Faculty Bibliography

INTRODUCTION/BACKGROUND:Adolescent pregnancy is a highly prevalent and significant public health problem in Kenya, and mental health needs of pregnant adolescent girls have been overlooked. Nearly, 50% of the world's population comprises children and adolescents and 85% live in lower and middle-income countries. OBJECTIVE:Pregnant adolescents were interviewed to ascertain certain social determinants of mental health such as social support, partner or parent support, and demographic profile and assessed for depression using EPDS and for severity of depression using BDI, and their alcohol abuse assessed using AUDIT. METHODS:A cross-sectional descriptive study using a purposive sample of 212 pregnant adolescents visiting Kangemi Health Centre in Nairobi was conducted. RESULTS:= 0.011). CONCLUSION AND RECOMMENDATIONS/CONCLUSIONS:Alcohol abuse during pregnancy presents a significant public health burden and the associated health risks for the adolescent mother and her baby are enormous. We need to bolster screening for the comorbid disorders such as depression and substance use disorders, particularly alcohol in order to address mental health and psychosocial functioning of adolescents. The underlying adversities and sociocultural challenges need to be better understood and mechanisms that lead to comorbidities require further research. Depression interventions for Kenyan adolescents would need to embed screening, treatment and management of substance abuse.

Approximately, 42% of the Kenyan population live below the poverty line. Rapid growth and urbanization of Kenya's population have resulted in a changing poverty and food security environment in high-density urban areas. Lack of basic food needs in Kenya affects approximately 34.8% rural population and 7.6% of its urban population. Using multi-community stakeholders such as teachers and community health workers (CHWs), this paper examined food insecurity and its consequences on caregiving practices and child development. A qualitative study design was utilized. Key informant interviews and focused-group discussions with four primary school teachers and three CHWs and a nurse in-charge working within Kariobangi and Kangemi were applied to elicit various perspectives from family-, school- and community-level challenges that influence caregiving practices and child development. Grounded theory method was applied for qualitative data sifting and thematic analysis. Our findings exposed various challenges at the school, family and the community levels that affect caregiving practices and consequent child development. School-level challenges included lack of adequate amenities for effective learning, food insecurity, absenteeism and mental health challenges. Family-level barriers included lack of parenting skills, financial constraints, domestic violence and lack of social support, while community challenges such as unemployment, poor living conditions, cultural practices, lack of social support and poor community follow-up mechanisms contributed to poor parenting practices and child development. Parenting practices and holistic child development strategies in resource poor settings should focus on parenting skills, food security, quality education and addressing parents and children's mental health challenges.

Children and adolescents are affected in different ways by HIV/AIDS. Neurocognitive deficits are one of the most significant long term effects on HIV infected children and adolescents. Several factors are thought to influence cognitive outcomes and this include immune status, Highly Active Antiretroviral Therapy (HAART), education and social support. The aim of the study was to assess the neurocognitive function of HIV infected children and adolescents and correlate it with psychosocial factors. A cross sectional study was carried out involving a sample of 90 children living with HIV between 8 and 15 years (M = 11.38, SD = 2.06) attending Comprehensive Care Clinic (CCC) at Kenyatta National Hospital (KNH). Samples were selected by using purposive sample technique. Kaufman Assessment Battery for Children-Second Edition was used to assess cognitive function and psychosocial issues were assessed using HEADS-ED. Data was analyzed using SPSS v23 and independent T-tests, Pearson's correlation and linear regression were used. The prevalence of neurocognitive deficits among HIV positive children attending CCC at KNH was 60% with neurocognitive performance of 54 children being at least 2SD below the mean based on the KABC-II scores. There was no significant correlation between mental processing index and CD4 count (Pearson's rho =  -0.01, p = 0.39). There was no significant association between Mental Processing Index and viral load (p = 0.056) and early ARV initiation (0.27). Using the HEADS-ED, risks factors related to education (β =  -5.67, p = 0.02) and activities and peer support (β =  -9.1, p = 0.002) were significantly associated with poor neurocognitive performance. Neurocognitive deficits are prevalent among HIV positive children attending CCC-KNH. This extent of the deficits was not associated with low CD4 count, high viral load or early initiation in HIV care. However, poor school performance and problem with peers was associated with poor neurocognitive performance.

OBJECTIVE:The key objective of this paper is to provide a phenomenological account of the mental health challenges and experiences of adolescent new mothers. We explore the role of social support and the absence of empathy plays in depression among pregnant adolescents. The project also collected data on the adolescents' caregiving environment which includes the adolescents' mothers, their partners, the community, and health care workers, as well as feedback from staff nurses at the maternal and child health centers. The caregivers provide additional insight into some of the barriers to access of mental health services and pregnancy care, and the etiology of adolescents' distress. METHODS:The interviews were conducted in two health facilities of Kariobangi and Kangemi's maternal and child health (MCH) centers that cover a huge low-income and low-middle-income formal and informal settlements of Nairobi. A grounded theory approach provided a unique methodology to facilitate discussion around adolescent pregnancy and depression among the adolescents and their caregivers. Our interviews were cut across four samples with 36 participants in total. The sample 1 comprised of eight pregnant adolescents who screened positive for depression in Kariobangi, sample 2 were six caregivers from both sites, and sample 3 were 22 new adolescent mothers from both sites. After individual interviews, we carried out one focused group discussion (FDG) in order to understand the cross-cutting issues and to gather some consensus on key issues, and the sample 4 were 20 community health workers, health workers, and nurses from both sites. We had one FGD with all health facility-based workers to understand the cross-cutting issues. The interviews in sample 1 and 2 were individual interviews with pregnant and parenting adolescents, and their caregivers. All our adolescent participants interviewed in sample 1 were screened for depression. Individual interviews followed the FGD. FINDINGS/RESULTS:Pregnant and parenting adolescents faced several adversities such as social stigma, lack of emotional support, poor healthcare access, and stresses around new life adjustments. We highlighted a few useful coping mechanisms and strategies that these adolescents were thinking to reduce their stress. Primary social support for pregnant and parenting teens comes from the adolescent's mother. The external family and male partners provide negligible support in the rearing of the child. While the mother's reactions to the daughters' pregnancy were empathetic sometimes, absence of food and resources made the mother distant and constraint in lending support. For those adolescents who were living with partners, in their new mother role, they had to negotiate additional challenges such as solutions to everyday childcare responsibilities and other family duties. The health care workers and community health workers confirmed that adolescent mothers have multiple needs, but there is a lack of holistic approach of service, and that their own training and capacities were very limited. CONCLUSIONS:Our paper highlights several individual stakeholder-related and system-level barriers in the MCH primary care setting that affect delivery of psychosocial support for pregnant adolescent. We have identified these knowledge, practice, and institutional gaps that need addressing through careful community and health service staff engagement using implementation strategies that are effective in low-resource settings. Pregnant adolescents are highly vulnerable group and mental health services needs to be understood better.

BACKGROUND:There is a significant link between insecure attachment and the development of psychopathology in adolescence. We investigated the relationship between adolescent attachment styles and the development of emotional and behavioral problems among adolescents in Kenya. We also examined the modifying influence of socio-economic-status (SES). METHOD/METHODS:One hundred and thirty-seven adolescents who were attending two schools participated in the study. One school (low SES school) catered for children from predominantly low-income households, while the second school (middle SES school) catered for children from predominantly middle-income households. The data were collected using three instruments: researcher designed questionnaire to obtain socio-demographic information, the Strength and Difficulties Questionnaire (SDQ) that is designed to assess symptoms of disorder, and the Vulnerable Attachment Scale Questionnaire (VASQ) that is designed to measure attachment style. RESULTS:< 0.01), experiencing significantly higher levels of attachment insecurity than those with lower scores. CONCLUSIONS AND RECOMMENDATIONS/CONCLUSIONS:This study supports the notion that attachment insecurity increases the adolescents' susceptibility to develop psychological problems.

OBJECTIVES:To estimate the costs of providing extended-release injectable naltrexone (XR-NTX) and buprenorphine-naloxone (BUP-NX) following inpatient detoxification using data derived from a multisite randomized controlled trial at 8 US community-based treatment programs. STUDY DESIGN:Cost data were collected for 3 intervention phases: program start-up, inpatient detoxification, and up to 24 weeks of medication induction and management visits (post detoxification). Cost analyses were from the healthcare sector perspective (2015 US$); patient costs are also reported. METHODS:We conducted site visits, administered a cost survey to treatment programs, and analyzed study data on medication and services utilization. Nationally representative sources were used to estimate unit costs. Uncertainty was evaluated in sensitivity analyses. RESULTS:Mean start-up costs were $1071 per program for XR-NTX and $828 per program for BUP-NX. Mean costs per participant were $5416 for XR-NTX (57% detoxification, 37% medication, 3% provider, 3% patient) and $4148 for BUP-NX (64% detoxification, 12% medication, 10% provider, 14% patient). Total cost per participant ranged by site from $2979 to $8963 for XR-NTX and from $2521 to $6486 for BUP-NX. CONCLUSIONS:For treatment providers, offering XR-NTX and/or BUP-NX as part of existing detoxification treatment modalities generates modest costs in addition to the costs of detoxification, which vary substantially among the 8 sites. From the patient's perspective, the costs associated with medication management visits may be a barrier for some individuals considering these treatments.

OBJECTIVE:To quantify the average and total hospital delivery costs associated with severe maternal morbidity in excess of nonsevere maternal morbidity deliveries over a 5-year period in New York City adjusting for other sociodemographic and clinical factors. METHODS:We conducted a population-based cross-sectional study using linked birth certificates and hospital discharge data for New York City deliveries from 2008 to 2012. Severe maternal morbidity was defined using a published algorithm of International Classification of Diseases, 9 Revision, Clinical Modification disease and procedure codes. Hospital costs were estimated by converting hospital charges using factors specific to each year and hospital and to each diagnosis. These estimates approximate what it costs the hospital to provide services (excluding professional fees) and were used in all subsequent analyses. To estimate adjusted mean costs associated with severe maternal morbidity, we used multivariable regression models with a log link, gamma distribution, robust standard errors, and hospital fixed effects, controlling for age, race and ethnicity, neighborhood poverty, primary payer, number of deliveries, method of delivery, comorbidities, and year. We used the adjusted mean cost to determine the average and total hospital delivery costs associated with severe maternal morbidity in excess of nonsevere maternal morbidity deliveries from 2008 to 2012. RESULTS:Approximately 2.3% (n=13,502) of all New York City delivery hospitalizations were complicated by severe maternal morbidity. Compared with nonsevere maternal morbidity deliveries, these hospitalizations were clinically complicated, required more and intensive clinical services, and had a longer stay in the hospital. The average cost of delivery with severe maternal morbidity was $14,442 (95% CI $14,128-14,756), compared with $7,289 (95% CI $7,276-7,302) among deliveries without severe maternal morbidity. After adjusting for other factors, the difference between deliveries with and without severe maternal morbidity remained high ($6,126). Over 5 years, this difference resulted in approximately $83 million in total excess costs (13,502×$6,126). CONCLUSION:Severe maternal morbidity nearly doubled the cost of delivery above and beyond other drivers of cost, resulting in tens of millions of excess dollars spent in the health care system in New York City. These findings can be used to demonstrate the burden of severe maternal morbidity and evaluate the cost-effectiveness of interventions to improve maternal health.

Health care utilization patterns for gender minority Medicare beneficiaries (those who are transgender or gender nonbinary people) are largely unknown. We identified gender minority beneficiaries using a diagnosis-code algorithm and compared them to a 5 percent random sample of non-gender minority beneficiaries from the period 2009-14 in terms of mental health and chronic diseases, use of preventive and mental health care, hospitalizations, and emergency department (ED) visits. Gender minority beneficiaries experienced more disability and mental illness. When we adjusted for age and mental health, we found that they used more mental health care. And when we adjusted for age and chronic conditions, we found that they were more likely to be hospitalized and to visit the ED. There were several small but significant differences in preventive care use. Findings were similar for disabled and older cohorts. These findings underscore the need to capture gender identity in health data to better address this population's health needs.

OBJECTIVE:In October 2004, the Food and Drug Administration directed pharmaceutical companies to issue a black box warning about the potential link between the use of antidepressants and suicidal ideation among children. This study analyzed long-run trends in antidepressant use among children before and after the black box warning for those with and without severe psychological impairment. METHODS:The analysis used data from the Medical Expenditure Panel Survey for children ages five to 17, covering years 2000-2011 (N=75,819). The study used multivariate probit models to compare the changes in the rate of any antidepressant use in the early (2004-2007) and late (2008-2011) postwarning years with the rate in the prewarning years (2002-2003). Recycled predictions methods were used to estimate yearly predicted probabilities of use. RESULTS:After adjustment for all covariates, there was a .5% statistically significant decline in the probability of using any antidepressants during the early postwarning years (2004-2007) compared with prewarning years. In the long run (2008-2011), however, there was no statistically significant difference. Five years after the black box warning, the adjusted rates of use increased to their prewarning levels (2.29% in 2003 and 2.26% in 2009). The initial impact of the warning differed between the severe and nonsevere populations, with a significant effect on those with nonsevere psychological impairment. CONCLUSIONS:The return to the rates before the black box warning raises concern that the impact of the warning may have dissipated over time. More frequent updates of the warning might be necessary.