Eve Puffer - Academia.edu (original) (raw)

Papers by Eve Puffer

PLOS ONE, 2019

This study suggests that rates of pediatric HIV disclosure may be larger than typically reported,... more This study suggests that rates of pediatric HIV disclosure may be larger than typically reported, but also reinforces the idea that most children do not know key details about their illness, such as how they were infected and that they can infect others.

and the entire IRC Liberia team in Lofa County for their tireless efforts. We also thank Smith pr... more and the entire IRC Liberia team in Lofa County for their tireless efforts. We also thank Smith provided technical support on project design and implementation , as well as valuable comments on this report. Elsa Friis provided assistance with data collection and management. Finally, we would like to thank the 270 families who participated in the study for their patience and generosity.

Men’s depression, alcohol use, and family problems commonly co-occur to create of cluster of ment... more Men’s depression, alcohol use, and family problems commonly co-occur to create of cluster of mental health problems. Yet, few treatments exist to address these problems, especially in low and middle-income countries (LMICs). This paper describes the development and initial feasibility and acceptability of a novel task-shifted intervention to address this cluster of men’s mental health problems with a focus on engaging and retaining men in treatment. The intervention, Learn, Engage, Act, Dedicate (LEAD), is based in behavioral activation blended with motivational interviewing and was pilot tested in Kenya. To develop LEAD, we engaged in a community-engaged multi-step, collaborative process with local Kenyan stakeholders. LEAD was piloted with nine fathers reporting problem drinking. To assess initial feasibility and acceptability, recruitment and participation were tracked and descriptive statistics were generated given engagement of men was key for proof of concept. Semi-structured ...

Children

Functional abdominal pain (FAP) is one of the most common childhood medical complaints, associate... more Functional abdominal pain (FAP) is one of the most common childhood medical complaints, associated with significant distress and impairment. Little is known about how children understand their pain. Do they attribute it to personal weakness? Do they perceive pain as having global impact, affecting a variety of activities? How do they cope with pain? We explored the pain beliefs of 5- to 9-year-old children with FAP using a novel Teddy Bear Interview task in which children answered questions about a Teddy bear’s pain. Responses were analyzed quantitatively and qualitatively. Results indicate that the majority of young children with FAP are optimistic about pain outcomes. Children generated many types of coping strategies for Teddy’s pain and adjusted their calibration of Teddy’s pain tolerance dependent on the activity being performed. Early warning signs also emerged: a subset of children were pessimistic about Teddy’s pain, and several children identified coping strategies that, wh...

International Journal of Drug Policy

BACKGROUND Problem drinking and co-occurring depression symptoms affect men at high rates and are... more BACKGROUND Problem drinking and co-occurring depression symptoms affect men at high rates and are associated with increased risk of family violence. In low- and middle-income countries, there is a large treatment gap for services due to a lack of human resources. Moreover, masculine norms are a barrier to men seeking treatment for drinking and depression in healthcare settings. We examined an approach for engaging peer-fathers to deliver an intervention to reduce alcohol use, improve depressive symptoms, and increase family involvement among fathers in Kenya with problem drinking. The intervention-LEAD (Learn, Engage, Act, Dedicate)-combines motivational interviewing, behavioral activation, and masculinity discussion strategies. METHODS Community and religious leaders nominated fathers with no mental health training to serve as counselors (N=12); clients were recruited through community referrals. Nominated fathers completed a 10-day training beginning with treatment principles followed by manualized content. Three counselors were selected after training based on quantitative and qualitative assessments of communication skills, intervention knowledge, willingness to learn, ability to use feedback, and empathy. Supervision was tiered with local supervisors and clinical psychologist consultation. During LEAD delivery, counselor fidelity, delivery quality, and general and intervention-specific competencies were assessed. To evaluate acceptability, qualitative interviews were conducted with lay-counselors and clients (N=11). Descriptive statistics were calculated for quantitative outcomes; interviews were analyzed using thematic analysis. RESULTS Peer-father lay counselors treated nine clients, with eight completing treatment. Counselors reached high rates of fidelity (93.8%) and high to optimal ratings on quality of delivery, clinical competency, and intervention-specific competencies. Qualitative results suggested high acceptability, with counselors expressing satisfaction and empowerment in their roles. Clients likewise described positive experiences with counselors. CONCLUSIONS Findings provide initial support for the acceptability and feasibility of recruitment, selection, and training processes for peer-father lay counselors to deliver LEAD through a lens of masculinity that aligned with clients help-acceptance practices.

Frontiers in Psychology

Family functioning is an important target of clinical intervention and research given its close t... more Family functioning is an important target of clinical intervention and research given its close ties with mental health outcomes of both children and adults. However, we lack family functioning measures validated for use in many low- and middle-income country (LMIC) settings. In this mixed-methods prospective diagnostic accuracy study, we first used formative qualitative data to develop an extensive battery of screening items to measure family functioning in Kenya. We then recruited 30 Kenyan families (N = 44 adults; 30 youth aged 8–17 years) to complete the questionnaires and participate in clinical interviews conducted by local interviewers. Quantitative and qualitative analyses were then conducted to select a subset of screening items that balanced conceptual understanding of family distress with diagnostic efficiency and accuracy to yield a brief but valid scale. The final index test consisting of 30 items correctly identified distressed families in 89% of cases according to adu...

The places where adolescents live, learn, and play are thought to influence behaviours and health... more The places where adolescents live, learn, and play are thought to influence behaviours and health, but we have limited tools for measuring environmental risk on a hyperlocal level. Working with 218 adolescents and their parents/guardians in rural western Kenya, we combined participatory mapping activities with satellite imagery to identify adolescent activity spaces and create a novel measure of social-ecological dangers. We then examined the associations between community risk and individual HIV risk beliefs and behaviours. We found support for the conjecture, derived from social-ecological models of HIV transmission, that community-level risks may be associated with individual beliefs and behaviours. As community risk increased for a sample of Kenyan adolescents, so did their reports of riskier sex beliefs and behaviours, as well as unsupervised outings at night. This study reinforces calls for disease prevention approaches that go beyond emphasizing individual behaviour change.

BACKGROUND Depression during pregnancy and in the postpartum period is associated with poor outco... more BACKGROUND Depression during pregnancy and in the postpartum period is associated with poor outcomes for women and their children. Although effective interventions exist for common mental disorders that occur during pregnancy and the postpartum period, most cases in low- and middle-income countries go untreated because of a lack of trained professionals. Task-sharing models such as the Thinking Healthy Program have shown potential in feasibility and efficacy trials as a strategy for expanding access to treatment in low-resource settings; however, there are significant barriers to scale-up. We address this gap by adapting Thinking Healthy for automated delivery via a mobile phone. This new intervention, Healthy Moms, uses an existing artificial intelligence system called Tess (Zuri in Kenya) to drive conversations with users. OBJECTIVE This prepilot study aims to gather preliminary data on the Healthy Moms perinatal depression intervention to learn how to build and test a more robust...

European Child & Adolescent Psychiatry

Assessment of potentially traumatic events and related psychological symptoms in refugee youth is... more Assessment of potentially traumatic events and related psychological symptoms in refugee youth is common in epidemiological and intervention research. The objective of this study is to characterize reactions to assessments of trauma exposure and psychological symptoms, including traumatic stress, in refugee youth and their caregivers. Eighty-eight Somali youth and their caregivers participated in a screening and baseline interview for a psychological intervention in three refugee camps in Ethiopia. Participants were asked about their levels of distress prior to, immediately after, and approximately two weeks after completing the interview. Other quantitative and qualitative questions inquired about specific reactions to interview questions and procedures. Children and caregivers became increasingly relaxed over the course of the interview, on average. Few children (5.3%) or caregivers (6.5%) who reported being relaxed at the beginning of the interview became upset by the end of the interview. Some children and caregivers reported that certain assessment questions were upsetting and that feeling upset interfered with their activities. Despite some participants reporting persistent negative reactions, most reported liking and benefitting from the interview. While the majority of refugee youth and their caregivers reported positive experiences associated with completing trauma-related assessments, some reported negative reactions. Researchers and practitioners must consider the necessity, risks, and benefits of including questions about potentially traumatic events and related symptoms that are particularly upsetting in screening, survey research, and clinical assessment. When included, it is important that researchers and practitioners monitor negative reactions to these assessments and connect participants who become distressed with appropriate services.

Journal of Child and Family Studies

Family-based interventions offer a promising avenue for addressing chronic negative family intera... more Family-based interventions offer a promising avenue for addressing chronic negative family interactions that contribute to lasting consequences, including family violence and the onset and maintenance of mental health disorders. The purpose of this study was to conduct a mixed-methods, single group pre-post pilot trial of a family therapy intervention (N = 10) delivered by lay counselors in Kenya. Results show that both caregivers and children reported reductions in family dysfunction and improved mental health after the intervention. Point estimates represent change of more than two standard deviations from baseline for the majority of primary outcomes. Treated families also reported a decrease in harsh discipline, intimate partner violence, and alcohol-related problems. These results were corroborated by findings from an observational measure of family functioning and in-depth qualitative interviews. This study presents preliminary evidence of pre-post improvements following a family therapy intervention consisting of streamlined, evidence-informed family therapy strategies to target family dysfunction and mental health.

Journal of Pediatric Psychology

Objectives To characterize the types and magnitude of psychosocial burden present in caregivers w... more Objectives To characterize the types and magnitude of psychosocial burden present in caregivers who have a child with sickle cell disease (SCD) in Kenya and to identify predictors of caregiver psychosocial burden, including disease severity and financial hardship. Methods Primary caregivers (N = 103) of children aged 1–10 years diagnosed with SCD completed surveys assessing multiple domains of caregiver quality of life (QOL), adjustment to child illness, mental health, and financial hardship. Descriptive statistics characterize psychosocial burden, and linear models assess associations. Results On indicators of QOL, caregivers report multiple difficulties across most domains, including daily activities and physical, social, cognitive, and emotional well-being. Daily activities emerged as most burdensome. On indicators of parental adjustment to chronic illness, guilt and worry emerged as the greatest concern, followed by long-term uncertainty and unresolved sorrow and anger; relative...

Men’s alcohol use and co-occurring family problems are critical issues, yet few treatments exist ... more Men’s alcohol use and co-occurring family problems are critical issues, yet few treatments exist to address these problems in low and middle-income countries (LMICs). This paper describes the development and initial feasibility and acceptability of a novel intervention to address men’s alcohol use and co-occurring family problems. The intervention is based in behavioral activation blended with motivational interviewing and was pilot tested in Kenya. To develop treatment, we engaged in a multi-step, collaborative process with a local Kenyan team. The treatment was piloted with nine fathers reporting problem drinking. To assess initial feasibility and acceptability, recruitment and participation were tracked and descriptive statistics were generated. Semi-structured interviews were conducted with participants and analyzed using thematic content analysis. The development process resulted in a weekly 5-session intervention rooted in behavioral activation, motivational interviewing, and ...

Objective: To evaluate a lay provider-delivered, brief intervention to reduce problem drinking an... more Objective: To evaluate a lay provider-delivered, brief intervention to reduce problem drinking and related family consequences among men in Kenya. The 5-session intervention combines behavioral activation (BA) and motivational interviewing (MI). It integrates family-related material explicitly and addresses central cultural factors through gender transformative strategies. Method: A nonconcurrent multiple-baseline design was used. We initiated treatment with nine men ages 30 to 48 who were fathers and screened positive for problem drinking; the median Alcohol Use Identification Test score was 17 (harmful range). Participants were randomized to staggered start dates. We measured the primary outcome of weekly alcohol consumption four weeks before treatment, during treatment, and four weeks post-treatment using the Timeline Followback measure. Secondary outcomes were assessed using a pre-post assessment (1-month) of men’s depression symptoms, drinking- and family-related problem behavi...

Background. Depression during pregnancy and in the postpartum period is associated with a number ... more Background. Depression during pregnancy and in the postpartum period is associated with a number of poor outcomes for women and their children. Although effective interventions exist for common mental disorders that occur during pregnancy and the postpartum period, most cases in low- and middle-income countries go untreated because of a lack of trained professionals. Task-sharing models such as the *Thinking Healthy* Program have shown great potential in feasibility and efficacy trials as a strategy for expanding access to treatment in low-resource settings, but there are significant barriers to scale-up. We are addressing this gap by adapting *Thinking Healthy* for automated delivery via a mobile phone. This new intervention, *Healthy Moms*, uses an existing artificial intelligence system called Tess (Zuri in Kenya) to drive conversations with users.Objective. The primary objective of this pre-pilot study was to gather preliminary data on the *Healthy Moms* perinatal depression int...

Maltreatment in early childhood is difficult to measure. Self-report surveys of parents and guard... more Maltreatment in early childhood is difficult to measure. Self-report surveys of parents and guardians are the most common method used, but in many settings social desirabil- ity may lead to underestimates of prevalence. There is also reason to be concerned about response bias in the context of intervention trials. To diversify the tools available to in- tervention researchers, we created and tested a discrete choice experiment to elicit parent preferences for harsh discipline. This study was conducted in Liberia as part of a random- ized controlled trial of a positive parenting program. Baseline data were collected from 609 parents and guardians living in Monrovia and caring for a child age 3 or 4. Participants completed a discrete choice experiment that consisted of 12 parenting vignettes, in addition to a survey of parenting attitudes and behaviors. The vignettes were presented to parents as digital comic strips. Each scene could vary on four attributes: child gender; child offens...

International Journal of Drug Policy

BACKGROUND In Kenya, the prevalence of alcohol use disorder (AUD) is close to 6%, but a notable t... more BACKGROUND In Kenya, the prevalence of alcohol use disorder (AUD) is close to 6%, but a notable treatment gap persists. AUD is especially pronounced among men, leading to negative consequences at both individual and family levels. This study examines the experiences of problem-drinking fathers in Kenya regarding previous treatment-seeking related to alcohol use. Experiences and dynamics of the family are also explored as they pertain to treatment-seeking experiences. METHODS In Eldoret, Kenya, semi-structured qualitative interviews were conducted with 11 families with a male exhibiting problem drinking, his spouse, and one child. Thematic content analysis was used to examine themes related to barriers and facilitators to treatment. RESULTS Participants only reported informal help received from family and community members; they exhibited little awareness of available formal treatments. Families were both deeply affected by alcohol use and actively involved in help-seeking. Indeed, fathers' experiences are described as help-accepting rather than help-seeking. Three overarching themes emerged from the results: poverty, people, and practices. Poverty could be a motivator to accept help to support one's family financially, but stress from lack of work also drove drinking behaviours. People were also crucial as both barriers and facilitators of help-accepting. Negative help strategies or peer influence deterred fathers from accepting help to quit. Positive motivation, social support, and stigma against drinking were motivators. Practices that were culturally salient, such as religiosity and gender roles, facilitated help acceptance. Overall, most help efforts were short-term and only lead to very short-term behaviour change. CONCLUSION Families and communities are active in help provision for problem-drinking men in Kenya, though results confirm remaining need for effective interventions. Future interventions could benefit from recognizing the role of family to aid in treatment-engagement and attending to the importance of poverty, people, and practices in designing treatment strategies.

Blood

4805 Children with sickle cell anemia (SCA) and a primary overt stroke are at high risk of recurr... more 4805 Children with sickle cell anemia (SCA) and a primary overt stroke are at high risk of recurrent (secondary) stroke. Chronic blood transfusion (CBT) dramatically reduces but does not eliminate this high risk, and results in transfusion-related hemosiderosis. We previously reported the use of hydroxyurea/phlebotomy as an alternative to CBT to reduce the risk of secondary stroke and improve management of iron overload (Ware et al. J Pediatr 2004). This study examines the caregiver and child experience with secondary stroke prevention. Individual semi-structured interviews were conducted with primary caregivers and children/adolescents (age…

Families, Systems, & Health

Introduction: Youth in low- and middle-income countries (LMICs) are at increased risk for poor me... more Introduction: Youth in low- and middle-income countries (LMICs) are at increased risk for poor mental health due to economic and social disadvantage. Interventions that strengthen families may equip children and adolescents with the supports and resources to fulfill their potential and buffer them from future stressors and adversity. Due to human resource constraints, task-sharing—delivery of interventions by nonspecialists—may be an effective strategy to facilitate the dissemination of mental health interventions in low resource contexts. To this end, we conducted a systematic review of the literature on family-based interventions delivered in LMICs by nonspecialist providers (NSPs) targeting youth mental health and family related outcomes. Method: Cochrane and PRISMA procedures guided this review. Searches were conducted in PsychInfo, PubMed, and Web of Science, with additional articles pulled from reference lists. Results: This search yielded 10 studies. Four studies were developed specifically for the delivery context using formative qualitative research; the remaining interventions underwent adaptation for use in the context. All interventions employed a period of structured training; nine studies additionally provided ongoing supervision to counselors. Interventions noted widespread acceptance of program material and delivery by NSPs. They also noted the need for ongoing supervision of NSPs to increase treatment fidelity. Discussion: Usage of NSPs is quite consistently proving feasible, acceptable, and efficacious and is almost certainly a valuable component within approaches to scaling up mental health programs. A clear next step is to establish and evaluate sustainable models of training and supervision to further inform scalability.

Global Social Welfare

The large burden of mental health disorders among young people worldwide calls for scalable preve... more The large burden of mental health disorders among young people worldwide calls for scalable prevention and treatment models that reach children and families in low-resource settings. This paper describes the development of an evidence-informed family therapy intervention designed for lay counselor delivery in low-resource settings and presents findings on the feasibility and acceptability of implementation in Kenya. Qualitative data guided the development of a components-based family therapy that integrates multiple strategies from solution-focused and systems-based therapies, as well as those from parenting skills training and cognitive behavioral therapies. Eight lay counselors delivered the intervention, with 10 families completing treatment. Lay counselors demonstrated adequate fidelity and clinical competency when treating families with a wide range of presenting clinical problems. Unique elements of the implementation model proved feasible and acceptable, including recruiting “natural” lay counselors from communities already engaged in informal counseling for families; participants indicated trust and respect in the counseling relationship that facilitated their participation. Both counselors and families reported positive perceptions of intervention content and strategies, including those least similar to local counseling practices. Results support the potential of this implementation strategy that aims to add evidence-based practices to local practices and routines rather than creating new cadres of lay counselors or health workers. Supervision, provided by psychology student trainees, also proved feasible and mutually beneficial, with phone-based supervision as acceptable as in-person meetings; this suggests the potential feasibility of this model for use in remote locations. Future directions include integrating these delivery approaches into existing social structures to develop and evaluate a comprehensive implementation model for scale-up.

PLOS ONE, 2019

This study suggests that rates of pediatric HIV disclosure may be larger than typically reported,... more This study suggests that rates of pediatric HIV disclosure may be larger than typically reported, but also reinforces the idea that most children do not know key details about their illness, such as how they were infected and that they can infect others.

and the entire IRC Liberia team in Lofa County for their tireless efforts. We also thank Smith pr... more and the entire IRC Liberia team in Lofa County for their tireless efforts. We also thank Smith provided technical support on project design and implementation , as well as valuable comments on this report. Elsa Friis provided assistance with data collection and management. Finally, we would like to thank the 270 families who participated in the study for their patience and generosity.

Men’s depression, alcohol use, and family problems commonly co-occur to create of cluster of ment... more Men’s depression, alcohol use, and family problems commonly co-occur to create of cluster of mental health problems. Yet, few treatments exist to address these problems, especially in low and middle-income countries (LMICs). This paper describes the development and initial feasibility and acceptability of a novel task-shifted intervention to address this cluster of men’s mental health problems with a focus on engaging and retaining men in treatment. The intervention, Learn, Engage, Act, Dedicate (LEAD), is based in behavioral activation blended with motivational interviewing and was pilot tested in Kenya. To develop LEAD, we engaged in a community-engaged multi-step, collaborative process with local Kenyan stakeholders. LEAD was piloted with nine fathers reporting problem drinking. To assess initial feasibility and acceptability, recruitment and participation were tracked and descriptive statistics were generated given engagement of men was key for proof of concept. Semi-structured ...

Children

Functional abdominal pain (FAP) is one of the most common childhood medical complaints, associate... more Functional abdominal pain (FAP) is one of the most common childhood medical complaints, associated with significant distress and impairment. Little is known about how children understand their pain. Do they attribute it to personal weakness? Do they perceive pain as having global impact, affecting a variety of activities? How do they cope with pain? We explored the pain beliefs of 5- to 9-year-old children with FAP using a novel Teddy Bear Interview task in which children answered questions about a Teddy bear’s pain. Responses were analyzed quantitatively and qualitatively. Results indicate that the majority of young children with FAP are optimistic about pain outcomes. Children generated many types of coping strategies for Teddy’s pain and adjusted their calibration of Teddy’s pain tolerance dependent on the activity being performed. Early warning signs also emerged: a subset of children were pessimistic about Teddy’s pain, and several children identified coping strategies that, wh...

International Journal of Drug Policy

BACKGROUND Problem drinking and co-occurring depression symptoms affect men at high rates and are... more BACKGROUND Problem drinking and co-occurring depression symptoms affect men at high rates and are associated with increased risk of family violence. In low- and middle-income countries, there is a large treatment gap for services due to a lack of human resources. Moreover, masculine norms are a barrier to men seeking treatment for drinking and depression in healthcare settings. We examined an approach for engaging peer-fathers to deliver an intervention to reduce alcohol use, improve depressive symptoms, and increase family involvement among fathers in Kenya with problem drinking. The intervention-LEAD (Learn, Engage, Act, Dedicate)-combines motivational interviewing, behavioral activation, and masculinity discussion strategies. METHODS Community and religious leaders nominated fathers with no mental health training to serve as counselors (N=12); clients were recruited through community referrals. Nominated fathers completed a 10-day training beginning with treatment principles followed by manualized content. Three counselors were selected after training based on quantitative and qualitative assessments of communication skills, intervention knowledge, willingness to learn, ability to use feedback, and empathy. Supervision was tiered with local supervisors and clinical psychologist consultation. During LEAD delivery, counselor fidelity, delivery quality, and general and intervention-specific competencies were assessed. To evaluate acceptability, qualitative interviews were conducted with lay-counselors and clients (N=11). Descriptive statistics were calculated for quantitative outcomes; interviews were analyzed using thematic analysis. RESULTS Peer-father lay counselors treated nine clients, with eight completing treatment. Counselors reached high rates of fidelity (93.8%) and high to optimal ratings on quality of delivery, clinical competency, and intervention-specific competencies. Qualitative results suggested high acceptability, with counselors expressing satisfaction and empowerment in their roles. Clients likewise described positive experiences with counselors. CONCLUSIONS Findings provide initial support for the acceptability and feasibility of recruitment, selection, and training processes for peer-father lay counselors to deliver LEAD through a lens of masculinity that aligned with clients help-acceptance practices.

Frontiers in Psychology

Family functioning is an important target of clinical intervention and research given its close t... more Family functioning is an important target of clinical intervention and research given its close ties with mental health outcomes of both children and adults. However, we lack family functioning measures validated for use in many low- and middle-income country (LMIC) settings. In this mixed-methods prospective diagnostic accuracy study, we first used formative qualitative data to develop an extensive battery of screening items to measure family functioning in Kenya. We then recruited 30 Kenyan families (N = 44 adults; 30 youth aged 8–17 years) to complete the questionnaires and participate in clinical interviews conducted by local interviewers. Quantitative and qualitative analyses were then conducted to select a subset of screening items that balanced conceptual understanding of family distress with diagnostic efficiency and accuracy to yield a brief but valid scale. The final index test consisting of 30 items correctly identified distressed families in 89% of cases according to adu...

The places where adolescents live, learn, and play are thought to influence behaviours and health... more The places where adolescents live, learn, and play are thought to influence behaviours and health, but we have limited tools for measuring environmental risk on a hyperlocal level. Working with 218 adolescents and their parents/guardians in rural western Kenya, we combined participatory mapping activities with satellite imagery to identify adolescent activity spaces and create a novel measure of social-ecological dangers. We then examined the associations between community risk and individual HIV risk beliefs and behaviours. We found support for the conjecture, derived from social-ecological models of HIV transmission, that community-level risks may be associated with individual beliefs and behaviours. As community risk increased for a sample of Kenyan adolescents, so did their reports of riskier sex beliefs and behaviours, as well as unsupervised outings at night. This study reinforces calls for disease prevention approaches that go beyond emphasizing individual behaviour change.

BACKGROUND Depression during pregnancy and in the postpartum period is associated with poor outco... more BACKGROUND Depression during pregnancy and in the postpartum period is associated with poor outcomes for women and their children. Although effective interventions exist for common mental disorders that occur during pregnancy and the postpartum period, most cases in low- and middle-income countries go untreated because of a lack of trained professionals. Task-sharing models such as the Thinking Healthy Program have shown potential in feasibility and efficacy trials as a strategy for expanding access to treatment in low-resource settings; however, there are significant barriers to scale-up. We address this gap by adapting Thinking Healthy for automated delivery via a mobile phone. This new intervention, Healthy Moms, uses an existing artificial intelligence system called Tess (Zuri in Kenya) to drive conversations with users. OBJECTIVE This prepilot study aims to gather preliminary data on the Healthy Moms perinatal depression intervention to learn how to build and test a more robust...

European Child & Adolescent Psychiatry

Assessment of potentially traumatic events and related psychological symptoms in refugee youth is... more Assessment of potentially traumatic events and related psychological symptoms in refugee youth is common in epidemiological and intervention research. The objective of this study is to characterize reactions to assessments of trauma exposure and psychological symptoms, including traumatic stress, in refugee youth and their caregivers. Eighty-eight Somali youth and their caregivers participated in a screening and baseline interview for a psychological intervention in three refugee camps in Ethiopia. Participants were asked about their levels of distress prior to, immediately after, and approximately two weeks after completing the interview. Other quantitative and qualitative questions inquired about specific reactions to interview questions and procedures. Children and caregivers became increasingly relaxed over the course of the interview, on average. Few children (5.3%) or caregivers (6.5%) who reported being relaxed at the beginning of the interview became upset by the end of the interview. Some children and caregivers reported that certain assessment questions were upsetting and that feeling upset interfered with their activities. Despite some participants reporting persistent negative reactions, most reported liking and benefitting from the interview. While the majority of refugee youth and their caregivers reported positive experiences associated with completing trauma-related assessments, some reported negative reactions. Researchers and practitioners must consider the necessity, risks, and benefits of including questions about potentially traumatic events and related symptoms that are particularly upsetting in screening, survey research, and clinical assessment. When included, it is important that researchers and practitioners monitor negative reactions to these assessments and connect participants who become distressed with appropriate services.

Journal of Child and Family Studies

Family-based interventions offer a promising avenue for addressing chronic negative family intera... more Family-based interventions offer a promising avenue for addressing chronic negative family interactions that contribute to lasting consequences, including family violence and the onset and maintenance of mental health disorders. The purpose of this study was to conduct a mixed-methods, single group pre-post pilot trial of a family therapy intervention (N = 10) delivered by lay counselors in Kenya. Results show that both caregivers and children reported reductions in family dysfunction and improved mental health after the intervention. Point estimates represent change of more than two standard deviations from baseline for the majority of primary outcomes. Treated families also reported a decrease in harsh discipline, intimate partner violence, and alcohol-related problems. These results were corroborated by findings from an observational measure of family functioning and in-depth qualitative interviews. This study presents preliminary evidence of pre-post improvements following a family therapy intervention consisting of streamlined, evidence-informed family therapy strategies to target family dysfunction and mental health.

Journal of Pediatric Psychology

Objectives To characterize the types and magnitude of psychosocial burden present in caregivers w... more Objectives To characterize the types and magnitude of psychosocial burden present in caregivers who have a child with sickle cell disease (SCD) in Kenya and to identify predictors of caregiver psychosocial burden, including disease severity and financial hardship. Methods Primary caregivers (N = 103) of children aged 1–10 years diagnosed with SCD completed surveys assessing multiple domains of caregiver quality of life (QOL), adjustment to child illness, mental health, and financial hardship. Descriptive statistics characterize psychosocial burden, and linear models assess associations. Results On indicators of QOL, caregivers report multiple difficulties across most domains, including daily activities and physical, social, cognitive, and emotional well-being. Daily activities emerged as most burdensome. On indicators of parental adjustment to chronic illness, guilt and worry emerged as the greatest concern, followed by long-term uncertainty and unresolved sorrow and anger; relative...

Men’s alcohol use and co-occurring family problems are critical issues, yet few treatments exist ... more Men’s alcohol use and co-occurring family problems are critical issues, yet few treatments exist to address these problems in low and middle-income countries (LMICs). This paper describes the development and initial feasibility and acceptability of a novel intervention to address men’s alcohol use and co-occurring family problems. The intervention is based in behavioral activation blended with motivational interviewing and was pilot tested in Kenya. To develop treatment, we engaged in a multi-step, collaborative process with a local Kenyan team. The treatment was piloted with nine fathers reporting problem drinking. To assess initial feasibility and acceptability, recruitment and participation were tracked and descriptive statistics were generated. Semi-structured interviews were conducted with participants and analyzed using thematic content analysis. The development process resulted in a weekly 5-session intervention rooted in behavioral activation, motivational interviewing, and ...

Objective: To evaluate a lay provider-delivered, brief intervention to reduce problem drinking an... more Objective: To evaluate a lay provider-delivered, brief intervention to reduce problem drinking and related family consequences among men in Kenya. The 5-session intervention combines behavioral activation (BA) and motivational interviewing (MI). It integrates family-related material explicitly and addresses central cultural factors through gender transformative strategies. Method: A nonconcurrent multiple-baseline design was used. We initiated treatment with nine men ages 30 to 48 who were fathers and screened positive for problem drinking; the median Alcohol Use Identification Test score was 17 (harmful range). Participants were randomized to staggered start dates. We measured the primary outcome of weekly alcohol consumption four weeks before treatment, during treatment, and four weeks post-treatment using the Timeline Followback measure. Secondary outcomes were assessed using a pre-post assessment (1-month) of men’s depression symptoms, drinking- and family-related problem behavi...

Background. Depression during pregnancy and in the postpartum period is associated with a number ... more Background. Depression during pregnancy and in the postpartum period is associated with a number of poor outcomes for women and their children. Although effective interventions exist for common mental disorders that occur during pregnancy and the postpartum period, most cases in low- and middle-income countries go untreated because of a lack of trained professionals. Task-sharing models such as the *Thinking Healthy* Program have shown great potential in feasibility and efficacy trials as a strategy for expanding access to treatment in low-resource settings, but there are significant barriers to scale-up. We are addressing this gap by adapting *Thinking Healthy* for automated delivery via a mobile phone. This new intervention, *Healthy Moms*, uses an existing artificial intelligence system called Tess (Zuri in Kenya) to drive conversations with users.Objective. The primary objective of this pre-pilot study was to gather preliminary data on the *Healthy Moms* perinatal depression int...

Maltreatment in early childhood is difficult to measure. Self-report surveys of parents and guard... more Maltreatment in early childhood is difficult to measure. Self-report surveys of parents and guardians are the most common method used, but in many settings social desirabil- ity may lead to underestimates of prevalence. There is also reason to be concerned about response bias in the context of intervention trials. To diversify the tools available to in- tervention researchers, we created and tested a discrete choice experiment to elicit parent preferences for harsh discipline. This study was conducted in Liberia as part of a random- ized controlled trial of a positive parenting program. Baseline data were collected from 609 parents and guardians living in Monrovia and caring for a child age 3 or 4. Participants completed a discrete choice experiment that consisted of 12 parenting vignettes, in addition to a survey of parenting attitudes and behaviors. The vignettes were presented to parents as digital comic strips. Each scene could vary on four attributes: child gender; child offens...

International Journal of Drug Policy

BACKGROUND In Kenya, the prevalence of alcohol use disorder (AUD) is close to 6%, but a notable t... more BACKGROUND In Kenya, the prevalence of alcohol use disorder (AUD) is close to 6%, but a notable treatment gap persists. AUD is especially pronounced among men, leading to negative consequences at both individual and family levels. This study examines the experiences of problem-drinking fathers in Kenya regarding previous treatment-seeking related to alcohol use. Experiences and dynamics of the family are also explored as they pertain to treatment-seeking experiences. METHODS In Eldoret, Kenya, semi-structured qualitative interviews were conducted with 11 families with a male exhibiting problem drinking, his spouse, and one child. Thematic content analysis was used to examine themes related to barriers and facilitators to treatment. RESULTS Participants only reported informal help received from family and community members; they exhibited little awareness of available formal treatments. Families were both deeply affected by alcohol use and actively involved in help-seeking. Indeed, fathers' experiences are described as help-accepting rather than help-seeking. Three overarching themes emerged from the results: poverty, people, and practices. Poverty could be a motivator to accept help to support one's family financially, but stress from lack of work also drove drinking behaviours. People were also crucial as both barriers and facilitators of help-accepting. Negative help strategies or peer influence deterred fathers from accepting help to quit. Positive motivation, social support, and stigma against drinking were motivators. Practices that were culturally salient, such as religiosity and gender roles, facilitated help acceptance. Overall, most help efforts were short-term and only lead to very short-term behaviour change. CONCLUSION Families and communities are active in help provision for problem-drinking men in Kenya, though results confirm remaining need for effective interventions. Future interventions could benefit from recognizing the role of family to aid in treatment-engagement and attending to the importance of poverty, people, and practices in designing treatment strategies.

Blood

4805 Children with sickle cell anemia (SCA) and a primary overt stroke are at high risk of recurr... more 4805 Children with sickle cell anemia (SCA) and a primary overt stroke are at high risk of recurrent (secondary) stroke. Chronic blood transfusion (CBT) dramatically reduces but does not eliminate this high risk, and results in transfusion-related hemosiderosis. We previously reported the use of hydroxyurea/phlebotomy as an alternative to CBT to reduce the risk of secondary stroke and improve management of iron overload (Ware et al. J Pediatr 2004). This study examines the caregiver and child experience with secondary stroke prevention. Individual semi-structured interviews were conducted with primary caregivers and children/adolescents (age…

Families, Systems, & Health

Introduction: Youth in low- and middle-income countries (LMICs) are at increased risk for poor me... more Introduction: Youth in low- and middle-income countries (LMICs) are at increased risk for poor mental health due to economic and social disadvantage. Interventions that strengthen families may equip children and adolescents with the supports and resources to fulfill their potential and buffer them from future stressors and adversity. Due to human resource constraints, task-sharing—delivery of interventions by nonspecialists—may be an effective strategy to facilitate the dissemination of mental health interventions in low resource contexts. To this end, we conducted a systematic review of the literature on family-based interventions delivered in LMICs by nonspecialist providers (NSPs) targeting youth mental health and family related outcomes. Method: Cochrane and PRISMA procedures guided this review. Searches were conducted in PsychInfo, PubMed, and Web of Science, with additional articles pulled from reference lists. Results: This search yielded 10 studies. Four studies were developed specifically for the delivery context using formative qualitative research; the remaining interventions underwent adaptation for use in the context. All interventions employed a period of structured training; nine studies additionally provided ongoing supervision to counselors. Interventions noted widespread acceptance of program material and delivery by NSPs. They also noted the need for ongoing supervision of NSPs to increase treatment fidelity. Discussion: Usage of NSPs is quite consistently proving feasible, acceptable, and efficacious and is almost certainly a valuable component within approaches to scaling up mental health programs. A clear next step is to establish and evaluate sustainable models of training and supervision to further inform scalability.

Global Social Welfare

The large burden of mental health disorders among young people worldwide calls for scalable preve... more The large burden of mental health disorders among young people worldwide calls for scalable prevention and treatment models that reach children and families in low-resource settings. This paper describes the development of an evidence-informed family therapy intervention designed for lay counselor delivery in low-resource settings and presents findings on the feasibility and acceptability of implementation in Kenya. Qualitative data guided the development of a components-based family therapy that integrates multiple strategies from solution-focused and systems-based therapies, as well as those from parenting skills training and cognitive behavioral therapies. Eight lay counselors delivered the intervention, with 10 families completing treatment. Lay counselors demonstrated adequate fidelity and clinical competency when treating families with a wide range of presenting clinical problems. Unique elements of the implementation model proved feasible and acceptable, including recruiting “natural” lay counselors from communities already engaged in informal counseling for families; participants indicated trust and respect in the counseling relationship that facilitated their participation. Both counselors and families reported positive perceptions of intervention content and strategies, including those least similar to local counseling practices. Results support the potential of this implementation strategy that aims to add evidence-based practices to local practices and routines rather than creating new cadres of lay counselors or health workers. Supervision, provided by psychology student trainees, also proved feasible and mutually beneficial, with phone-based supervision as acceptable as in-person meetings; this suggests the potential feasibility of this model for use in remote locations. Future directions include integrating these delivery approaches into existing social structures to develop and evaluate a comprehensive implementation model for scale-up.