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.

University students' access to mental health services: A qualitative study of the experiences of health service professionals through the lens of candidacy in England.

OBJECTIVES: In order to develop a better understanding of students' access to mental health services, we explored the experiences of health care professionals interacting with university students with mental health problems. METHODS: We interviewed 23 professionals working across university advice and counselling services, NHS general practice, crisis, and psychological services in North and East London between June 2022 and January 2023. Our approach drew on reflexive thematic analysis and the principles of abductive analysis. The notion of candidacy - that is, how different needs are deemed deserving of health service attention - was particularly helpful to our understanding of the ongoing phenomenon of interest in the data. RESULTS: Each student's access to mental health support was highly contingent on the student's dynamic social context and the pressures and organisation of the local health system. Professionals described how different students viewed different needs as deserving of health service attention. Which students reached the professional's service depended on the resources and relationships a student could draw upon, and the service's relative permeability. Once there, what action professionals took was strongly influenced by the professional's service expertise, resource constraints, the relationships the professional's service had with other organisations, the students' wishes, and whether students regarded treatment offers as acceptable. CONCLUSIONS: Candidacy offers a useful lens to view university students' access to mental health support. Access appears to be an increasingly intricate task for students, given the fragmented service landscape, surging demand for mental health care and challenges of emerging adulthood. Our findings suggest that policy goals to increase use of mental health services are unlikely to improve outcomes for students without policy makers and health systems giving holistic consideration of inter-service relationships and available resources.

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.

Lessons learned from conducting mental health intervention research in schools in the global south: Our experiences in South Africa and Kenya.

Most of the world's population of young people live in lower-and middle-income countries (LMICs; (Weine, Horvath Marques, Singh, & Pringle, 2020)), and these young people experience heightened rates of known risk factors for developing mental disorders such as poverty and exposure to trauma (Atwoli, Stein, Koenen, & McLaughlin, 2015). Access to professional psychological treatments is limited in LMICs due to structural barriers (e.g., a dearth of trained professionals) and cultural factors like stigma and beliefs about mental health and illness. Therefore, schools, which are widely attended, may be a good location for providing mental health interventions, and it is important that we develop and evaluate feasible, acceptable, effective, and scalable interventions for use in this context. Yet under 10% of clinical trials of psychotherapies (Venturo-Conerly, Eisenman, Wasil, Singla, & Weisz, 2022) have been conducted in LMICs. And there are particular challenges to conducting research in schools, as has been highlighted in the UK context by Moore et al. (2022). Building on that commentary, our aim herein is to share our learnings from conducting psychotherapy research in schools in Kenya and South Africa.

Psychometric properties of the Curiosity and Exploration Inventory-II among Kenyan adolescents.

Introduction: Curiosity is a fundamental trait that drives exploration, motivation, learning, and growth. However, research on this character strength in sub-Saharan African populations is very scarce. To address this gap in the literature, we sought to determine the psychometric properties of the Curiosity and Exploration Inventory- II (CEI-II), a measure for trait curiosity, to provide evidence of validity for its use in research among populations in sub-Saharan Africa. We also aimed to assess for demographic and psychosocial correlates of curiosity among Kenyan high school students. Methods: A sample of 375 participants in Kenya completed the CEI-II, as well as demographic information on sex, age, form in school, psychosocial measures of depression, anxiety, school climate, and social support. Using cross-sectional data, parallel analysis, scree plot, and structural equation modeling were used to determine the factor structure of the CEI-II among the Kenyan adolescent population. Results: A one-factor solution was found to be the best fitting model, differing from the two-factor structure found in the original development of the measure. Internal consistency, convergent and discriminant validity, and predictors of trait curiosity were also examined. The CEI-II demonstrated good internal consistency and convergent validity with social support from family, friends, significant others, and school climate. Discriminant validity was demonstrated by the non-significant correlation between curiosity and depression. A hierarchical regression model showed that curiosity was significantly predicted by social support from family, significant others, school climate, and anxiety, with males being more curious than females. Discussion: The CEI-II is a valid measurement tool to capture trait curiosity in Kenyan adolescents, and our findings provide insight into the relationship between curiosity and other psychosocial factors in this population.

Group-based psychoeducational workshop for parents in Kenya: findings from a pilot study.

Introduction: Low levels of mental health literacy amongst parents can have negative effects on youth mental wellbeing and help-seeking behaviors. Here, we explored the impact of a brief psychoeducational workshop on improving parent mental health literacy and family relationships in Kibera, a low-resource high-risk setting in Nairobi, Kenya. Methods: The workshop was designed to address this issue, and it was delivered by trained facilitators to small groups of parents (N = 72). Data was collected at baseline, post-workshop, two-week follow-up, and one-month follow-up. Results: Statistical and thematic analysis of the data revealed significant improvements in parent mental health literacy scores and family relationships, indicating the acceptability and effectiveness of this workshop. Discussion: The findings suggest that brief, group-based psychoeducational workshops can be effective in improving parent mental health literacy and family relationships, thereby addressing challenges faced by parents and youth in the Kenyan context. Future studies are needed to conclusively determine if such workshops can improve participants' own mental health or their perception of child behavior.

Testing pathways to scale: study protocol for a three-arm randomized controlled trial of a centralized and a decentralized ("Train the Trainers") dissemination of a mental health program for Kenyan adolescents.

BACKGROUND: Providing care in Kenya to all youth in need is difficult because of a shortage of professional providers and societal stigma. Previous trials of the Anansi model, which involves delivering low-touch mental health interventions through a tiered caregiving model (including lay-providers, supervisors, and clinical experts), have shown its effectiveness for reducing depression and anxiety symptoms in school-going Kenyan adolescents. In this trial, we aim to assess two different scale-up strategies by comparing centralized implementation (i.e., by the organization that designed the Anansi model) against implementation through an implementing partner. METHODS: In this three-arm trial, 1600 adolescents aged 13 to 20 years will be randomized to receive the Shamiri intervention from either the Shamiri Institute or an implementation partner or to be placed in the treatment as usual (TAU) control group. The implementation partner will be trained and supplied with protocols to ensure that the same procedures are followed by both implementors. Implementation activities will run concurrently for both implementors. The Shamiri intervention will be delivered by trained lay providers to groups of 10-15 adolescents over four weekly sessions which will take place in secondary schools in Machakos and Makueni counties in Kenya. The TAU group will receive the usual care offered by their respective schools. Outcomes will be assessed at baseline, midpoint (2 weeks), endpoint (4 weeks), and 1 month follow-up. The analysis will be based on an intent-to-treat approach. Mixed effects models will be used to assess trajectories over time of the primary outcomes (anxiety and depressive symptoms, mental well-being, perceived social support, and academic performance) and secondary outcomes for the intervention groups and the control group. Effect sizes will be computed for the mean differences of the intervention and control arms at midpoint, endpoint, and follow-up. DISCUSSION: This trial will provide insight into the comparative effectiveness of different strategies for scaling a school-based mental health care model. Findings will also indicate areas for improved efficiency of the model to enhance its replicability by other implementors. TRIAL REGISTRATION: Pan African Clinical Trials Registry (PACTR) (ID: PACTR202305589854478, Approved: 02/05/2023).

Costs and cost-effectiveness of Shamiri, a brief, layperson-delivered intervention for Kenyan adolescents: a randomized controlled trial.

BACKGROUND: Low- and middle-income countries (LMICs) have the highest socio-economic burden of mental health disorders, yet the fewest resources for treatment. Recently, many intervention strategies, including the use of brief, scalable interventions, have emerged as ways of reducing the mental health treatment gap in LMICs. But how do decision makers prioritize and optimize the allocation of limited resources? One approach is through the evaluation of delivery costs alongside intervention effectiveness of various types of interventions. Here, we evaluate the cost-effectiveness of Shamiri, a group- and school-based intervention for adolescent depression and anxiety that is delivered by lay providers and that teaches growth mindset, gratitude, and value affirmation. METHODS: We estimated the cost-effectiveness of Shamiri using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) guidelines for economic evaluations. Changes in depression and anxiety were estimated using the Patient Health Questionnaire (PHQ-8) and Generalized Anxiety Disorder questionnaire (GAD-7) at treatment termination and 7-month follow-up using two definitions of treatment benefit. Cost-effectiveness metrics included effectiveness-cost ratios and cost per number needed to treat. RESULTS: Base case cost assumptions estimated that delivering Shamiri cost $15.17 (in 2021 U.S. dollars) per student. A sensitivity analysis, which varied cost and clinical change definitions, estimated it cost between $48.28 and $172.72 to help 1 student in Shamiri, relative to the control, achieve reliable and clinically significant change in depression and anxiety by 7-month follow-up. CONCLUSIONS: Shamiri appears to be a low-cost intervention that can produce clinically meaningful reductions in depression and anxiety. Lay providers can deliver effective treatment for a fraction of the training time that is required to become a licensed mental health provider (10 days vs. multiple years), which is a strength from an economic perspective. Additionally, Shamiri produced reliable and clinically significant reductions in depression and anxiety after only four weekly sessions instead of the traditional 12-16 weekly sessions necessary for gold-standard cognitive behavioral therapy. The school setting, group format, and economic context of a LMIC influenced the cost per student; however, broader conclusions about the cost-effectiveness of Shamiri have yet to be determined due to limited economic evaluations of mental health programs in LMICs. TRIAL REGISTRATION: This study was registered prior to participant enrollment in the Pan-African Clinical Trials Registry (PACTR201906525818462), registered 20 Jun 2019, https://pactr.samrc.ac.za/Search.aspx .

A dataset of the mental health and wellbeing of Kenyan adolescents.

This article presents data on the mental health and wellbeing of 2,192 Kenyan adolescents collected using self-reported questionnaires administered at four secondary schools in Nairobi and Kiambu counties. The data was collected using a range of validated scales to access for depression (PHQ-8), anxiety (GAD-7), gratitude (GQ-6), social support (MSPSS), perceived control (PCS), happiness and optimism (EPOCH). Data were analyzed using Microsoft Excel and R, and results are reported in terms of frequencies and percentages of responses. Linear mixed models were used to determine factors significantly associated with depression and anxiety symptoms. The study provides a platform for future research into factors associated with depression and anxiety in Kenyan adolescents, and policymakers and mental health actors can use the results to design interventions that promote mental health in this population.

The network approach: A path to decolonize mental health care.

The violent colonial history of psychiatry in Africa prevents individuals from help-seeking. Because of this history, mental health care is now stigmatized, and clinical research, practice, and policy fail to capture the salient features of distress across African communities. If we are to transform mental health care for all, we must adopt decolonizing frameworks to ensure mental health research, practice, and policy are enacted in a manner that is ethical, democratic, critical, and serves the needs of local communities. Here, we present that the network approach to psychopathology as an invaluable tool in achieving this purpose. The network approach recognizes mental health disorders not as discrete entities, but rather as dynamic networks that are made of psychiatric symptoms (called nodes) and the relationships between these symptoms (called edges). This approach can pave a path to decolonizing mental health care by alleviating stigma, allowing context-based understanding of mental health and mental health problems, opening new avenues for (low-cost) mental health care and empowering local researchers to pioneer context-based knowledge production and treatment.

Students stress patterns in a Kenyan socio-cultural and economic context: toward a public health intervention.

This study aimed at determining the prevalence of stress, different types of stress, their severity and their determinants in Kenyan university, college and high school students. The following tools were administered to 9741 students: (1) Researcher-designed socio-demographic tool, (2) Psychiatric Diagnostic Screening Questionnaire (PDSQ) for psychiatric disorders, (3) WERC Stress Screen for stress, (4) Washington Early Recognition Center Affectivity and Psychosis (WERCAP) screen for psychosis and affectivity, (5) Wealth Index Questionnaire for economic indicators. Descriptive analysis for the prevalence of different types of stress and inferential analysis for stress and independent variables were done. Significant variables (p < 0.05) were fitted into generalized linear model to determine independent predictors. The mean age of the respondents was 21.4 years (range 16-43). Money issues were the commonest stressors while alcohol and drug use were the least. The independent predictors of stress were females, college students and use of gas stove. In conclusion, up to 30% of the students suffer from mild to severe stress. The students experience a wide range of stressors. The most important stressors include money and finances, family related problems and concerns about their future. Our findings suggest a public health approach to create stress awareness in students.

An arts-literacy intervention for adolescent depression and anxiety symptoms: outcomes of a randomised controlled trial of Pre-Texts with Kenyan adolescents.

Background: Mental health problems are prevalent among youth in low-resource countries and are further compounded by stigma and limited access to traditional treatments. The need for scalable, accessible, and stigma-free mental health interventions is urgent. We developed and tested Pre-Texts, an arts-literacy intervention that targets adolescent depression and anxiety, in Kenya. Methods: We conducted a universal RCT (Randomized Controlled Trial). Students from Kenyan high schools (N = 235, ages 13-19, 53.19% female) were randomized to either Pre-Texts or a study skills control intervention. Pre-Texts involves the use of a text-such an excerpt from a novel, a physics lesson, or a technical manual-to inspire art-making that is followed by collective reflection on the process of interpretation through artmaking. Participants met daily for a week in groups of 6-12 youths for 1-h sessions. Groups were facilitated by high school graduates trained as lay-providers. This study was pre-registered at the Pan African Clinical Trials Registry (PACTR; registration number: PACTR202111497122432). The trial took place between August 11th 2021 and December 18th 2021. Findings: Pre-Texts produced a greater reduction in depression (d = 0.52, 95% CI [0.19, 0.84]) and anxiety (d = 0.51, 95% CI [0.20, 0.81]) symptoms from baseline to 1-month follow-up compared to the control group. Similarly, in a sub-sample of participants with elevated depression and anxiety symptoms, Pre-Texts produced a greater reduction in depression (d = 1.10, 95% CI [0.46, 1.75]) and anxiety (d = 0.54, 95% CI [-0.07, 1.45]) symptoms. Interpretation: Our findings suggest that a brief arts-literacy intervention with challenging school material in a group setting, implemented as an afterschool program, can reduce depression and anxiety symptoms in adolescents in Sub-Saharan Africa. Future replication trials with larger sample sizes with extended follow-ups will help assess the strength and sustainability of these effects. Funding: The study was funded by grants from the Mind, Brain, and Behaviour (MBB) Initiative at Harvard University and the Center for African Studies at Harvard University.

Centering decriminalization of suicide in low - and middle - income countries on effective suicide prevention strategies.

Globally, over 800,000 people die by suicide every year. For every one completed suicide, 20 more attempts have been made. As previous attempts are one of the strongest predictors of future suicide, help-seeking in moments of crisis, particularly after an attempt, may have important implications for suicide prevention. Unfortunately, the criminalization of suicide in several countries hinders help-seeking, increases the stigmatization of those who attempt suicide and obstructs the accurate tracking of suicides. Here, we highlight the negative effects of suicide criminalization and discuss evidence-based strategies for suicide prevention such as means restriction, improved mental health literacy and access to psychosocial support, and responsible media coverage of suicides.

Depression and anxiety symptoms amongst kenyan adolescents: Psychometric Properties, Prevalence Rates and Associations with Psychosocial Wellbeing and Sociodemographic factors.

This study assessed the psychometric properties of standard Western-derived instruments, the prevalence of depression and anxiety symptoms, and their associations with sociodemographic and wellbeing variables in a large sample of Kenyan adolescents. Self-report measures of depression (PHQ-8) and anxiety (GAD-7) symptoms, social support, gratitude, happiness, optimism, and perceived control were administered to 2,192 Kenyan youths (57.57% female) aged 12-19. Both the PHQ-8 (α = 0.78) and GAD-7 (α = 0.82) showed adequate internal consistency. EFA with a sub-sample (N = 1096) yielded a 1-factor structure for both PHQ-8 and GAD-7, a subsequent CFA conducted on the basis of a 1-factor model on another sub-sample (N = 1096) yielded good and moderate goodness of fit, respectively, for the PHQ-8 (χ2 = 76.73; p < 0.001; RMSEA = 0.05; CFI = 0.96; TLI = 0.95) and the GAD-7 (χ2 = 88.19; p < 0.001; RMSEA = 0.07; CFI = 0.97; TLI = 0.95). Some 28.06% and 30.38% of participants met the clinical cut-off for depressive and anxiety symptoms, respectively. Social support, gratitude, happiness, and perceived control were negatively associated with both depression and anxiety symptoms. Older adolescents reported higher symptoms while adolescents with more siblings reported lower symptoms. The western-derived PHQ and GAD met conventional psychometric standards with adolescents in Kenya; depression and anxiety symptoms showed relatively high prevalence and significant associations with important psychosocial and sociodemographic factors.

Long-term health outcomes of adolescent character strength interventions: 3- to 4-year outcomes of three randomized controlled trials of the Shamiri program.

BACKGROUND: Adolescents in low- and middle-income countries in need of mental health care often do not receive it due to stigma, cost, and lack of mental health professionals. Culturally appropriate, brief, and low-cost interventions delivered by lay-providers can help overcome these barriers and appear effective at reducing symptoms of depression and anxiety until several months post-intervention. However, little is known about whether these interventions may have long-term effects on health, mental health, social, or academic outcomes. METHODS: Three previous randomized controlled trials of the Shamiri intervention, a 4-week, group-delivered, lay-provider-led intervention, have been conducted in Kenyan high schools. Shamiri teaches positively focused intervention elements (i.e., growth mindset and strategies for growth, gratitude, and value affirmation) to target symptoms of depression and anxiety and to improve academic performance and social relationships, by fostering character strengths. In this long-term follow-up study, we will test whether these mental health, academic, social, and character-strength outcomes, along with related health outcomes (e.g., sleep quality, heart-rate variability and activity level measured via wearables, HIV risk behaviors, alcohol and substance use), differ between the intervention and control group at 3-4-year follow-up. For primary analyses (Nanticipated = 432), youths who participated in the three previous trials will be contacted again to assess whether outcomes at 3-4-year-follow-up differ for those in the Shamiri Intervention group compared to those in the study-skills active control group. Multi-level models will be used to model trajectories over time of primary outcomes and secondary outcomes that were collected in previous trials. For outcomes only collected at 3-4-year follow-up, tests of location difference (e.g., t-tests) will be used to assess group differences in metric outcomes and difference tests (e.g., odds ratios) will be used to assess differences in categorical outcomes. Finally, standardized effect sizes will be used to compare groups on all measures. DISCUSSION: This follow-up study of participants from three randomized controlled trials of the Shamiri intervention will provide evidence bearing on the long-term and health and mental health effects of brief, lay-provider-delivered character strength interventions for youth in low- and middle-income countries. TRIAL REGISTRATION: PACTR Trial ID: PACTR202201600200783 . Approved on January 21, 2022.

Loneliness in Kenyan adolescents: Socio-cultural factors and network association with depression and anxiety symptoms.

Loneliness is associated with negative mental health outcomes and is particularly common among adolescents. Yet, little is known about the dynamics of adolescent loneliness in non-Western, low-income nations. Accordingly, we estimated the severity of loneliness in a sample of Kenyan adolescents and used mixed-effects regression modelling to determine the socio-cultural factors associated with loneliness. We also used network analysis to examine the associations between loneliness, depression, and anxiety at the symptom level. We analyzed data from a large sample (N = 2,192) of school-attending Kenyan adolescents aged 12-19 (58.3% female, 41.7% male). Standardized measures of loneliness (ULS-8), depression (PHQ-8), and anxiety (GAD-7) were used. Our mixed-effects model revealed that female and lower-income adolescents felt lonelier. The perception of feeling alone emerged as the aspect of loneliness most strongly linked to depression and anxiety symptoms. Our findings establish an estimate of loneliness levels in Kenyan adolescents, and identify possible socio-cultural factors associated with loneliness. We found that perceptions of isolation more strongly linked loneliness to psychopathology than did objective measures of isolation or preferences for social contact. Finally, we identify specific aspects of loneliness that could prove to be treatment targets for youth psychopathology; however, further research is needed. Limitations, future directions, and clinical implications are discussed.

Prevalence and perception of substance abuse and associated economic indicators and mental health disorders in a large cohort of Kenyan students: towards integrated public health approach and clinical management.

BACKGROUND: The earlier younger people begin to use drugs, the more vulnerable they become to both their short term and long-term harmful effects. The overall aim of this study is to determine the prevalence of alcohol and drug abuse, the socio-demographic characteristic, perception of abuse and associated economic indicators and mental disorders and how they inform potential intervention in a cohort of Kenyan students. METHODS: This was a cross-sectional study on a total of 9742 high school, college and university students. We used tools to document socio-demographic characteristics, economic indicators, drug and alcohol use and related perceptions and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) related psychiatric disorders. Basic descriptive statistics (means and standard deviations for numerical variables and frequencies for nominal and ordinal variables) were done. Logistic regression models were used to assess the association and odds ratios between the use of a given substance and the use of the other substances, as well as associations with the various available socio-demographic factors and economic indicators. Chi-squared tests were used in socio-economic characteristics disaggregated by current alcohol use. RESULTS: The mean age was 21.4 ± 2.4; median = 21.3 (range 15-43) years. We found a wide range of different drugs of abuse. Alcohol abuse was the commonest and inhalants were the least, with different perceptions.Both alcohol and drug abuse were associated with various economic indicators and various mental disorders. CONCLUSION: This study has established for the first time in Kenya the multifaceted associations and predictors of alcohol and drug abuse in a cross-sectional student population ranging from high school to college and university levels. In the process, the study contributes to global data on the subject. These associations call for an integrated and multifaceted approach in addressing alcohol and substance abuse. This approach should take into account various associations and predictors as part of holistic approach in both public awareness and clinical interventions.