The impact of care environment on the mental health of orphaned, separated and street-connected children and adolescents in western Kenya: A prospective cohort analysis

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Study Justification:
The study aimed to investigate the impact of care environment on the mental health of orphaned, separated, and street-connected children and adolescents in western Kenya. This is an important area of research because the effect of care environment on mental health in this population is not well understood in sub-Saharan Africa. By comparing the risk of mental health disorders among children living in different care environments, the study provides valuable insights into the potential benefits and challenges of different care settings.
Study Highlights:
The study followed a prospective cohort of 1,931 participants from 2009 to 2019. The participants were divided into three groups: those living in Charitable Children’s Institutions (CCIs), family-based care (FBC), and street-connected children and youth (SCY). The analysis found that children in CCIs were significantly less likely to be diagnosed with post-traumatic stress disorder (PTSD), depression, anxiety, and suicidality compared to those in FBC. On the other hand, SCY were significantly more likely to be diagnosed with these mental health disorders compared to those in FBC.
Study Recommendations:
Based on the findings, the study recommends that efforts should be made to improve the care environment for orphaned, separated, and street-connected children and adolescents. Specifically, there is a need to enhance the quality of family-based care and provide support for street-connected children and youth. Additionally, interventions should focus on addressing the mental health needs of these vulnerable populations, including the prevention and treatment of PTSD, depression, anxiety, and suicidality.
Key Role Players:
To address the recommendations, key role players may include:
1. Government agencies responsible for child welfare and protection
2. Non-governmental organizations (NGOs) working in the field of child care and mental health
3. Charitable Children’s Institutions (CCIs) and family-based care providers
4. Community leaders and traditional authorities
5. Mental health professionals, including psychologists and psychiatrists
6. Social workers and counselors
7. Education institutions and teachers
8. Health care providers, including primary care clinics and hospitals
Cost Items for Planning Recommendations:
While the actual cost will depend on the specific interventions and programs implemented, some budget items to consider in planning the recommendations may include:
1. Training and capacity building for caregivers and staff working with orphaned, separated, and street-connected children and adolescents
2. Mental health services, including screening, assessment, and treatment for PTSD, depression, anxiety, and suicidality
3. Outreach and community engagement activities to raise awareness and reduce stigma surrounding mental health
4. Support for education and vocational training programs for vulnerable children and youth
5. Provision of basic material needs, such as clothing, shoes, and blankets, for children in family-based care
6. Development and implementation of policies and guidelines to improve the quality of care in Charitable Children’s Institutions (CCIs)
7. Research and monitoring to evaluate the effectiveness of interventions and inform evidence-based practices
Please note that these cost items are provided as examples and may vary depending on the specific context and needs of the target population.

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong, but there are some areas for improvement. The study design is prospective and includes a large sample size, which enhances the validity of the findings. The analysis includes adjusted regression models, which control for potential confounding variables. The results show significant associations between care environment and mental health outcomes. However, the abstract could be improved by providing more specific details about the methods used, such as the specific assessments and scales used for measuring mental health outcomes. Additionally, it would be helpful to include information about the statistical significance of the associations and the magnitude of the effect sizes. Finally, the abstract could benefit from a clearer statement of the implications and potential actions that can be taken based on the findings.

Introduction The effect of care environment on orphaned and separated children and adolescents’ (OSCA) mental health is not well characterised in sub-Saharan Africa. We compared the risk of incident post-traumatic stress disorder (PTSD), depression, anxiety and suicidality among OSCA living in Charitable Children’s Institutions (CCIs), family-based care (FBC) and street-connected children and youth (SCY). Methods This prospective cohort followed up OSCA from 300 randomly selected households (FBC), 19 CCIs and 100 SCY in western Kenya from 2009 to 2019. Annual data were collected through standardised assessments. We fit survival regression models to investigate the association between care environment and mental health diagnoses. Results The analysis included 1931 participants: 1069 in FBC, 783 in CCIs and 79 SCY. At baseline, 1004 participants (52%) were male with a mean age (SD) of 13 years (2.37); 54% were double orphans. In adjusted analysis (adjusted HR, AHR), OSCA in CCIs were significantly less likely to be diagnosed with PTSD (AHR 0.69, 95% CI 0.49 to 0.97), depression (AHR 0.48 95% CI 0.24 to 0.97), anxiety (AHR 0.56, 95% CI 0.45 to 0.68) and suicidality (AHR 0.73, 95% CI 0.56 to 0.95) compared with those in FBC. SCY were significantly more likely to be diagnosed with PTSD (AHR 4.52, 95% CI 4.10 to 4.97), depression (AHR 4.72, 95% CI 3.12 to 7.15), anxiety (AHR 4.71, 95% CI 1.56 to 14.26) and suicidality (AHR 3.10, 95% CI 2.14 to 4.48) compared with those in FBC. Conclusion OSCA living in CCIs in this setting were significantly less likely to have incident mental illness, while SCY were significantly more, compared with OSCA in FBC.

The Orphaned and Separated Children’s Assessments Related to their (OSCAR’s) Health and Well-Being Project is a two-phase longitudinal cohort investigating the effects of care environment on the physical and psychosocial well-being of OSCA in Uasin Gishu (UG) County, Kenya. Phase 1 ran from 2010 to 2015 and Phase 2 ran from 2016 to 2019. The study enrolled participants aged 18 years or less from May 2010 to April 2013. The OSCAR cohort comprises participants from communities within eight administrative locations in UG County and includes 300 randomly selected households caring for OSCA (FBC), 19 Charitable Children’s Institutions (CCIs) (institutional care) (of 21 in the county at the time of study start-up) and a convenience sample of 100 street-connected children and youth (SCY) in ‘self-care’ on the streets. Children were eligible to participate in the study if they were resident of the care environment at the time, irrespective of orphan status (non-orphaned children were included in order to reduce the risk of stigma against orphans and to provide a small, nested comparator group of non-orphaned children in these same environments), and irrespective of the cause of orphanhood (ie, HIV and all other causes). The present analysis included participants with at least one follow-up visit with a psychosocial assessment. In-depth details about the OSCAR cohort’s study design, setting and recruitment have been previously reported.24 This study conforms to the principles embodied in the Declaration of Helsinki. Written informed consent for participation was provided by the head of household, Director of the CCI, or in the case of SCY, by the District (now County) Children’s Officer. Individual written informed assent was provided by each child aged 7 years and above. Fingerprints were used for both children and guardians who were unable to sign or write their name. This study used community-based, participatory processes to inform the research questions, hypotheses and methods, detailed elsewhere.24 To summarise briefly, the Children’s Officers in the region and representatives from CCIs were initially consulted prior to the funding application. They were requested to provide input as to whether such a study would be important from their perspective, and what their priority questions and concerns were. In addition, traditional community assemblies were held in some of the target communities to identify community concerns and priorities with respect to the care of orphaned and vulnerable children. These assemblies were also held following the initiation of the study to maintain regular contact with the community and disseminate findings. We formed an Advisory Board early on, consisting of representatives from communities, CCIs and Children’s Officers, and this board met regularly throughout the life of the study. Our study disseminated findings through the monthly Uasin Gishu Children’s Services Forum, through additional traditional community assemblies and through the study website (https://www.oscarcohort.comhttps://www.oscarcohort.com). Data collection processes were conducted in situ at CCIs and at the OSCAR Project clinic for participants from households and SCY. Annually (semiannually for SCY), participants completed a standardised clinical encounter and those ≥10 years of age also completed a psychosocial encounter. The clinical encounter was an enhanced well-child ‘check-up’ that included a complete physical history and review of health symptoms. The psychosocial encounter measured education and employment, material well-being, behaviours and risks, peer and family relationships, and mental health. The psychosocial assessment was self-administered for those who could read and write, or psychologist-administered for those that could not adequately read or write. In OSCAR Phase 2, two versions of the psychosocial encounter were employed: one for adolescents aged 10–17 years and one for young adults (≥18 years of age) using age-appropriate validated scales and tools to assess PTEs and mental health outcomes. A clinical psychologist was always available during the assessments to assist in case of questions, lack of understanding or distress. Follow-up of cases requiring individual counselling or social work took place on a case-by-case basis as needed, by study staff. The primary exposure of interest was care environment (institutional, family-based or street-based), determined by a participant’s living circumstances at enrolment.21 Separated children were defined as those whose biological mother or father was potentially alive, but functionally not part of the child’s life. Sociodemographic characteristics, ascertained through the clinical encounter, included age, sex, orphan/separated status (maternal, paternal, both or neither, in the case of non-orphaned children living in these environments), HIV status (positive, negative, unknown) and time living with caregiver at baseline (5 years, all the child’s life). PTEs (physical abuse, sexual abuse, emotional abuse and bullying) were ascertained through the psychosocial encounters. PTEs for those less than 18 years of age were ascertained using the Child Abuse Screening Tool for Children at Home (ICAST-CH) which measures violence against children.25 The OSCAR study used 11 questions from ICAST-CH based on extensive consultations with Kenyan psychiatrists, psychologists and paediatricians. There were four questions specific to the emotional domain, three to the physical abuse domain and four questions specific to sexual abuse domain. For all questions, responses took on four levels and included ‘Never’, ‘Sometimes’, ‘Many times’ and ‘Not in the past 6 months, but this has happened’. For participants age ≥18, a history of emotional, sexual and physical abuse was assessed using the Childhood Trauma Questionnaire (CTQ) through a five-item subscale: emotional, sexual, and physical abuse, emotional, and physical neglect, as well as three-item subscale to screen for false-negative trauma reports.26–28 For all participants, bullying was measured using the eight items from Strengths and Difficulties Questionnaire,29 30 one item from the Social and Health Assessment Peer Victimisation Scale,31 and one question regarding bullying due to orphan status developed by the research team. If participants answered yes to any of these items, a participant was categorised as having experienced bullying. For this analysis, we dichotomised (yes/no) the PTE variables to capture any history of physical abuse, sexual abuse, emotional abuse or bullying at baseline and at each follow-up. Hypothesised factors that may mediate or confound the relationship between care environment and mental health outcomes included: social support (continuous score measured using the 12-item Multidimensional Scale of Perceived Social Support),32 33 importance of religion in a participant’s life, having basic material possessions (shoes, blanket and at least two pairs of non-school clothes),34 participation in sports and spending time in nature. These factors were measured only on the psychosocial encounter administered to participants 10–17 years of age in OSCAR Phase 2, with the exception of ‘importance of religion’ that was measured in Phase 1 and Phase 2. They assessed these issues currently and are not able to establish temporality with regard to which came first, care environment, outcome or the third factor. We tested whether there were major differences between these factors and outcomes of interest, and differences between these factors and care environment, and concluded that it would be most appropriate to treat them as potential confounding variables. Depression for participants aged 10–17 years was measured with the Child Depression Inventory Short-Form (CDI-SF) with questions specific to the past 2 weeks.35 36 In order to approximate a Diagnostic and Statistical Manual (DSM)-IV Test Revision (TR) diagnosis of depression, scores were summed and a cut-off point of 8 was used to determine probable presence of depression in childhood.37 Depression for participants ≥18 years of age was measured using the Patient Health Questionnaire (PHQ)-9 (Depression) on a four-point Likert scale. Presence of probable depression in those ≥18 years was diagnosed if a participant scored at least 2 (more than half the day) on two or more of the eight items, of which one had to be either item 1 or 2, consistent with the DSM-IV TR criteria.37–39 Adolescent post-traumatic stress was measured using Amaya-Jackson’s ‘Child PTSD Checklist’, a 28-item scale derived from the DSM-IV criteria, which uses a four-point Likert severity scale.40 41 Participants were asked to imagine their worst trauma, and a diagnosis of probable PTSD in adolescents occurred when participants reported currently meeting three diagnostic criteria as indicated by the DSM-IV TR: re-experiencing of the event (a score of 2 or more on any of items 1–5, 10, 11, 14), avoidance symptoms (a score of 2 or more on any three of items 7–9, 12, 13, 22, 25, 28) and arousal symptoms (a score of 2 or more on any two of items 15–21).37 Post-traumatic stress in young adults was measured using the Post-Traumatic Diagnostic Scale (PDS). A diagnosis of probable PTSD in young adults occurred when participants met the same three diagnostic criteria: re-experiencing of the event (a score of 1 or more on items 1–5), avoidance symptoms (a score of at least 3 or more on items 6–12) and arousal symptoms (a score of at least 2 of items 13–17).42 43 Suicidality was measured in adolescents using one question from the CDI-SF scale to ascertain whether they had any suicidal ideation or attempt within the previous 2 weeks. The variable was categorised as no suicidality, suicidal ideation, and suicidal intent, and dichotomised as suicidality (yes/no) in this analysis by combining ideation and intent. Adult suicidality was measured using the PHQ-9 (Suicidality).44–46 A diagnosis of suicidality for adults occurred when a participant scored 1 or above. Adolescent anxiety was measured using the 28-item Revised Children’s Manifest Anxiety Scale (R-CMAS).47 Participants were asked about current thoughts and feelings. A cut-off of 19 was used determine presence of probable anxiety based on the participants score on the R-CMAS. We report mean values and SD or frequencies and percentages for continuous and categorical characteristics, respectively, overall and by care environment. We conducted survival analysis to assess the impact of care environment on four probable diagnostic events: (1) PTSD, (2) depression, (3) anxiety and (4) suicidality. We implemented approaches for recurrent events to account for the fact that individuals may have experienced the events of interest more than once during study follow-up. Time zero was either enrolment into the study or the first visit after the child turned 10 years. For each diagnostic outcome, we present overall survival by care environment using Kaplan-Meier estimates of the cumulative incidence. We use the Prentice-Williams-Peterson (PWP) conditional survival model for recurrent events to evaluate unadjusted and adjusted effects of care environment on each of the four diagnostic outcomes. Adjustment variables were for age, sex, orphan status, length of time in care environment, PTSD/depression/anxiety/suicidality at baseline, emotional/physical/sexual abuse at baseline and during follow-up, bullied at baseline and during follow-up, and clustering by household/institution. The PWP model is a Cox-extended survival model accounting for clustering due to within-subject correlation and stratifying on the order in which the recurrent events occurred. Robust SEs for the model estimates were calculated to also adjust for clustering by care environment. Results from models are presented as HRs with 95% CIs.48 49 We also conducted a subanalysis, restricted to participants aged 10–18 years in CCIs and FBC (data were not collected on SCY) using data from OSCAR Phase 2 to test whether the relationship between care environment and the outcomes were confounded by social support, basic material possessions, importance of religion and time in nature. There was no imputation for missing data. All analyses were conducted using RStudio V.1.3.1056. The funder of the study had no role in study design, data collection, data analysis, data interpretation or writing of the report. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.

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The study titled “The impact of care environment on the mental health of orphaned, separated and street-connected children and adolescents in western Kenya: A prospective cohort analysis” investigates the effects of different care environments on the mental health of orphaned and separated children and adolescents (OSCA) in western Kenya. The study compares the risk of incident post-traumatic stress disorder (PTSD), depression, anxiety, and suicidality among OSCA living in Charitable Children’s Institutions (CCIs), family-based care (FBC), and street-connected children and youth (SCY).

The study found that OSCA in CCIs were significantly less likely to be diagnosed with PTSD, depression, anxiety, and suicidality compared to those in FBC. On the other hand, SCY were significantly more likely to be diagnosed with these mental health conditions compared to those in FBC.

Based on this study, potential innovations to improve access to maternal health could include:

1. Implementing mental health support programs within CCIs: Since OSCA in CCIs had lower rates of mental health conditions, providing mental health support services within CCIs could help improve the mental well-being of OSCA and potentially extend these services to their mothers.

2. Strengthening family-based care programs: Given that OSCA in FBC had better mental health outcomes compared to SCY, investing in and strengthening family-based care programs could be an effective way to improve access to maternal health. These programs could provide support and resources to families caring for OSCA, including maternal health services.

3. Developing targeted interventions for street-connected children and youth: Since SCY had higher rates of mental health conditions, developing targeted interventions specifically tailored to the needs of street-connected children and youth could help improve their access to maternal health. These interventions could address the unique challenges faced by SCY and provide them with necessary support and resources.

4. Integrating mental health services into maternal health programs: To improve access to maternal health for OSCA, integrating mental health services into existing maternal health programs could be beneficial. This would ensure that mental health needs are addressed alongside physical health needs, providing a comprehensive approach to maternal health care.

It is important to note that these recommendations are based on the findings of the study and should be further explored and evaluated for their effectiveness in improving access to maternal health for OSCA.
AI Innovations Description
The study titled “The impact of care environment on the mental health of orphaned, separated and street-connected children and adolescents in western Kenya: A prospective cohort analysis” examines the relationship between care environment and mental health outcomes among orphaned and separated children and adolescents (OSCA) in western Kenya. The study compares the risk of incident post-traumatic stress disorder (PTSD), depression, anxiety, and suicidality among OSCA living in Charitable Children’s Institutions (CCIs), family-based care (FBC), and street-connected children and youth (SCY).

The findings of the study indicate that OSCA living in CCIs were significantly less likely to be diagnosed with PTSD, depression, anxiety, and suicidality compared to those in FBC. On the other hand, SCY were significantly more likely to be diagnosed with these mental health conditions compared to those in FBC.

Based on these findings, a recommendation to improve access to maternal health could be to develop innovative interventions that focus on improving the care environment for OSCA. This could include strengthening and expanding the availability of CCIs that provide a supportive and nurturing environment for OSCA. Additionally, efforts should be made to provide resources and support for families who are providing family-based care for OSCA. This could involve providing training and education for caregivers, as well as ensuring access to essential services and support networks.

Furthermore, interventions should be developed to address the specific mental health needs of SCY. This could involve outreach programs that provide mental health support and counseling for SCY, as well as initiatives to address the underlying factors that contribute to their increased risk of mental health issues, such as poverty, homelessness, and social isolation.

Overall, the recommendation is to prioritize and invest in interventions that improve the care environment for OSCA, with a focus on providing support and resources for both CCIs and family-based care settings. Additionally, targeted interventions should be developed to address the mental health needs of SCY. By improving the care environment for OSCA, access to maternal health can be enhanced, leading to better overall health outcomes for this vulnerable population.
AI Innovations Methodology
The study you provided is focused on the impact of care environment on the mental health of orphaned, separated, and street-connected children and adolescents in western Kenya. It compares the risk of incident post-traumatic stress disorder (PTSD), depression, anxiety, and suicidality among children living in different care environments, including Charitable Children’s Institutions (CCIs), family-based care (FBC), and street-connected children and youth (SCY).

To improve access to maternal health, here are some potential recommendations:

1. Strengthening healthcare infrastructure: Investing in healthcare facilities, equipment, and trained healthcare professionals in areas with limited access to maternal health services can improve access and quality of care.

2. Mobile health clinics: Implementing mobile health clinics that travel to remote areas can provide essential maternal health services, including prenatal care, postnatal care, and family planning, to underserved populations.

3. Telemedicine: Using telecommunication technologies, such as video consultations and remote monitoring, can enable pregnant women to access healthcare services and receive medical advice from healthcare professionals without the need for physical travel.

4. Community health workers: Training and deploying community health workers who are knowledgeable about maternal health can help bridge the gap between healthcare facilities and communities, providing education, support, and basic healthcare services.

5. Maternal health awareness campaigns: Conducting awareness campaigns to educate communities about the importance of maternal health, including prenatal care, safe delivery practices, and postnatal care, can help increase awareness and encourage women to seek appropriate care.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the target population: Identify the specific population or geographic area that will be the focus of the simulation.

2. Collect baseline data: Gather relevant data on the current state of maternal health access in the target population, including factors such as healthcare infrastructure, availability of services, and utilization rates.

3. Define indicators: Determine the key indicators that will be used to measure the impact of the recommendations, such as the number of women accessing prenatal care, the rate of skilled attendance at birth, or the availability of emergency obstetric care.

4. Develop a simulation model: Create a mathematical or computational model that simulates the impact of the recommendations on the defined indicators. The model should take into account factors such as population size, healthcare resources, and the effectiveness of the recommended interventions.

5. Input data and run simulations: Input the baseline data into the simulation model and run multiple simulations to assess the potential impact of the recommendations. Varying parameters, such as the scale of intervention implementation or the coverage of mobile health clinics, can help explore different scenarios.

6. Analyze results: Analyze the simulation results to determine the potential impact of the recommendations on improving access to maternal health. Assess the changes in the defined indicators and compare them to the baseline data.

7. Validate and refine the model: Validate the simulation model by comparing the simulated results with real-world data, if available. Refine the model based on feedback and additional data to improve its accuracy and reliability.

8. Communicate findings: Present the findings of the simulation study in a clear and concise manner, highlighting the potential benefits of the recommendations for improving access to maternal health. This information can be used to inform policy decisions and guide the implementation of interventions.

It’s important to note that the specific methodology for simulating the impact of recommendations may vary depending on the available data, resources, and context of the study.

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