, with parent support programs as the critical prevention strategy. In Kenya, 70 % of children are at risk of experiencing abuse and neglect, most often by their parents. Yet, there is a lack of evidence-based parent support programs, and a limited understanding of Kenya's capacity and infrastructures (e.g., policies, funding, service agencies) to support and sustain such programs.

OBJECTIVE

The purpose of this study was to assess systematically Kenya's strengths and limitations to implement a parent support program using a mixed-methods study design.

PARTICIPANTS AND METHODS

Twenty-one community stakeholders from Kenya completed the World Health Organization's (WHO) Readiness Assessment for the Prevention of Child Maltreatment to understand Kenya's preparedness to undertake a prevention program. In addition, 91 participants (e.g., parents, community health workers, community leaders) took part in focus group discussions or individual interviews to understand existing support networks around parenting programs.

RESULTS

Kenya's overall 'readiness' score was comparable to the other countries that completed the WHO survey. The survey results revealed Kenya's strengths and limitations across the ten readiness dimensions. Several themes emerged from the focus groups and interviews, including the diverse sources of support for parents, specific programs available for parents, and gaps in services offered.

CONCLUSIONS

The results document ways to build upon Kenyan's existing strengths to facilitate implementation of an evidence-based prevention program. These results also highlight the significant need to understand local context when adapting parenting programs for low/middle income countries (LMICs).

Engagement in home visiting: An overview of the problem and how a coalition of researchers worked to address this cross-model concern

Home visiting is a widely supported intervention strategy for parents of young children who are in need of parenting skill improvement. However, parental engagement limits the potential public health impact of home visiting, as these programs often have low enrollment rates, as well as high attrition and low completion rates for those who enroll in these programs. The Coalition for Research on Engagement and Well-being (CREW) provided support for three pilot projects representing different home visiting models and aspects of engagement. The results of these pilot projects are presented in this special section. The purpose of this commentary is to introduce CREW and highlight the importance of a cross-model project to improve engagement among home visiting programs.

Efficacy of a Home-Based Parent Training-Focused Weight Management Intervention for Preschool Children: The DRIVE Randomized Controlled Pilot Trial

OBJECTIVES

To pilot-test a home-based parent training intervention aimed at maintaining body weight among children at risk for obesity (> the 75th body mass index percentile).

METHODS

Sixteen parent-child dyads were randomized to a health education or Developing Relationships that Include Values of Eating and Exercise (DRIVE) intervention arm. The DRIVE curriculum was a structured parenting program to promote healthy weight in children by relying on behavioral principles to promote skill acquisition in the family's natural setting. Body weight and waist circumference were measured at baseline and weeks 9 and 19.

RESULTS

Body mass index z-score, body weight, and percent body weight increased in children in the health education arm vs DRIVE at weeks 9 and 19. Body weight, percent body weight, and waist circumference decreased in parents in DRIVE vs the health education arm at week 19, whereas no differences were shown at week 9.

CONCLUSIONS AND IMPLICATIONS

The DRIVE program mitigated weight gain in a small sample of at-risk children and showed promising results in reducing weight in parents. Home-based interventions emphasizing parent-child interactions are indicated as a practical model to deliver weight management in children.

Initial implementation indicators from a statewide rollout of SafeCare within a child welfare system

There is a strong movement toward implementation of evidence-based practices (EBP) in child welfare systems. The SafeCare parenting model is one of few parent-training models that addresses child neglect, the most common form of maltreatment. Here, the authors describe initial findings from a statewide effort to implement the EBP, SafeCare®, into a state child welfare system. A total of 50 agencies participated in training, with 295 individuals entering training to implement SafeCare. Analyses were conducted to describe the trainee sample, describe initial training and implementation indicators, and to examine correlates of initial training performance and implementation indicators. The quality of SafeCare uptake during training and implementation was high with trainees performing very well on training quizzes and role-plays, and demonstrating high fidelity when implementing SafeCare in the field (performing over 90% of expected behaviors). However, the quantity of implementation was generally low, with relatively few providers (only about 25%) implementing the model following workshop training. There were no significant predictors of training or implementation performance, once corrections for multiple comparisons were applied. The Discussion focuses on challenges to large-scale system-wide implementation of EBP.

Therapists' attitudes toward evidence-based practices and implementation of parent-child interaction therapy

Child abuse and neglect affects many families each year, but evidence-based parent training programs can be instrumental in reducing maltreatment. Parent-Child Interaction Therapy, a parent training program developed for treatment of disruptive child behavior, has demonstrated effectiveness with families at risk of or exposed to child maltreatment. However, methods for disseminating this evidence-based intervention in community settings are not well understood. This study examined the association between community-based therapists' attitudes toward evidence-based practices (EBPs) and their participation in an implementation research project in which they received two forms of consultation. Results showed that therapists' self-reported unwillingness to diverge from EBPs was positively associated with their use of phone consultation and satisfaction with consultation. The degree to which therapists found EBPs appealing was positively associated with satisfaction as well. Open therapist attitudes toward EBPs were associated with greater attendance for online consultation. The next step in this line of research is to examine how therapists' attitudes toward EBPs can be improved, if changing attitudes affects therapist acquisition of treatment skills, and if such improvements enhance implementation efforts.

U.S. child death review programs: assessing progress toward a standard review process

BACKGROUND

Child death review (CDR) programs examine the circumstances of children's deaths to gain information on how and why children die for the purpose of promoting the health, safety, and protection of children.

PURPOSE

The purpose of this study was to conduct a systematic review of the 50 states and District of Columbia CDR programs, with specific focus on the use of standardized procedures and best-practice recommendations. This included assessment of which deaths are reviewed, the model of review, team membership, and standardization of data collection and reporting.

METHODS

Data were collected through semistructured phone interviews with representatives of the 50 states and District of Columbia CDR programs and online sources. Data collection and analyses were conducted in 2009.

RESULTS

Forty-eight states and the District of Columbia have active CDR programs at the state and/or local level, and the majority use a national data collection system. However, results revealed numerous inconsistencies across programs in policies, procedures, and data collection.

CONCLUSIONS

This study reflects the minimal progress that has been made in the CDR process in the U.S. since the last systematic review of the programs in 2001. The study documents substantial discrepancies among the U.S. CDR programs, affecting the consistency of data obtained by individual states and, ultimately, prevention efforts at the national level. Information from this review can inform CDR programs as they develop and refine procedures and guide future research on the effectiveness and limitations of variations in procedures.

Coaching parents to change: the impact of in vivo feedback on parents' acquisition of skills

Behavioral parent training (BPT) includes a variety of evidence-based treatments with diverse techniques to alter parent behavior. Parent-Child Interaction Therapy is an innovative BPT with its use of in vivo feedback (i.e., "coaching") during parent-child interactions. An experimental design was used to assess whether coaching without elaborate didactic improves parenting. Sixty mothers with children 2 to 7 years old were recruited from the community and randomly assigned to a coaching or no coaching group. After a baseline assessment, all dyads participated in two play interactions 1 week apart during which parents in the coaching group were provided with in vivo feedback. Coached parents displayed significant improvements in skills, and coaching predicted skill gains beyond the influence of baseline ability. Findings suggest that providing parents with feedback through in vivo coaching is an important mechanism of change.

Serum stimulation, cell-cell interactions, and extracellular matrix independently influence smooth muscle cell phenotype in vitro

Vascular injury profoundly alters the vessel wall microenvironment, and smooth muscle cells respond with cell cycle re-entry, loss of contractile elements, extracellular matrix remodeling, and altered signaling by endogenous growth factors and their receptors. Environmental cues include stimulation by exogenous mitogens and both cell-cell and cell-matrix interactions. Modeling this process in smooth muscle cells in vitro, these environmental determinants were varied independently and the phenotypic consequences assessed. Mitogenic stimulation with serum promoted the synthesis of collagen and fibronectin and the expression of fibroblast growth factor receptor-1 and suppressed the content of smooth muscle alpha-actin, myosin heavy chain, and basic fibroblast growth factor. Low cell density (reduced cell-cell contact) was also associated with enhanced extracellular matrix protein production, increased fibroblast growth factor receptor-1 expression, and reduced contractile protein and basic fibroblast growth factor content. The influence of serum stimulation and reduced cell-cell contact were independent and additive. Provision of a type I collagen matrix blunted the influence of serum and cell-cell contact on collagen synthesis but had minor effects on other measures of phenotype. Environmental factors thus independently influence smooth muscle cell phenotype, including endogenous growth factor expression and responsiveness, which can in turn influence the microenvironment of the vessel wall after injury.

Antisense inhibition of basic fibroblast growth factor induces apoptosis in vascular smooth muscle cells

Basic fibroblast growth factor (bFGF), a potent mitogen for many cell types, is expressed by vascular smooth muscle cells and plays a prominent role in the proliferative response to vascular injury. Basic FGF has also been implicated as a survival factor for a variety of quiescent or terminally differentiated cells. Autocrine mechanisms could potentially mediate both proliferation and cell survival. To probe such autocrine pathways, endogenous bFGF production was inhibited in cultured rat vascular smooth muscle cells by the expression of antisense bFGF RNA. Inhibition of endogenous bFGF production induced apoptosis in these cells independent of proliferation, and apoptosis could be prevented by exogenous bFGF but not serum or epidermal growth factor. The induction of apoptosis was associated with an inappropriate entry into S phase. These data demonstrate that interruption of autocrine bFGF signaling results in apoptosis of vascular smooth muscle cells, and that the mechanism involves disruption of normal cell cycle regulation.