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Depressive Symptoms in Youth Heads of Household in Rwanda Correlates and Implications for Intervention

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Depressive Symptoms in Youth Heads of Household in Rwanda Correlates and Implications for Intervention ARTICLE Depressive Symptoms in Youth Heads of Household in Rwanda Correlates and Implications for Intervention Neil W. Boris, MD; Lisanne A. Brown, PhD; Tonya R. Thurman, PhD; Janet C. Rice, PhD; Leslie M. Snider, MD, MPH; Joseph Ntaganira, PhD; Laetitia N. Nyirazinyoye, MPH Objective: To examine the level of depressive symp- depressive symptoms that exceeded the clinical cutoff were toms and their predictors in youth from one region of associated with having 3 basic household assets or fewer, Rwanda who function as heads of household (ie, those such as a mattress and a spare set of clothes (odds ratio responsible for caring for other children) and care for [OR], 1.69; 95% confidence interval [CI], 1.06-2.70), eat- younger orphans. ing less than 1 meal per day (OR, 1.68; 95% CI, 1.09- 2.60), reporting fair health (OR, 1.32; 95% CI, 0.76- Design: Cross-sectional survey 2.29) or poor health (OR, 2.33; 95% CI, 1.17-4.64), endorsing high levels of grief (OR, 2.67; 95% CI, 1.73- Setting: Four adjoining districts in Gigonkoro, an im- 4.13), having at least 1 parent die in the genocide as op- poverished rural province in southwestern Rwanda. posed to all other causes of parental death (OR, 1.83; 95% CI, 1.10-3.04), and not having a close friend (OR, 1.91; Participants: Trained interviewers met with the eldest 95% CI, 1.17-3.12). There was an interaction between member of each household (n=539) in which a youth marginalization from the community and alcohol use; 24 years old or younger was caring for 1 child or more. youth who were highly marginalized and did not drink alcohol were more than 3 times more likely to report Main Exposure: Serving as a youth head of house- symptoms of depression (OR, 3.07; 95% CI, 1.73-5.42). hold. When models were constructed by grouping theoreti- cally related variables into blocks and controlling for other Main Outcome Measures: Rates and severity of de- blocks, the emotional status block of variables (grief and pressive symptoms using the Center for Epidemiologic marginalization) accounted for the most variance in de- Studies Depression scale; measures of grief, adult sup- pressive symptoms. port, social marginalization, and sociodemographic fac- tors using scales developed for this study. Conclusions: Orphaned youth who head households in rural Rwanda face many challenges and report high rates Results: Of the 539 youth heads of household, 77% were of depressive symptoms. Interventions designed to go be- subsistence farmers and only 7% had attended school for yond improving food security and increasing house- 6 years or more. Almost half (44%) reported eating only hold assets may be needed to reduce social isolation of 1 meal a day in the last week, and 80% rated their health youth heads of household. The effect of head-of- as fair or poor. The mean score on the Center for Epi- household depressive symptoms on other children liv- demiologic Studies Depression scale was 24.4, exceed- ing in youth-headed households is unknown. ing the most conservative published cutoff score for ado- lescents. Multivariate analysis revealed that reports of Arch Pediatr Adolesc Med. 2008;162(9):836-843 Author Affiliations: Department of Psychiatry and N 2005, IT WAS ESTIMATED THAT overwhelmed, and many orphans either Neurology, Tulane University 290 000 children younger than 18 head households or live on the streets.4-7 School of Medicine (Dr Boris), years in Rwanda were orphans, The demographic makeup of such house- and Departments of one of the highest numbers holds and the psychological status of or- International Health and worldwide of children who have phans caring for other children are not well Development (Drs Brown, lost both parents.1 The combined effects characterized.8 Furthermore, the num- Thurman, and Snider), and I of the 1994 genocide, in which approxi- ber of youth-headed households (de- Biostatistics (Dr Rice), Tulane mately 10% of the population was killed, fined for this study as households headed University School of Public Health and Tropical Medicine, and the human immunodeficiency virus by unmarried individuals younger than 24 New Orleans, Louisiana; and (HIV) epidemic make Rwanda unique. years) will increase with time in areas af- 9-11 Rwanda School of Public Health Most African orphans have been ab- fected by HIV/AIDS. (Dr Ntaganira and sorbed into informal fostering systems.2,3 Depressive symptoms in heads of Ms Nyirazinyoye), Kigali. Such systems, however, are increasingly household are of particular concern be- (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 162 (NO. 9), SEP 2008 WWW.ARCHPEDIATRICS.COM 836 ©2008 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 cause of the association between poor developmental out- propriate instruments.20 Translation and backtranslation pre- comes for children and caregiver depression.12 Across cul- ceded review of survey items by a technical committee of youth tures, depression affects interactive patterns between the and professionals who attended to the context, cultural, and caregiver and the child, disturbing the development of linguistic relevance of the questions. The survey was then pre- children’s emotion regulation.13-15 Defining and measur- tested at a local street-children’s center and then piloted with 79 youth heads of households living adjacent to the survey area. ing depression across cultures, however, requires con- The Center for Epidemiologic Studies Depression (CES-D)21 sideration of how culture and language might affect symp- scale was incorporated into the survey with no substantive changes. 16 tom expression. Local terms equivalent to the CES-D 4-point scale were devel- Studies suggest that valid and reliable surveys for de- oped. The CES-D measures affective, somatic, and cognitive com- pression can be constructed using local language, though ponents of depression and has been widely used as a screening an extensive process of piloting, adapting, and translating tool, including in adolescents and high-risk groups.22,23 The Cron- western surveys for use in nonwestern settings, is neces- bach ␣ for the CES-D in this study was 0.86. sary.17-19 A primary objective of the present study was to Recent findings suggest that the distribution of CES-D scores is different for older adults than for adolescents and young examine the level of depressive symptoms and their pre- 24 dictors in youth from one region of Rwanda who function adults. For this analysis, we used the scale as continuous and also used a cutoff score of 24 to identify those youth with mod- as heads of household and care for younger orphans. erate to severe symptoms.25 The cutoff score of 24 improves case detection in this age group,26 although, to our knowl- METHODS edge, there are no published studies of youth from Rwanda. We developed several scales using our focus group and pi- loting to inform each scale. Principal factor analysis ensured SURVEY SITES AND SAMPLING PROCEDURES that each scale was unidimensional. Respondents indicated their level of agreement from “strongly agree” to “strongly dis- In 2004, a survey was conducted in the former Gigonkoro prov- agree,” with “don’t know/uncertain” scored in the middle. We ince, a rural province in southwestern Rwanda, selected be- dichotomized each scale at the median to facilitate the estima- cause it is particularly impoverished. Before the survey, insti- tion of odds ratios. tutional review board approval from the health sciences panel An adult support scale was formed from 4 items (Cron- at Tulane University and from a national review panel in Rwanda bach ␣, .85). Items included whether youth had an adult in their was received. Youth-headed households are common in south- life whom they could trust to give them advice and guidance western Rwanda, and in 2001, an international nongovern- or an adult who comforts them. mental organization had begun to target the more than 700 A marginalization scale was formed to assess the degree to households in this region that community leaders identified as which youth felt isolated from the surrounding community being headed by youth; the survey was designed to guide pro- (Cronbach ␣, .77).27 Respondents indicated their level of agree- gram expansion. To be included in this study, youth heads of ment with 6 items including whether they thought that no one household had to have little or no contact with their parents cared about them or that people in the community would rather (ie, be functioning as orphans). hurt than help them. During the course of the survey field work, 41 of the homes Focus group data confirmed that ongoing grief about pa- originally identified were found not classifiable as youth- rental loss was important. A 7-item grief scale (Cronbach ␣, headed households (ie, parent had returned, youth had been .66) was created for this study, including questions such as adopted, or other adult caregiver was present) and, thus, were whether youth often thought about their lost loved one(s) and ineligible; 115 of the households could not be located; most whether the loss of their loved one(s) had led to residual an- youth heads of household were reported to have moved for work, ger, loss of faith in God, or loss of confidence in others. Ͻ marriage, or boarding school. Only 2 eligible respondents ( 1%) We created 2 binary item scales. The first was an assets scale refused to participate. The final sample (N=539) included those that indicates whether the head of household owns a blanket aged 24 years or younger who were caring for 1 or more other and/or a spare set of clothes or shoes and whether the house- household members.
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