Correction: Ethics in Community-Based Research with Vulnerable Children: Perspectives from Rwanda.

[This corrects the article DOI: 10.1371/journal.pone.0157042.].

Mental Health and Antiretroviral Adherence Among Youth Living With HIV in Rwanda.

BACKGROUND AND OBJECTIVES: In Rwanda, significant progress has been made in advancing access to antiretroviral therapy (ART) among youth. As availability of ART increases, adherence is critical for preventing poor clinical outcomes and transmission of HIV. The goals of the study are to (1) describe ART adherence and mental health problems among youth living with HIV aged 10 to 17; and (2) examine the association between these factors among this population in rural Rwanda. METHODS: A cross-sectional analysis was conducted that examined the association of mental health status and ART adherence among youth (n = 193). ART adherence, mental health status, and related variables were examined based on caregiver and youth report. Nonadherence was defined as ever missing or refusing a dose of ART within the past month. Multivariate modeling was performed to examine the association between mental health status and ART adherence. RESULTS: Approximately 37% of youth missed or refused ART in the past month. In addition, a high level of depressive symptoms (26%) and attempt to hurt or kill oneself (12%) was observed in this population of youth living with HIV in Rwanda. In multivariate analysis, nonadherence was significantly associated with some mental health outcomes, including conduct problems (odds ratio 2.90, 95% confidence interval 1.55-5.43) and depression (odds ratio 1.02, 95% confidence interval 1.01-1.04), according to caregiver report. A marginally significant association was observed for youth report of depressive symptoms. CONCLUSIONS: The findings suggest that mental health should be considered among the factors related to ART nonadherence in HIV services for youth, particularly for mental health outcomes, such as conduct problems and depression.

Ethics in Community-Based Research with Vulnerable Children: Perspectives from Rwanda.

A "risk of harm" protocol to identify youth in need of immediate emergency assistance in a study on mental health and HIV in Rwanda among 680 youth ages 10-17 is described. Cases are presented that describe the experience in using this protocol to ensure safety of participants, with ethical and logistical challenges considered. Among the population of the study, 3.2% were deemed "risk of harm." The most prevalent presenting problem was non-fatal suicidal behavior (91% of risk of harm cases), with 36% having a history of a reported previous attempt. Challenges included: acute food insecurity/significant poverty; lack of support/adequate supervision from family members; family violence; alcohol abuse; and HIV-related stigma. Development of a "risk of harm" protocol and collaboration between study staff, community leadership, health authorities, and health workers are critical to ensuring participants' safety in research among vulnerable populations.

Family-based prevention of mental health problems in children affected by HIV and AIDS: an open trial.

OBJECTIVE: The objective of this study is to assess the feasibility and acceptability of an intervention to reduce mental health problems and bolster resilience among children living in households affected by caregiver HIV in Rwanda. DESIGN: Pre-post design, including 6-month follow-up. METHODS: The Family Strengthening Intervention (FSI) aims to reduce mental health problems among HIV-affected children through improved child-caregiver relationships, family communication and parenting skills, HIV psychoeducation and connections to resources. Twenty families (N = 39 children) with at least one HIV-positive caregiver and one child 7-17 years old were enrolled in the FSI. Children and caregivers were administered locally adapted and validated measures of child mental health problems, as well as measures of protective processes and parenting. Assessments were administered at pre and postintervention, and 6-month follow-up. Multilevel models accounting for clustering by family tested changes in outcomes of interest. Qualitative interviews were completed to understand acceptability, feasibility and satisfaction with the FSI. RESULTS: Families reported high satisfaction with the FSI. Caregiver-reported improvements in family connectedness, good parenting, social support and children's pro-social behaviour (P < 0.05) were sustained and strengthened from postintervention to 6-month follow-up. Additional improvements in caregiver-reported child perseverance/self-esteem, depression, anxiety and irritability were seen at follow-up (P < .05). Significant decreases in child-reported harsh punishment were observed at postintervention and follow-up, and decreases in caregiver reported harsh punishment were also recorded on follow-up (P < 0.05). CONCLUSION: The FSI is a feasible and acceptable intervention that shows promise for improving mental health symptoms and strengthening protective factors among children and families affected by HIV in low-resource settings.

Validating the Center for Epidemiological Studies Depression Scale for Children in Rwanda.

OBJECTIVE: We assessed the validity of the Center for Epidemiological Studies Depression Scale for Children (CES-DC) as a screen for depression in Rwandan children and adolescents. Although the CES-DC is widely used for depression screening in high-income countries, its validity in low-income and culturally diverse settings, including sub-Saharan Africa, is unknown. METHOD: The CES-DC was selected based on alignment with local expressions of depression-like problems in Rwandan children and adolescents. To examine criterion validity, we compared CES-DC scores to depression diagnoses on a structured diagnostic interview, the Mini International Neuropsychiatric Interview for Children (MINI KID), in a sample of 367 Rwandan children and adolescents aged 10 through 17 years. Caregiver and child or adolescent self-reports endorsing the presence of local depression-like problems agahinda kenshi (persistent sorrow) and kwiheba (severe hopelessness) were also examined for agreement with MINI KID diagnosis. RESULTS: The CES-DC exhibited good internal reliability (α = .86) and test-retest reliability (r = .85). The area under the receiver operating characteristic curve for the CES-DC was 0.825 when compared to MINI KID diagnoses, indicating a strong ability to distinguish between depressed and nondepressed children and adolescents in Rwanda. A cut point of≥30 corresponded with a sensitivity of 81.9% and a specificity of 71.9% in this referred sample. MINI KID diagnosis was well aligned with local expressions of depression-like problems. CONCLUSION: The CES-DC demonstrates good psychometric properties for clinical screening and evaluation in Rwanda, and should be considered for use in this and other low-resource settings. Population samples are needed to determine a generalizable cut point in nonreferred samples.

Nothing can defeat combined hands (Abashize hamwe ntakibananira): protective processes and resilience in Rwandan children and families affected by HIV/AIDS.

In Rwanda, the dual vectors of HIV and legacy of the 1994 genocide have had devastating consequences for children and families. In this and other low-resource settings, extreme poverty, poor access to services, family conflict, and other adversities put children and families affected by HIV/AIDS at increased risk of mental health problems. However, even in the face of tremendous hardship, many children and families demonstrate better than expected outcomes. To design interventions that harness these natural sources of resilience, greater knowledge of local protective processes is needed. This study used free listing exercises (N = 68) and key informant interviews (N = 58) with adults and children (ages 10-17) to investigate strengths and sources of resilience in Rwandan children and families at risk for psychosocial difficulties due to HIV/AIDS. Clinician key informants (N = 10) were also interviewed. Five forms of protective resources emerged through this research: perseverance (kwihangana); self-esteem/self-confidence (kwigirira ikizere); family unity/trust (kwizerana); good parenting (kurera neza) and collective/communal support (ubufasha abaturage batanga). Operating within individual, family, and collective/community systems, these resources support children at multiple ecological levels. Study evidence suggests that these protective processes provide "leverage points" for strengths-based interventions designed to increase resilient outcomes and prevent mental health problems. This information on culturally-appropriate practices for building resilience, along with input from local community advisory boards and the government, has informed the development of a Family Strengthening Intervention, which has broad applications to many forms of adversity and trauma.

Using Mixed-Methods Research to Adapt and Evaluate a Family Strengthening Intervention in Rwanda.

INTRODUCTION: Research in several international settings indicates that children and adolescents affected by HIV and other compounded adversities are at increased risk for a range of mental health problems including depression, anxiety, and social withdrawal. More intervention research is needed to develop valid measurement and intervention tools to address child mental health in such settings. OBJECTIVE: This article presents a collaborative mixed-methods approach to designing and evaluating a mental health intervention to assist families facing multiple adversities in Rwanda. METHODS: Qualitative methods were used to gain knowledge of culturally-relevant mental health problems in children and adolescents, individual, family and community resources, and contextual dynamics among HIV-affected families. This data was used to guide the selection and adaptation of mental health measures to assess intervention outcomes. Measures were subjected to a quantitative validation exercise. Qualitative data and community advisory board input also informed the selection and adaptation of a family-based preventive intervention to reduce the risk for mental health problems among children in families affected by HIV.. Community-based participatory methods were used to ensure that the intervention targeted relevant problems manifest in Rwandan children and families and built on local strengths. RESULTS: Qualitative data on culturally-appropriate practices for building resilience in vulnerable families has enriched the development of a Family-Strengthening Intervention (FSI). Input from community partners has also contributed to creating a feasible and culturally-relevant intervention. Mental health measures demonstrate strong performance in this population. CONCLUSION: The mixed-methods model discussed represents a refined, multi-phase protocol for incorporating qualitative data and community input in the development and evaluation of feasible, culturally-sound quantitative assessments and intervention models. The mixed-methods approach may be applied to research in other parts of sub-Saharan Africa and beyond.