Sexual transgression and social disconnection: healing through community-based sociotherapy in Rwanda.

A distinguishing feature of the 1994 genocide against the Tutsi and the preceding 1990-1994 war in Rwanda was the social intimacy of the crimes committed. The legacy of this kind of violence includes distrust in social relations within communities and families, an increase of violence in everyday social interaction, transgressive sexual engagements, and a range of psychological problems. Many people feel nostalgia for their past social life, but are unable to change their current situation. In 2005, a community-based sociotherapy programme was introduced into this context of mental and social distress. The goal was to help people regain feelings of dignity and safety and to reduce distress. This paper is based on qualitative research, in particular, case studies. It explores how sociotherapy, as a specific form of peer group counselling, may facilitate the healing of suffering related to issues of sexuality, violence within the family and the breakdown of social connections on a community level.

Community based sociotherapy for depressive symptomatology of Congolese refugees in Rwanda and Uganda (CoSTAR): a protocol for a cluster randomised controlled trial.

Background: Conflict in the Democratic Republic of Congo has led to large numbers of refugees fleeing to Uganda and Rwanda. Refugees experience elevated levels of adverse events and daily stressors, which are associated with common mental health difficulties such as depression. The current cluster randomised controlled trial aims to investigate whether an adapted form of Community-based Sociotherapy (aCBS) is effective and cost-effective in reducing depressive symptomatology experienced by Congolese refugees in Uganda and Rwanda.Methods: A two-arm, single-blind cluster randomised controlled trial (cRCT) will be conducted in Kyangwali settlement, Uganda and Gihembe camp, Rwanda. Sixty-four clusters will be recruited and randomly assigned to either aCBS or Enhanced Care As Usual (ECAU). aCBS, a 15-session group-based intervention, will be facilitated by two people drawn from the refugee communities. The primary outcome measure will be self-reported levels of depressive symptomatology (PHQ-9) at 18-weeks post-randomisation. Secondary outcomes will include levels of mental health difficulties, subjective wellbeing, post-displacement stress, perceived social support, social capital, quality of life, and PTSD symptoms at 18-week and 32-week post-randomisation. Cost effectiveness of aCBS will be measured in terms of health care costs (cost per Disability Adjusted Life Year, DALY) compared to ECAU. A process evaluation will be undertaken to investigate the implementation of aCBS.Conclusion: This cRCT will be the first investigating aCBS for mental health difficulties experienced by refugees and will contribute to knowledge about the use of psychosocial interventions for refugees at a time when levels of forced migration are at a record high.Trial registration: ISRCTN.org identifier: ISRCTN20474555.

There is a need to evaluate community-based psychosocial interventions for refugees.Community-based sociotherapy has been used to support communities in post-conflict situations but has not been evaluated in a randomised controlled trial.This protocol outlines a proposed randomised controlled trial of community-based sociotherapy adapted for Congolese refugees in Uganda and Rwanda.

"They tell us little and we end up being confused": Parent-child communication on familial experiences of genocide and its aftermath in Rwanda.

In the current study we explore how Rwandan youth negotiate, within the family setting, a myriad of social and interpersonal dilemmas around silence and disclosure of genocide-related experiences of their parents. The study draws primarily on individual interviews and focus group discussions with 20 children of genocide survivor and perpetrator parents in the western and eastern provinces of Rwanda. Using the conceptual framework of social navigation which theorizes agency in a fluid, often unpredictable, and constantly moving social environment, we focus specifically on the difficult and often contradictory complex of factors that drive the communication strategies and tactics of the children as they seek information to understand the past of their parents. This includes the children's urge to get to know the specific stories of their family but fearing the emotional disruption it may cause in the parent-child relationship; the push-pull dynamics of the parents wanting to disclose some experiences but admonishing silence on others; and the often ambiguous divergences between the public and private discourses. Our findings show that the steadiest navigational point guiding communication choices, made by both parents and their offspring, was a desire to contribute to a peaceful social environment, and to reduce the risk of future violence. We present emerging evidence suggesting that community-based sociotherapy, a program that includes healing the social space and not only intrapsychic wounds, may contribute to a steadier navigation of the tricky communication issues, enhancing psychosocial wellbeing.

The 'good life', personal appearance, and mental health of Congolese refugees in Rwanda and Uganda.

RATIONALE: Research into mental health and wellbeing recognises the role of positive mental health to enable people to lead healthy and emotionally fulfilling lives. Mental health difficulties continue to be associated with high levels of disability worldwide, and refugees fleeing conflict are known to suffer from poor mental health for years after their forced migration. METHOD: Informed by Sen's Capability Approach and as part of a wider research project, we used semi-structured interviews to engage with 60 men and women in two refugee communities in Uganda and Rwanda to explore their aspirations and what a 'good life' meant to them. FINDINGS: While aspects of what constituted a good life were gendered, both men and women struggled to achieve their aspirations within their communities. Following the basic needs of food and shelter, the complex needs of being dressed well and being clean were consistently associated with be able to achieve a 'good life' by women and men across age groups. Looking good and being clean were highly valued and associated with gaining the respect of others, achieving good relationships with neighbours, and avoiding conflict. Participants identified personal appearance and related social status as critical precursors to their successful engagement with other gendered dimensions of social and economic life in their communities, such as finding employment and being well regarded in their religious communities. CONCLUSIONS: Our findings suggest that without the means to present a good appearance, people living in refugee communities may experience feelings of shame and isolation and are unable to gain self-respect and the respect of others needed to achieve the positive mental and physical health they associate with leading 'a good life'.

Evaluating the impact of Community-Based Sociotherapy on social dignity in post-genocide Rwanda: study protocol for a cluster randomized controlled trial.

BACKGROUND: Community-Based Sociotherapy (CBS) is an approach that was introduced in Rwanda in 2005, with the aim of improving psychosocial well-being among its participants and facilitating reconciliation processes. Over the years, CBS has been adapted contextually and the effectiveness of the approach has been measured in different ways, using qualitative and quantitative study designs. This study specifically assesses the effectiveness of CBS in terms of fostering the social dignity of participants as the primary outcome. METHODS/DESIGN: A cluster randomized controlled trial design with person-level outcomes whereas the CBS treatment is delivered at the cluster level. A total of 1200 eligible participants will be randomly assigned to two groups in a 1:1 ratio. Participants in the intervention group will receive the CBS intervention, while the control group will be waitlisted. The primary outcome measure is a self-designed and psychometrically validated Social Dignity Scale. The secondary outcome measures will be the WHO (Five) Well-Being Index (WHO-5), the Multidimensional Scale of Perceived Social Support (MSPSS), the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5), the Self-reporting Questionnaire (SRQ-20), and the perceived parental self-efficacy scale. The primary analysis will be performed following an intention to treat analysis, using generalized estimating equation modeling. DISCUSSION: We expect this cluster randomized controlled trial to provide insight into the effectiveness of CBS on social dignity and secondary psychosocial outcomes among its group participants, who have different socio-historical backgrounds including genocide survivors, perpetrators, bystanders and their descendants, people in conflicts (family/community), and local leaders. This study will inform CBS implementers, policymakers, practitioners, and other stakeholders on the role of social dignity in interventions that focus on psychosocial healing. TRIAL REGISTRATION: ISRCTN ISRCTN11199072. It was registered on 2 April 2022.

Psychometric properties and longitudinal validation of the self-reporting questionnaire (SRQ-20) in a Rwandan community setting: a validation study.

BACKGROUND: This study took place to enable the measurement of the effects on mental health of a psychosocial intervention in Rwanda. It aimed to establish the capacities of the Self-Reporting Questionnaire (SRQ-20) to screen for mental disorder and to assess symptom change over time in a Rwandan community setting. METHODS: The SRQ-20 was translated into Kinyarwanda in a process of forward and back-translation. SRQ-20 data were collected in a Rwandan setting on 418 respondents; a random subsample of 230 respondents was assessed a second time with a three month time interval. Internal reliability was tested using Cronbach's alpha. The optimal cut-off point was determined by calculating Receiver Operating Curves, using semi-structured clinical interviews as standard in a random subsample of 99 respondents. Subsequently, predictive value, likelihood ratio, and interrater agreement were calculated. The factor structure of the SRQ-20 was determined through exploratory factor analysis. Factorial invariance over time was tested in a multigroup confirmatory factor analysis. RESULTS: The reliability of the SRQ-20 in women (α = 0.85) and men (α = 0.81) could be considered good. The instrument performed moderately well in detecting common mental disorders, with an area under the curve (AUC) of 0.76 for women and 0.74 for men. Cut-off scores were different for women (10) and men (8). Factor analysis yielded five factors, explaining 38% of the total variance. The factor structure proved to be time invariant. CONCLUSIONS: The SRQ-20 can be used as a screener to detect mental disorder in a Rwandan community setting, but cut-off scores need to be adjusted for women and men separately. The instrument also shows longitudinal factorial invariance, which is an important prerequisite for assessing changes in symptom severity. This is a significant finding as in non-western post-conflict settings the relevance of diagnostic categories is questionable. The use of the SRQ-20 can be considered an alternative option for measuring the effect of a psychosocial intervention on mental health. TRIAL REGISTRATION: Nederlands Trial Register NTR1120.

Exploring the mental health and psychosocial problems of Congolese refugees living in refugee settings in Rwanda and Uganda: a rapid qualitative study.

BACKGROUND: Refugees fleeing conflict often experience poor mental health due to experiences in their country of origin, during displacement, and in new host environments. Conditions in refugee camps and settlements, and the wider socio-political and economic context of refugees' lives, create structural conditions that compound the effects of previous adversity. Mental health and psychosocial support services must address the daily stressors and adversities refugees face by being grounded in the lived reality of refugee's lives and addressing issues relevant to them. METHODS: We undertook a rapid qualitative study between March and May 2019 to understand the local prioritisation of problems facing Congolese refugees living in two refugee settings in Uganda and Rwanda. Thirty free list interviews were conducted in each setting, followed by 11 key informant interviews in Uganda and 12 in Rwanda. RESULTS: Results from all interviews were thematically analysed following a deductive process by the in-country research teams. Free list interview findings highlight priority problems of basic needs such as food, shelter, and healthcare access; alongside contextual social problems including discrimination/inequity and a lack of gender equality. Priority problems relating to mental and psychosocial health explored in key informant interviews include discrimination and inequity; alcohol and substance abuse; and violence and gender-based violence. CONCLUSIONS: Our findings strongly resonate with models of mental health and psychosocial wellbeing that emphasise their socially determined and contextually embedded nature. Specifically, findings foreground the structural conditions of refugees' lives such as the physical organisation of camp spaces or refugee policies that are stigmatising through restricting the right to work or pursue education. This structural environment can lead to disruptions in social relationships at the familial and community levels, giving rise to discrimination/inequity and gender-based violence. Therefore, our findings foreground that one consequence of living in situations of pervasive adversity caused by experiences of discrimination, inequity, and violence is poor mental health and psychosocial wellbeing. This understanding reinforces the relevance of feasible and acceptable intervention approaches that aim to strengthening familial and community-level social relationships, building upon existing community resources to promote positive mental health and psychosocial wellbeing among Congolese refugees in these settings.

Everyday suffering outside prison walls: a legacy of community justice in post-genocide Rwanda.

Twenty years after the 1994 genocide, Rwanda shows all indications of moving quickly towards socio-economic prosperity. Rwanda's community justice system, Gacaca, was to complement this prosperity by establishing peace and stability through justice, reconciliation and healing. Evaluations of the Gacaca courts' achievements from 2002 to 2012 have had widely differing conclusions. This article adds to previous evaluations by drawing attention to specific forms of relatively neglected suffering (in literature and public space) that have emerged from the Gacaca courts or were amplified by these courts and jeopardize Gacaca's objectives. The ethnographic study that informs the article was conducted in southeastern Rwanda from September 2008-December 2012 among 19 ex-prisoners and 24 women with husbands in prison including their family members, friends and neighbors. Study findings suggest that large scale imprisonment of genocide suspects coupled with Gacaca court proceedings have tainted the suffering of ex-prisoners and women with imprisoned husbands in unique ways, which makes their plight unparalleled in other countries. We argue that the nature and scale of this suffering and the potentially detrimental impact on families and communities require humanitarian action. However, in Rwanda's post-genocide reality, the suffering of these two groups is overwhelmed by that of other vulnerable groups, such as genocide survivors and orphaned children; hence it is rarely acknowledged.

The validation of a social functioning questionnaire in an African postconflict context.

This study evaluated the reliability and criterion validity of the Byumba Social Functioning Questionnaire (BSFQ), an instrument to measure social functioning in Rwanda. The instrument was locally composed in concordance with a well-described method for culture-specific and sex-specific function assessment. Respondents in a Northern Province of Rwanda (N = 393) were assessed with the BSFQ and a 19-item scale (SF-19) drawn from the Medical Outcomes Study 36-Item Short-Form (SF-36). The BSFQ's internal consistency was just acceptable for women but poor for men, while the SF-19 had good to excellent internal consisteny. BSFQ total scores showed a strong floor effect, while the SF-19 showed more variation in total score distribution. The BSFQ did not perform as well as we expected, and appears not to be suitable for measuring social functioning in the study context. This outcome seems to reflect the conceptualization of social functioning used in constructing the BSFQ. Implications for the development of culture-specific measures of functional status are discussed.

Intimate partner violence in Rwanda: the mental health of victims and perpetrators.

Exposure to intimate partner violence (IPV) is a common feature of women living in low- and middle-income countries. Several studies have shown a significant association between IPV against women and mental health in both developed and in low- and middle-income countries. In postconflict settings, the relationship between IPV and mental health is likely more complex, given the high levels of violence experienced by the population as a whole. In this cross-sectional study the authors explore the association between IPV and common mental health disorders (CMD), and more specifically, suicidal ideation, among inhabitants of postgenocide Rwanda. The authors use the concept of "mutual partner violence," thereby exploring the association between IPV and CMD in victims, perpetrators, and those who state they are both. Data of 241 married men and women were used. Symptoms suggestive of CMD were established by use of the Self-Reporting Questionnaire (SRQ-20), and physical intimate partner violence was measured using the Conflict Tactics Scale, Short Version (CTS2S). The authors applied multivariate logistic regressions with total SRQ-20 scores (above/below cutoff) and suicidal ideation as the outcome measures and corrected for age and gender. The study findings suggest that reported IPV is associated with CMD (odds ratio [OR] = 1.7, 95% confidence interval [95% CI] = 0.92-3.15) and suicidal ideation (OR = 1.6, 95% CI = 0.70-3.53). Those who state to be both victim and perpetrator (OR = 1.75, 95% CI = 0.82-3.72), or only perpetrator (OR = 3.13, 95% CI = 0.49-20.0), are more likely to report mental health problems than victims and people who do not report IPV. In a postconflict situation, perpetrators of IPV may suffer from mental health problems as much as, or even more than, victims. Longitudinal data are needed to clarify the complex relationship between CMD and IPV, especially if outcomes may also be related to other forms of violence experienced in the past.

The effect on mental health of a large scale psychosocial intervention for survivors of mass violence: a quasi-experimental study in Rwanda.

BACKGROUND: War has serious and prolonged mental health consequences. It is argued that post-emergency mental health interventions should not only focus on psychological factors but also address the social environment. No controlled trials of such interventions exist. We studied the effect on mental health of a large scale psychosocial intervention primarily aimed at social bonding in post-genocide Rwanda. The programme is implemented at population level without diagnostic criteria for participation. It is open to any person older than 15 years, and enables participation of over 1500 individuals per year. We postulated that the mental health of programme participants would improve significantly relative to non-participants. METHODS AND FINDINGS: We used a prospective quasi-experimental study design with measurement points pre and post intervention and at 8 months follow-up. 100 adults from both sexes in the experimental condition entered the study; follow-up measurements were taken from 81. We selected a control group of 100 respondents with similar age, sex and symptom score distribution from a random community sample in the same region; of these, 73 completed the study. Mental health was assessed by use of the Self Reporting Questionnaire (SRQ-20), a twenty item instrument to detect common mental disorders in primary health care settings. Mean SRQ-20 scores decreased by 2.3 points in the experimental group and 0.8 in the control group (p = 0.033). Women in the experimental group scoring above cut-off at baseline improved with 4.8 points to below cut-off (p<0.001). Men scoring above cut-off at baseline showed a similar trend which was statistically non-significant. No adverse events were observed. CONCLUSIONS: A large scale psychosocial intervention primarily aimed at social bonding caused a lasting improvement of mental health in survivors of mass violence in Rwanda. This approach may have a similar positive effect in other post-conflict settings. TRIAL REGISTRATION: Nederlands Trial Register 1120.