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This paper investigates the farmers’ perception on soil fertility replenishment technologies in the North Rift Region of Kenya. A survey was conducted in Trans Nzoia and Uasin Gishu counties of the North Rift Region of Kenya. A total of 108 respondents were interviewed. A two stage random sampling technique was employed in the study. In the first stage, farmer groups growing maize as the main crop were selected. The second stage involved the selection of farmers who were practicing cereal banking for ease of marketing of their produce. A survey and field demonstration plots were adopted. On-farm demonstration were carried out and used to ascertain the farmers’ perception towards the technologies. A structured questionnaire was administered to them to elicit information on their perception on soil fertility replenishment technologies (SFRT). Descriptive statistics and the multiple regression analysis was done using a Statistical Package for Social Sciences (SPSS). The results revealed that farmers perceived that technologies could be used to address the declining soil fertility. The inputs were affordable available, the Ministry of Agriculture, Livestock and Fisheries (MOALF) was effective in disseminating the technologies and that the technologies could work on any farm at mean score of 3.5, 4.1, 4.0, 3.4 and 4.6 out of 5.0 respectively. Farmers in Trans Nzoia county identified lack of capital (70.4%) compared to Uasin Gishu (39.9%) as the greatest challenge in the adoption of SFRT technologies. Credit schemes that offer loans with low interest rates should be established to enable farmers have access to credit.

AimsIn low- and middle-income countries (LMIC) in general and sub-Sahara African (SSA) countries in particular, there is both a large treatment gap for mental disorders and a relative paucity of empirical evidence about how to fill this gap. This is more so for severe mental disorders, such as psychosis, which impose an additional vulnerability for human rights abuse on its sufferers. A major factor for the lack of evidence is the few numbers of active mental health (MH) researchers on the continent and the distance between the little evidence generated and the policy-making process.MethodsThe Partnership for Mental Health Development in Africa (PaM-D) aimed to bring together diverse MH stakeholders in SSA, working collaboratively with colleagues from the global north, to create an infrastructure to develop MH research capacity in SSA, advance global MH science by conducting innovative public health-relevant MH research in the region and work to link research to policy development. Participating SSA countries were Ghana, Kenya, Liberia, Nigeria and South Africa. The research component of PaM-D focused on the development and assessment of a collaborative shared care (CSC) program between traditional and faith healers (T&FHs) and biomedical providers for the treatment of psychotic disorders, as a way of improving the outcome of persons suffering from these conditions. The capacity building component aimed to develop research capacity and appreciation of the value of research in a broad range of stakeholders through bespoke workshops and fellowships targeting specific skill-sets as well as mentoring for early career researchers.ResultsIn the research component of PaM-D, a series of formative studies were implemented to inform the development of an intervention package consisting of the essential features of a CSC for psychosis implemented by primary care providers and T&FHs. A cluster randomised controlled trial was next designed to test the effectiveness of this package on the outcome of psychosis. In the capacity-building component, 35 early and mid-career researchers participated in the training workshops and several established mentor-mentee relationships with senior PaM-D members. At the end of the funding period, 60 papers have been published and 21 successful grant applications made.ConclusionThe success of PaM-D in energising young researchers and implementing a cutting-edge research program attests to the importance of partnership among researchers in the global south working with those from the north in developing MH research and service in LMIC.

Background In low- and middle-income countries, the paucity of conventional health services means that many people with mental health problems rely on traditional health practitioners (THPs). This paper examines the possibility of forging partnerships at the Primary Health Care (PHC) level in two geopolitical regions of Ghana, to maximize the benefits to both health systems. Methods The study was a qualitative cross-sectional survey. Eight (8) focus group discussions (FGDs) were conducted between February and April 2014. The views of THPs, PHC providers, service users (i.e. patients) and their caregivers, on the perceived benefits, barriers and facilitators of forging partnerships were examined. A thematic framework approach was employed for analysis. Results The study revealed that underlying the widespread approval of forging partnerships, there were mutual undertones of suspicion. While PHC providers were mainly concerned that THPs may incur harms to service users (e.g., through delays in care pathways and human rights abuses), service users and their caregivers highlighted the failure of conventional medical care to meet their healthcare needs. There are practical challenges to these collaborations, including the lack of options to adequately deal with human rights issues such as some patients being chained and exposed to the vagaries of the weather at THPs. There is also the issue of the frequent shortage of psychotropic medication at PHCs. Conclusion Addressing these barriers could enhance partnerships. There is also a need to educate all providers, which should include sessions clarifying the potential value of such partnerships.

Background Addressing adolescent pregnancies associated health burden demands new ways of organizing maternal and child mental health services to meet multiple needs of this group. There is a need to strengthen integration of sustainable evidence-based mental health interventions in primary health care settings for pregnant adolescents. The proposed study is guided by implementation science frameworks with key objective of implementing a pilot trial testing a full IPT-G version along with IPT-G mini version under the mhGAP/IPT-G service framework and to study feasibility of the integrated mhGAP/IPT-G adolescent peripartum depression care delivery model and estimate if a low cost and compressed version of IPT-G intervention would result in similar size of effect on mental health and family functioning as the Full IPT-G. There are two sub- studies embedded which are: 1) To identify multi-level system implementation barriers and strategies guided by the Consolidated Framework for Implementation Research (CFIR) to enhance perinatal mhGAP-depression care and evidence-based intervention integration (i.e., group interpersonal psychotherapy; IPT-G) for pregnant adolescents in primary care contexts; 2) To use findings from aim 1 and observational data from Maternal and Child Health (MCH) clinics that run within primary health care facilities to develop a mental health implementation workflow plan that has buy-in from key stakeholders, as well as to develop a modified protocol and implementation training manual for building health facility staff’s capacity in implementing the integrated mhGAP/IPT-G depression care. Methods For the primary objective of studying feasibility of the integrated mhGAP/IPT-G depression care in MCH service context for adolescent perinatal depression, we will recruit 90 pregnant adolescents to a three-arm pilot intervention (unmasked) trial study (IPT-G Full, IPT-G Mini, and wait-list control in the context of mhGAP care). Pregnant adolescents ages 13–18, in their 1st-2nd trimester with a depression score of 13 and above on EPDS would be recruited. Proctor’s implementation evaluation model will be used. Feasibility and acceptability of the intervention implementation and size of effects on mental health and family functioning will be estimated using mixed method data collection from caregivers of adolescents, adolescents, and health care providers. In the two sub-studies, stakeholders representing diverse perspectives will be recruited and focus group discussions data will be gathered. For aim 2, to build capacity for mhGAP-approach of adolescent depression care and research, the implementation-capacity training manual will be applied to train 20 providers, 12 IPT-G implementers/health workers and 16 Kenyan researchers. Acceptability and appropriateness of the training approach will be assessed. Additional feedback related to co-located service delivery model, task-shifting and task-sharing approach of IPT-G delivery will be gathered for further manual improvement. Discussion This intervention and service design are in line with policy priority of Government of Kenya, Kenya Vision 2030, World Health Organization, and UN Sustainable Development Goals that focus on improving capacity of mental health service systems to reduce maternal, child, adolescent health and mental health disparities in LMICs. Successfully carrying out this study in Kenya will provide an evidence-based intervention service development and implementation model for adolescents in other Sub-Saharan African (SSA) countries. The study is funded by FIC/NIH under K43 grant.

Background: Cognitive interviewing is a well-recognized methodology to identify clinical and commonsensical relevance of mental health questionnaire items by our research participants. Depression is amongst the most common condition impacting pregnant and parenting adolescents in sub-Saharan Africa (SSA). In Kenya, studies have reported depression prevalence estimates of 12-50% in peripartum adolescents. While young people prefer using English, there has not been enough data to point to how well they respond to Kiswahili translations of the commonly used tools.Method: Thirty-two participants between ages 14-18 years were approached and through informed consent for them to participate. We used Edinburgh Postnatal Depression Scale (EPDS) and Patient Health Questionnaire-9 (PHQ-9) in English and Kiswahili versions to carry out the interviews and were coded along four domains of comprehension, retrieval, judgement and patient response. Scores were tabulated for all participants and simple reliability analyses were offered. The interviews were discussed within the team and tables were shared between three raters for further consensus. The interview transcripts were analyzed manually using thematic analysis.Discussion: We found that adolescents had challenges in fully understanding items in both set of tools however, EPDS was better received than PHQ-9. Psychometrically, EPDS English version and Kiswahili versions fared better than the PHQ-9 English and Kiswahili versions. PHQ-9 presented considerable issues with regards to semantic clarity however had simpler response options in comparison to EPDS which was more experientially appropriate, but response options were not simple. On our thematic analysis we felt that the adolescents were significantly challenged by the new, unanticipated pregnancy or motherhood experience. Poverty, poor partner support, discord with parents and distress in the family, and traumatic end of supportive and helpful relationships were the notable problems.Conclusion: While sensitive cross-cultural translations for the commonly used open access depression tools is critical, it is also pertinent to understand whether these are developmentally appropriate. Our participants had multiple psychosocial and material challenges that necessitate measures sensitive to their age, social context and health experiences. Additionally, we felt that both the tools may not be suitable for self-administration and may need involvement of a case worker or community health worker.

Background This study describes adaptation and modification of World Health Organization (WHO) recommended group interpersonal psychotherapy (IPT-G) for depressed peripartum adolescents. The adaptation process includes accommodating contextual factors and strategies to address intervention implementation barriers, such as engagement problems with adolescents, caregivers, and providers, and stigma and dearth of mental health specialists. The modifications include and adolescent relevant iterations to the therapy format and content. Methods A multi-stakeholder led two-stage intervention adaptation and modification process integrating mixed qualitative methods were used with pregnant and parenting adolescents, their partners, and health care workers. In-depth interviews focusing on personal, relationship, social, and cultural barriers experienced by adolescents were carried out modeled on the Consolidated Framework for Implementation Research. Focus group discussions with depressed adolescents on their experiences, feedback from caregivers, partners, health workers inform focused modifications. An IPT expert committee of three practitioners, along with UNICEF adolescent officer, and mental health policy expert from Ministry of Health and representative community advisory body reviewed the adaptations and modifications made to the WHO IPT-G manual. Discussion Integration of mental health needs of peripartum adolescents as demonstrated in the stakeholder engagement process, adaptation of key terms into locally relevant language, determination of number of sessions, and user-centric design modifications to digitize a brief version of group interpersonal psychotherapy are presented.

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 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.

We examined the scope of collaborative care for persons with mental illness as implemented by traditional healers, faith healers, and biomedical care providers. We conducted semistructured focus group discussions in Ghana, Kenya, and Nigeria with traditional healers, faith healers, biomedical care providers, patients, and their caregivers. Transcribed data were thematically analyzed. A barrier to collaboration was distrust, influenced by factionalism, charlatanism, perceptions of superiority, limited roles, and responsibilities. Pathways to better collaboration were education, formal policy recognition and regulation, and acceptance of mutual responsibility. This study provides a novel cross-national insight into the perspectives of collaboration from four stakeholder groups. Collaboration was viewed as a means to reach their own goals, rooted in a deep sense of distrust and superiority. In the absence of openness, understanding, and respect for each other, efficient collaboration remains remote. The strongest foundation for mutual collaboration is a shared sense of responsibility for patient well-being.

Traditional and faith healers (TFH) provide care to a large number of people with psychosis in many sub-Saharan African countries but they practise outside the formal mental health system. We aimed to assess the effectiveness and cost-effectiveness of a collaborative shared care model for psychosis delivered by TFH and primary health-care providers (PHCW).In this cluster-randomised trial in Kumasi, Ghana and Ibadan, Nigeria, we randomly allocated clusters (a primary care clinic and neighbouring TFH facilities) 1:1, stratified by size and country, to an intervention group or enhanced care as usual. The intervention included a manualised collaborative shared care delivered by trained TFH and PHCW. Eligible participants were adults (aged ≥18 years) newly admitted to TFH facilities with active psychotic symptoms (positive and negative syndrome scale [PANSS] score ≥60). The primary outcome, by masked assessments at 6 months, was the difference in psychotic symptom improvement as measured with the PANSS in patients in follow-up at 3 and 6 months. Patients exposure to harmful treatment practices, such as shackling, were also assessed at 3 and 6 months. Care costs were assessed at baseline, 3-month and 6-month follow-up, and for the entire 6 months of follow-up. This trial was registered with the National Institutes of Health Clinical Trial registry, NCT02895269.Between Sept 1, 2016, and May 3, 2017, 51 clusters were randomly allocated (26 intervention, 25 control) with 307 patients enrolled (166 [54%] in the intervention group and 141 [46%] in the control group). 190 (62%) of participants were men. Baseline mean PANSS score was 107·3 (SD 17·5) for the intervention group and 108·9 (18·3) for the control group. 286 (93%) completed the 6-month follow-up at which the mean total PANSS score for intervention group was 53·4 (19·9) compared with 67·6 (23·3) for the control group (adjusted mean difference -15·01 (95% CI -21·17 to -8·84; 0·0001). Harmful practices decreased from 94 (57%) of 166 patients at baseline to 13 (9%) of 152 at 6 months in the intervention group (-0·48 [-0·60 to -0·37] p0·001) and from 59 (42%) of 141 patients to 13 (10%) of 134 in the control group (-0·33 [-0·45 to -0·21] p0·001), with no significant difference between the two groups. Greater reductions in overall care costs were seen in the intervention group than in the control group. At the 6 month assessment, greater reductions in total health service and time costs were seen in the intervention group; however, cumulative costs over this period were higher (US $627 per patient vs $526 in the control group). Five patients in the intervention group had mild extrapyramidal side effects.A collaborative shared care delivered by TFH and conventional health-care providers for people with psychosis was effective and cost-effective. The model of care offers the prospect of scaling up improved care to this vulnerable population in settings with low resources.US National Institute of Mental Health.

Objective: Although patient-therapist collaboration (working alliance) has been studied extensively in Europe and America, it is unknown to what extent the importance of working alliance for psychotherapy outcome generalizes to lower-and middle-income countries. Additionally, there is a need for more studies on the alliance using methods that are robust to confounders of its effect on outcome. Method: In this study, 345 outpatients seeking care at the 2 public psychiatric hospitals in Nairobi, Kenya, filled out the Session Alliance Inventory (SAI) and the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) during each session. The effect of alliance on next-session psychological distress was modeled using the random intercept cross-lagged panel model, which estimates a cross-lagged panel model on within- and between-subjects disaggregated data. Results: Changes in the working alliance from session to session significantly predicted change in psychological distress by the next session, with an increase of 1 point of the SAI in a given session resulting in a decrease of 1.27 points on the CORE-OM by the next session (SE = 60, 95% confidence interval [-2.44, -.10]). This finding represents a medium-sized standardized regression coefficient of between.16 and.21. Results were generally robust to sensitivity tests for stationarity, missing data assumptions, and measurement error. Conclusion: Results affirm cross-cultural stability of the session-by-session reciprocal effects model of alliance and psychological distress-symptoms as seen in a Kenyan psychiatric outpatient sample, using the latest developments in cross-lagged panel modeling. A limitation of the study is its naturalistic design and lack of control over several variables. Funding Agencies|Sormland County Council [1R24TW008889]; [DLL-514111]; [DLL-569981]

Introduction Epilepsy is a common neurological condition, with a lifetime prevalence of 1% in children. Research has shown a high prevalence of emotional and behavioral problems in children with epilepsy. The aim of this study was to determine the prevalence of emotional and behavioral problems in children with epilepsy attending the pediatric neurology clinic in a referral hospital in Kenya and examine associated sociodemographic and clinical variables. Methods This was a cross-sectional descriptive study. Children with epilepsy aged between 6 and 12 years attending the Kenyatta National Hospital pediatric neurology clinic were recruited. Inclusion criteria for the study were children diagnosed with epilepsy, age between 6 and 12 years, accompanied by a primary caregiver, and the primary caregiver being willing to participate in the study. A sociodemographic questionnaire as well as the Child Behavior Checklist school-age version (CBCL/6–18) was administered to the caregiver accompanying the child. Results One hundred and seventy-seven children with epilepsy were recruited (66% males) with a mean age of 8.9 (standard deviation (SD): 2) years. The mean age at onset of seizures was 4.5 years; 48% of the children had first seizure while aged less than 2 years, 76% reported generalized tonic–clonic seizures, and 58% were on antiepileptic drugs (AEDs). The overall prevalence of emotional and behavioral problems was 46%, and the four leading symptom clusters were attention problems, aggressive behavior, social problems, and withdrawal/depression. The risk of emotional and behavioral problems was increased in children using more than one AED (odds ratio (OR) = 2.21, 95% confidence interval (CI), 1.18–4.14) and those aged ten years and above (OR = 2.7, 95% CI, 1.3–5.64). The risk of emotional and behavioral problems was reduced in children with infrequent seizures (OR = 0.08, 95% CI, 0.01–0.06) and in children reporting no seizure in the past year (OR = 0.08, 95% CI, 0.01–0.65). Conclusion Emotional and behavioral problems are common among children with epilepsy in Kenya. This highlights the need to screen for these problems in children on treatment for epilepsy for early identification and subsequent management to improve outcome.

Background: Cognitive interviewing is a well-recognised methodology to identify clinical and commonsensical relevance of mental health questionnaire items by our research participants. Depression is amongst the most common condition impacting pregnant and parenting adolescents in sub-Saharan Africa (SSA). In Kenya, studies have reported depression prevalence estimates of 12-50% in peripartum adolescents. While young people prefer using English, there has not been enough data to point to how well they respond to Kiswahili translations of the commonly used tools. Method: Thirty-two participants between ages 14-18 years were approached and through informed consent for them to participate. We used Edinburgh Postnatal Depression Scale (EPDS) and Patient Health Questionnaire-9 (PHQ-9) in English and Kiswahili versions to carry out the interviews and were coded along with 4 domains of comprehension, retrieval, judgement, and patient response. The interviews were discussed within the team and tables were shared between 3 raters for further consensus. The interview transcripts were analyzed manually using thematic analysis. We used the findings from the interviews to make modifications to the existing English versions of EPDS and PHQ-9 and to modify Kiswahili versions too. Discussion: We found that adolescents had challenges in fully understanding items in both sets of tools however, EPDS was better received than PHQ-9. Psychometrically, the EPDS English version and Kiswahili versions fared better than the PHQ-9 English and Kiswahili versions. PHQ-9 presented considerable issues with regards to semantic clarity however had simpler response options in comparison to EPDS which was more experientially appropriate, but response options were not simple. On our thematic analysis, we felt that the adolescents were significantly challenged by the new, unanticipated pregnancy or motherhood experience. Poverty, poor partner support, discord with parents and distress in the family, and traumatic end of supportive and helpful relationships were the notable problems. We believe the cultural and linguistic modifications made on these tools would make them more suitable to be validated with a sample of pregnant adolescents. Conclusion: While sensitive cross-cultural translations for the commonly used open access depression tools is critical, it is also pertinent to understand whether these are developmentally appropriate. Our participants had multiple psychosocial and material challenges that necessitate measures sensitive to their age, social context, and health experiences. Additionally, we felt that both the tools may not be suitable for self-administration and may need the involvement of a case worker or community health worker.

Most cultures in sub-Saharan Africa subscribe to the belief that the root cause of psychosis is supernatural. Individuals in the community who hold a religiomagical explanatory model of causation have been shown to exhibit more stigmatizing attitudes towards people with psychosis. Self-stigma among individuals with psychosis is less frequently studied. We used a mixed-method approach, consisting of key informant’s interviews to elicit information on explanatory models of causation of psychosis and questionnaire assessment of internalized stigma with an adapted version of the Scale for Internalized Stigma of Mental Illness. Twenty-four, 31, and 30 subjects with recent experience of utilizing the service of traditional or faith healers for severe mental disorders in Ibadan (Nigeria), Kumasi (Ghana), and Nairobi (Kenya), respectively, were interviewed. About 44 % (42.1 %) of the Nigerian respondents had a high (severe) level of self-stigma with the respective proportions among Ghanaian and Kenyan respondents being 20.7 and 37.5 %. Compared with 4 out of a total of 12 respondents (33.3 %) who reported low self-stigma reported supernatural attribution, 14 out of 20 respondents (70 %) with the highest level of self-stigma reported supernatural attribution across the three sites. When low scorers ascribed supernatural causation, it was often with a religious focus. There is a greater tendency for persons with high levels of self-stigma than those with low levels to ascribe supernatural attribution to their experience of a severe mental health condition.

Mental and substance use disorders are a leading cause of disability worldwide. Despite this, there is a paucity of mental health research in low- and middle-income countries, especially in sub-Saharan Africa. We carried out a semi-systematic scoping review to determine the extent of mental health research in Botswana. Using a predetermined search strategy, we searched the databases Web of Science, PubMed, and EBSCOhost (Academic Search Complete, CINAHL with Full Text, MEDLINE, MEDLINE with Full Text, MLA International Bibliography, Open Dissertations) for articles written in English from inception to June 2020. We identified 58 studies for inclusion. The most researched subject was mental health aspects of HIV/AIDS, followed by research on neurotic and stress-related disorders. Most studies were cross-sectional and the earliest published study was from 1983. The majority of the studies were carried out by researchers affiliated to the University of Botswana, followed by academic institutions in the USA. There seems to be limited mental health research in Botswana, and there is a need to increase research capacity.

Background There is no generic psychotherapy outcome measure validated for Kenyan populations. The objective of this study was to test the acceptability and factor structure of the Clinical Outcomes in Routine Evaluation – Outcome Measure in patients attending psychiatric clinics at two state-owned hospitals in Nairobi. Methods Three hundred and forty-five patients filled out the CORE-OM after their initial therapy session. Confirmatory and Exploratory Factor Analysis (CFA/EFA) were used to study the factor structure of the CORE-OM. Results The English version of the CORE-OM seemed acceptable and understandable to psychiatric patients seeking treatment at the state-owned hospitals in Nairobi. Factor analyses showed that a model with a general distress factor, a risk factor, and a method factor for positively framed items fit the data best according to both CFA and EFA analysis. Coefficient Omega Hierarchical showed that the general distress factor was reliably measured even if differential responding to positively framed items was regarded as error variance. Conclusions The English language version of the CORE-OM can be used with psychiatric patients attending psychiatric treatment in Nairobi. The factor structure was more or less the same as has been shown in previous studies. The most important limitation is the relatively small sample size.

This paper is the first in a planned series of papers studying the effectiveness of psychotherapy and counselling in Nairobi. It describes a method for checking the effectiveness of psychotherapy and improving service quality in a Kenyan context. Rather than prematurely imposing psychotherapy protocols developed in Western countries in another cultural context, we believe that first studying psychological interventions as they are practised may generate understanding of which psychological problems are common, what interventions therapists use, and what seems to be effective in reducing psychiatric problems. The initial step is to assess outcome of psychological treatments as they are conducted. This is followed by statistical analyses aimed at identifying patient groups who are not improving at acceptable rates. Therapists will then be trained in a ‘best practice’ approach, and controlled trials are used in a final step, testing new interventions specifically targeted at patient groups with sub-optimal outcomes.

BackgroundPsychotherapy and mental health services in Nairobis public hospitals are increasing. Rather than prematurely imposing psychotherapy protocols developed in Western countries to Kenya, we argue that first studying psychological interventions as they are practiced may generate understanding of which psychological problems are common, what interventions therapists use, and what seems to be effective in reducing psychiatric problems in a lower and middle income country like Kenya.MethodWe present preliminary findings from a process-outcome study involving 345 patients from two public institutions, Kenyatta National and Mathare National Hospitals. We asked our patients to fill out a brief personal information questionnaire, Clinical Outcomes in Routine Evaluation-Outcome Measure (Evans et al. in Br J Psychiatry 180:51-60, 2002, and the Session Alliance Inventory (Falkenstrom et al. in Psychol Assess 27:169-183, 2015) after each session. We present descriptives for CORE-OM, patient-therapist concordance on the SAI, and using longitudinal mixed-effects model, test change in CORE-OM over time with various therapy and patient factors as predictors in regression analyses.ResultsThe majority of patients who attended the outpatient care clinics were young males. Our regression analysis suggested that patients with depression reported higher initial distress levels (2.75 CORE-OM scores, se=1.11, z=2.48, p=0.013, 95% CI 0.57-4.93) than patients with addictions, anxiety, or psychosis. Older clients improved slower (0.08 CORE-OM scores slower improvement per session per year older age; se=0.03, z=3.02 p=0.003, 95% CI 0.03, 0.14). Female patients reported higher initial distress than men (2.62 CORE-OM scores, se=1.00, z=2.61, p=0.009, 95% CI 0.65, 4.58). However, interns had patients who reported significantly higher initial distress (3.24 CORE-OM points, se=0.90, z=3.60, pamp;lt;0.001, 95% CI 1.48, 5.00), and improved more over time (-1.20 CORE-OM scores per session, se=0.51, z=-2.35, p=0.019, 95% CI -2.20, -0.20) than patients seeing mental health practitioners. The results showed that at average alliance, CORE-OM decreased by 1.74 points per session (se=0.21, pamp;lt;0.001). For each point higher on the SAI at session 2, the CORE-OM decreased by an additional 0.58 points per session (se=0.25, p=0.02).DiscussionOur objective was to study psychotherapies as they are practiced in naturalistic settings. The overall significant finding is that our participants report improvement in their functioning mental health condition and distress reduced as psychotherapy progressed. There were many more male than female participants in our sample; younger patients improved more than older ones; and while interns had patients with higher distress, their patients improved better than those patients attended by professionals.ConclusionsThese are preliminary observations to consider for a larger sample follow-up study. Before changing practices, evaluating the existing practices by mapping clinical outcomes is a helpful route. Funding Agencies|Center for Clinical Research Sormland; US National Institutes of Health [1R24TW008889]

Both malaria and mental disorders are associated with immune changes. We have previously reported the association between malaria and mental disorder in a household survey conducted in a health and demographic surveillance site of 70,000 population in an area endemic for malaria in western Kenya. We now report on the associations between malaria, mental disorders and immunity. We found marginally raised CD4/CD3 ratios of people with malaria parasites, but no difference in CD4/CD3 ratios for people with common mental disorder (CMD) or psychotic symptoms. People with psychotic symptoms had increased levels of IL-6. IL-8, and IL-10, and lower levels of IL-1beta. People with CMD had higher levels of IL-8 and IL-10. People with malaria had higher levels of IL-10 and lower levels of TNF-alpha. At the bivariate level, CMD was associated with log TNF-α levels using unadjusted odds ratios, but not after adjusting for malaria. Psychotic symptoms were associated with log IL-10 and log TNF-α levels at the bivariate level while in the adjusted analysis, log TNF-α levels remained highly significant. This is the first population based study of immune markers in CMD and psychotic symptoms, and the first to examine the 3 way relationship with malaria. Our findings suggest that TNF-α may mediate the relationship between malaria and CMD. Funding: The study was funded by UK Aid, Department for International Development, Kenya office. Declaration of Interest: The authors have no conflicts of interest to declare. Ethical Approval: Ethical approval was granted by the Kings College London and the Kenya Medical Research Institute Boards of Research Ethics respectively (PNM/11/12-54, SSC2374), and permission was obtained to conduct the study in households in Maseno area, which is part of the KEMRI/WRP Kombewa HDSS. Informed written and witnessed consent was asked of heads of sampled households, and then of sampled participants to take part in the study.

Background: Mental illness affects every segment of population including young adults. The beliefs held by young patients regarding the causes of mental illness impact their treatment-seeking behaviour. It is pertinent to know the commonly held attributions around mental illness so as to effectively provide psychological care, especially in a resource constrained context such as Kenya. This helps in targeting services around issues such as stigma and extending youth-friendly services. Methods: Guided by the private theories interview (PTI-P) and attributional framework, individual semi-structured interviews were carried out with ten young adults of ages 18-25 years about their mental health condition for which they were undergoing treatment. Each interview took 30-45 min. We mapped four attributions (locus of control, stability, controllability and stigma) on PTI-P questions. Data was transcribed verbatim to produce transcripts coded using interpretive phenomenological analysis. These codes were then broken down into categories that could be used to understand various attributions. Results: We found PTI-P to be a useful tool and it elicited three key themes: (a) psychosocial triggers of distress (with themes of negative thoughts, emotions around mental health stigma and negative childhood experiences, parents separation or divorce, death of a loved one etc.), (b) biological conditions and psychopathologies limiting intervention, and (c) preferences and views on treatment. Mapping these themes on our attributional framework, PTI-P themes presented as causal attributions explaining stigma, locus of control dimensions and stability. External factors were mainly ascribed to be the cause of unstable and uncontrollable attributions including persistent negative emotions and thoughts further exacerbating psychological distress. Nine out of the ten participants expressed the need for more intense and supportive therapy. Conclusion: Our study has provided some experiential evidence in understanding how stigma, internal vs external locus of control, stability vs instability attributions play a role in shaping attitudes young people have towards their mental health. Our study points to psychosocial challenges such as stigma, poverty and lack of social support that continue to undermine mental well-being of Kenyan youth. These factors need to be considered when addressing mental health needs of young people in Kenya. Funding Agencies|NIMH; NIH [1R24TW008889]

This study aimed to assess the prevalence of probable post-traumatic stress disorder (PTSD), and its associated risk factors in a general household population in Kenya. Data were drawn from a cross-sectional household survey of mental disorders and their associated risk factors. The participants received a structured epidemiological assessment of common mental disorders, and symptoms of PTSD, accompanied by additional sections on socio-demographic data, life events, social networks, social supports, disability/activities of daily living, quality of life, use of health services, and service use. The study found that 48% had experienced a severe trauma, and an overall prevalence rate of 10.6% of probable PTSD, defined as a score of six or more on the trauma screening questionnaire (TSQ). The conditional probability of PTSD was 0.26. Risk factors include being female, single, self-employed, having experienced recent life events, having a common mental disorder (CMD)and living in an institution before age 16. The study indicates that probable PTSD is prevalent in this rural area of Kenya. The findings are relevant for the training of front line health workers, their support and supervision, for health management information systems, and for mental health promotion in state boarding schools.

Objective To describe the prevalence and types of injuries in relation to traumatic experiences, posttraumatic stress symptoms, depression, and health-risk behaviors among university students in Kenya. Method A cross-sectional study collected data on a random sample of university students using a questionnaire to record sociodemographic variables while injuries experiences recorded using the Centers for Disease control criteria and Breslau’s seven-item screener was used to identify post-traumatic stress disorder (PTSD) symptoms. Depressive symptoms were measured using Center for Epidemiological Studies Short Depression Scale. Results Nine hundred and twenty-three students (525 male and 365 female) were included in the study, mean age 23 years (SD 4.0). Serious injury in the previous 12 months was reported by 29.00% of the students. PTSD was present in 15.67% (men 15.39% and women 16.1%). Out of the total, 41.33% of the students had depressive symptoms (35.71% mild–moderate symptoms and 5.62% severe). In the multivariable logistic regression being poor, binge drinking, tobacco use, ever been diagnosed with HIV, physically abused as a child, high PTSD score, and depression (adjusted odds ratio 5.49, 95% confidence interval 4.32–13.21) were significantly ( p value Conclusion Unintentional injuries and PTSD symptoms are common in this student population and are positively linked to depression and other risky behaviors. Measures aimed at improving the mental health, such as early identification and treatment of depression, may be useful in reducing the prevalence of such injuries among the youth.

Background Psychotic disorders are a group of severe mental disorders that cause considerable disability to sufferers and a high level of burden to families. In many low- and middle-income countries (LMIC), traditional and faith healers are the main providers of care to affected persons. Even though frequently canvassed as desirable for improved care delivery, collaboration between these complementary alternative health providers (CAPs) and conventional health providers has yet to be rigorously tested for feasibility and effectiveness on patient outcomes. Methods/design COSIMPO is a single-blind, cluster randomized controlled trial (RCT) being conducted in Nigeria and Ghana to compare the effectiveness of a collaborative shared care (CSC) intervention program implemented by CAPs and primary health care providers (PHCPs) with care as usual (CAU) at improving the outcome of patients with psychosis. The study is designed to test the hypotheses that patients receiving CSC will have a better clinical outcome and experience fewer harmful treatment practices from the CAPs than patients receiving CAU at 6 months after study entry. An estimated sample of 296 participants will be recruited from across 51 clusters, with a cluster consisting of a primary care clinic and its neighboring CAP facilities. CSC is a manualized intervention package consisting of regular and scheduled visits of PHCPs to CAP facilities to assist with the management of trial participants. Assistance includes the administration of antipsychotic medications, management of comorbid physical condition, assisting the CAP to avoid harmful treatment practices, and engaging with CAPs, caregivers and participants in planning discharge and rehabilitation. The primary outcome, assessed at 6 months following trial entry, is improvement on the Positive and Negative Symptom Scale (PANSS). Secondary outcomes, assessed at 3 and 6 months, consist of levels of disability, experience of harmful treatment practices and of victimization, and levels of perceived stigma and of caregivers’ burden. Discussion Information about whether collaboration between orthodox and complementary health providers is feasible and can lead to improved outcome for patients is important to formulating policies designed to formally engage the services of traditional and faith healers within the public health system. Trial registration National Institutes of Health Clinical Trial registry, ID: NCT02895269. Registered on 30 July 2016 Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2187-x) contains supplementary material, which is available to authorized users.

Background Alcohol use and hazardous drinking have been studied in school children and in urban areas of Kenya, but there has been no adult survey of these issues in a rural household population. Methods This study reports the prevalence of alcohol consumption and hazardous drinking in a household survey of a demographic surveillance site in rural Kenya. Information collected included demographic characteristics, socio-economic factors, recent life events and perceived social support. Alcohol consumption was assessed by questions about quantity and frequency. The Alcohol Use Disorders Identification Test (AUDIT) measured hazardous alcohol use. The Clinical Interview Schedule- Revised assessed common mental disorder, and the Psychosis Screening Questionnaire indicated the presence of psychotic symptoms. Results The study found that lifetime and current alcohol consumption were 10.8 % and 9.2 % respectively. Current alcohol consumption was significantly higher in men (OR 0.4, p

Background The prevalence of malaria parasites in adults in Africa is less well researched than in children. Therefore, a demographic surveillance site was used to conduct a household survey of adults in the malaria endemic area of Maseno division in Kisumu County near Lake Victoria. Methods A random survey of 1,190 adults living in a demographic health surveillance site in a malaria endemic area of 70,805 population size was conducted, measuring presence of malaria parasites by slide microscopy. Data were analysed using STATA to calculate the prevalence of malaria and associated risk factors. Results The adult prevalence of presence of malaria parasites in Maseno was 28% (95% CI: 25.4–31.0%). Gender was a significant sociodemographic risk factor in both univariate (OR 1.5, p = 0.005) and multivariate (OR 1.4, p = 0.019) analyses. Females were 50% more likely to have malaria than men. Conclusions Presence of malaria parasites is common in the adult population of this endemic area, and the rate is greatly increased in women. The presence of such an adult pool of malaria parasites represents a key reservoir factor in transmission of parasites to children, and is relevant for plans to eradicate malaria.

There have been no repeat surveys of psychotic symptoms in Kenya or indeed subSaharan Africa. A mental health epidemiological survey was therefore conducted in a demographic surveillance site of a Kenyan household population in 2013 to test the hypothesis that the prevalence of psychotic symptoms would be similar to that found in an earlier sample drawn from the same sample frame in 2004, using the same overall methodology and instruments. This 2013 study found that the prevalence of one or more psychotic symptoms was 13.9% with one or more symptoms and 3.8% with two or more symptoms, while the 2004 study had found that the prevalence of single psychotic symptoms in rural Kenya was 8% of the adult population, but only 0.6% had two symptoms and none had three or more psychotic symptoms. This change was accounted for by a striking increase in psychotic symptoms in women (17.8% in 2013 compared with 6.9% in 2004, p &lt, 0.001), whereas there was no significant change in men (10.6% in 2013 compared with 9.4% in 2004, p = 0.582). Potential reasons for this increase in rate of psychotic symptoms in women are explored.

Background Prevalence rates of human immunodeficiency virus (HIV) infection among the youth are disproportionately high compared to that of other age groups in Kenya. Poor mental health has been linked to risky HIV behaviour, yet few local studies have explored these aspects. This study sought to determine associations between HIV risky sexual behaviour and depression among undergraduate students at the University of Nairobi. Method A random sample of 923 (525 males and 365 females) undergraduate students was interviewed using a questionnaire to record sociodemographic variables and risky sexual behaviour including having multiple sexual partners, inconsistent condom use and engaging in sex after drinking. Depressive symptoms were measured using the Centre for Epidemiological Studies Short Depression Scale (CES-D 10). Results The students’ mean age was 23 years (s.d.4.0). Overall, 41.33% of the students scored above the cut-off point of 10 on the CES-D 10 scale, with 35.71% having moderate symptoms and 5.62% having severe depressive symptoms. The percentage of those who had ever been diagnosed with sexually transmitted infections (STIs) was 9.71% (males 8.65%; females 11.01%); and for HIV 3.04% (males 2.02%; females 4.05%). Nearly 30% reported having had multiple partners in the previous 12 months, 27.4% of the students did not use condoms with sexual partners and 21% had engaged in sex after drinking within the previous 3 months. In multivariable-bivariate logistic regression, being older, having depressive symptoms, alcohol use/binge drinking, tobacco use, sex after drinking, previous diagnosis of STI, physical abuse, sexual coercion and history of sexual abuse as a child were significantly associated with having multiple partners. Further, younger age, being female, tobacco use and previous diagnosis of STI were significantly associated with inconsistent condom use. Conclusion The prevalence of HIV rate infection is low compared to the national average but risky sexual behaviour is common among the students and is positively linked to depressive symptoms among other factors. Programmes aimed at HIV prevention should be integrated with mental health interventions.

Background There has been no previous household population study of suicidal ideation and attempts in Kenya. Therefore this study aimed to establish the prevalence of suicidal ideation and attempts in a rural population in Kenya, and to assess risk factors. Methods An epidemiological survey of a household population, using standardised structured interviews. We examined the prevalence of suicidal ideation and suicide attempts and the predictors of suicidal thoughts and attempts, using STATA to calculate unadjusted and adjusted odds ratios. Results A quarter of the sample (24.1 %) had thought that life was not worth living (tedium vitae) at some point in their lives, while a fifth had experienced death wishes at some stage. About 7.9 % reported suicidal thoughts and 1.9 % had made actual suicide attempts at some point in their lives. It can be seen that the prevalence of suicidal thoughts was 0.7 %, 4.2 %, 3.7 % and 7.9 % for last week, last year, at some other time, and lifetime respectively, while the prevalence of suicidal attempts was 0.5 %, 1.2 %, 0.7 and 1.9 % respectively. In the adjusted analysis of factors associated with suicidal thoughts, being female (OR 1.8, p = 0.017), having CMD (OR 2.7, p = 0.001), having a number of recent life events (OR 2.3, p = 0.001 for 2–3 life events and OR 2.6, p = 0.004 for 4 or more life events), and having a large social group size (OR 7.7, p = 0.006 for social group size of 4–8 and OR 9.1, p = 0.003 for social group size of 9 or more) were all associated with increased rates of life time suicidal thoughts, but psychotic symptoms were no longer significant after adjustment for the other variables. In the adjusted analysis of suicide attempts, having any psychotic symptoms (OR 5.1, p = 0.001) was the only factor associated with suicide attempts after adjustment for other factors significant at the bivariate level. Conclusion Suicidal ideation and attempts pose a significant public health burden in this poor rural area of Kenya. The findings are relevant for mental health promotion and prevention programmes, public education and professional training programmes in relevant sectors, especially in front line health workers and social workers.

Background.There have been no household surveys of adult attention deficit and hyperactivity disorder (ADHD) in Kenya, and only one in sub-Saharan Africa.Methods.Data on ADHD was used from a household survey of mental disorders and their associated risk factors conducted in Maseno area (population 70 805), near Lake Victoria in Kenya, using a demographic surveillance site as the sample frame, as part of a wider survey of mental health, malaria and immunity A total of 1190 households were selected, and 1158 adult participants consented to the study while 32 refused to participate in the study interviews, giving a response rate of 97.3%. ADHD symptoms were assessed with the WHO Adult ADHD Self-Report Scale (ASRS) Screener.Results.This survey found that the overall prevalence of ADHD using the ASRS was 13.1%. This suggests a high level of ADHD in the Kenyan population which needs to be further investigated for its impact on adult mental health. In the adjusted analysis, increased odds ratios (ORs) were found in those with higher assets (OR 1.7, p = 0.023), those with life events (OR 2.4, p = 0.001 for those with 2–3 life events and OR 2.6, p p = 0.001).Conclusion.The study demonstrates the magnitude of ADHD symptoms as a public health issue, relevant for health worker training, and the importance of further research into its prevalence in adults and associated risk factors.

Background Depression is a common cause of morbidity but prevalence levels among Kenyan university students are poorly understood. A better understanding of depression and its correlates is essential in planning for appropriate interventions in this population group. Method A random sample of 923 University of Nairobi students (525 male and 365 female) were interviewed using a questionnaire to record sociodemographic variables. Depressive symptoms were measured using Centre for Epidemiological Studies Short Depression Scale (CES – D 10). Results The mean age was 23 (s.d. 4.0). Using a cut-off point of 10, the overall prevalence of moderate depressive symptoms was 35.7% (33.5% males and 39.0% females) and severe depression was 5.6% (5.3% males and 5.1% female). Depressive illness was significantly more common among the first year students, those who were married; those who were economically disadvantaged and those living off campus. Other variables significantly related to higher depression levels included year of study, academic performance, religion and college attended. Logistic regression showed that those students who used tobacco, engaged in binge drinking and those who had an older age were more likely to be depressed. No difference was noted with respect to gender. Limitations This was a cross sectional study relying on self report of symptoms and could therefore be inaccurate. Although the study was conducted in the largest university in the country that admits students from diverse backgrounds in the country there could still be regional differences in other local universities. Conclusion Depression occurs in a significant number of students. Appropriate interventions should be set up in higher institutions of learning to detect and treat these disorders paying particular attention to those at risk.

A sample of 50 (36 male and 14 female) street children currently in a remand home at Kabete in Nairobi, Kenya, were interviewed using a predesigned questionnaire in order to estimate prevalence rates for use of selected substances. The lifetime prevalence rates of the drugs most commonly used were volatile hydrocarbons 42%, tobacco 32%, alcohol 14%, cannabis 14% and Khat (catha edulis) 12%. Ten percent were habitual users of tobacco while 4% were regular users of cannabis or khat. The prevalence for use of hard drugs was low, cocaine 4 (8%) and Mandrax (methaqualone) 1 (2%). These findings are similar to those from Cameroon where solvent use was found mainly among street children. (Southern Af. J. of Child and Adolescent Mental Health, 2000, 12(2): 145-150)

Worldwide, mental disorders affect 450 million people and account for 15% of the overall burden of diseases from all causes (World Health Organization, 2001). Two-thirds of those affected do not receive adequate care owing to stigma, discrimination, neglect and poverty. The World Health Organization (2001) found that only 1% of the total health expenditure went to mental health in most countries.

Background Health system weaknesses in Africa are broadly well known, constraining progress on reducing the burden of both communicable and non-communicable disease (Afr Health Monitor, Special issue, 2011, 14-24), and the key challenges in leadership, governance, health workforce, medical products, vaccines and technologies, information, finance and service delivery have been well described (Int Arch Med, 2008, 1:27). This paper uses focus group methodology to explore health worker perspectives on the challenges posed to integration of mental health into primary care by generic health system weakness. Methods Two ninety minute focus groups were conducted in Nyanza province, a poor agricultural region of Kenya, with 20 health workers drawn from a randomised controlled trial to evaluate the impact of a mental health training programme for primary care, 10 from the intervention group clinics where staff had received the training programme, and 10 health workers from the control group where staff had not received the training). Results These focus group discussions suggested that there are a number of generic health system weaknesses in Kenya which impact on the ability of health workers to care for clients with mental health problems and to implement new skills acquired during a mental health continuing professional development training programmes. These weaknesses include the medicine supply, health management information system, district level supervision to primary care clinics, the lack of attention to mental health in the national health sector targets, and especially its absence in district level targets, which results in the exclusion of mental health from such district level supervision as exists, and the lack of awareness in the district management team about mental health. The lack of mental health coverage included in HIV training courses experienced by the health workers was also striking, as was the intensive focus during district supervision on HIV to the detriment of other health issues. Conclusion Generic health system weaknesses in Kenya impact on efforts for horizontal integration of mental health into routine primary care practice, and greatly frustrate health worker efforts. Improvement of medicine supplies, information systems, explicit inclusion of mental health in district level targets, management and supervision to primary care are likely to greatly improve primary care health worker effectiveness, and enable training programmes to be followed by better use in the field of newly acquired skills. A major lever for horizontal integration of mental health into the health system would be the inclusion of mental health in the national health sector reform strategy at community, primary care and district levels rather than just at the higher provincial and national levels, so that supportive supervision from the district level to primary care would become routine practice rather than very scarce activity. Trial registration Trial registration ISRCTN 53515024

Background Harmful alcohol use has been linked to the spread of HIV in Kenya. It also adversely affects those on antiretroviral (ARV) treatment through poor compliance. This study using participatory research and action (PRA) methods sought to understand factors related to alcohol abuse and non-adherence and to formulate appropriate interventions in a sample of people living with HIV and AIDS (PLWHA) who were also abusing alcohol, at Kariobangi in Nairobi, Kenya. Methods Entry into the community was gained through previous PRA work in that community and PLWHA were recruited through snowballing. Working together with the community members, the researchers explored the participants’ understanding of alcohol use problem, its effects on compliance to ARV treatment and discussed possible action areas through PRA techniques that included focus group and market place discussions; visual aids such as spider diagrams, community mapping and ranking. Follow-up meetings were held to discuss the progress. Results By the final meeting, 67 PLWHA and 19 community members had been recruited. Through discussions, misconceptions regarding alcohol use were identified. It emerged that alcohol abuse was poorly recognised among both the community and health workers. Screening for alcohol use was not routinely done and protocols for managing alcohol related disorders were not available at the local health centres providing ARVs. The study participants identified improving communication, psychoeducation and screening for alcohol use as possible action areas. Poverty was identified as a major problem but the interventions to mitigate this were not easy to implement. Conclusion We propose that PRA could be useful in improving communication between the health workers and the clients attending primary health care (PHC) facilities and can be applied to strengthen involvement of support groups and community health workers in follow up and counselling. Integrating these features into primary health care (PHC) would be important not only to PLWHA but also to other diseases in the PHC setting . Longer term follow up is needed to determine the sustained impact of the interventions. Problems encountered in the PRA work included great expectations at all levels fostered by handouts from other donors and cognitive impairment that interfered with constructive engagement in some of the PLWHA.

The plant pigment (carotenoid and chlorophyll) composition of fresh green leaf of tea for a selection of clones was studied in relation to the quality of black tea produced from processing the same green leaf. The plant pigment composition of the green leaf for nine Kenyan clones was monitored by HPLC at 450 nm. Using discriminant analysis it was shown that clones could be distinguished from one another on the basis of their green leaf plant pigment composition. Using step-wise multiple regression analysis, a linear relationship was established between the levels of six green leaf plant pigments peak 5 (neochrome), peak 17 and 18 (isomers of lutein and/or lutein epoxide), peak 23 (chlorophyll b type compound), peak 26 (aurochrome) and peak 28 @-carotene)) and the quality of the manufactured black tea for the selected clones as assessed by tea tasters' evaluations. The model had an adjusted R-square value of 0.912 and was significant at P < 0.05. The value of the relationship as a means of predicting black tea quality is discussed.

The desire for self-mutilation in the absence of any discernible psychopathology is relatively rare. Self-mutilation is most commonly a manifestation of an underlying psychopathology such as depression, schizophrenia, personality disorder, transexuality, body dysmorphic disorder and factitious disorder. In this article, a case in which a 29-year-old single Kenyan lady of African origin demanded a surgical operation to modify and reduce the size of her external genitalia is presented. Although female genital mutilation is still widespread in the country, this case is of interest in that the woman did not seek the usual circumcision but sought to specifically reduce the size of her labia minora so that she could feel like a normal woman. The unique challenges in her management are discussed. Possible aetiological factors in patients who demand surgical removal or modification of parts of their bodies without an obvious cause is discussed.

Objectives: To determine the prevalence and distribution of psychiatric morbidity among convicted male sex offenders and to establish factors associated with sexual offending. Design : A Cross-sectional descriptive survey. Setting: Kamiti Maximum Security Prison, Nairobi, Kenya. Subjects : Seventy six male convicts. Results: Forty seven (61.8%) had defi lement-related convictions, 23 (30.3%) had rape-related, while six (7.9%) had other convictions. Twenty seven (35.5%) out of 76 had a DSM-IV Axis I disorder, majority of whom (71.1%) were dependent on or abused substances, and 26 (34.2%) had an Axis II disorder, most of whom had antisocial and impulsive personality disorders (46.2%). Of these 12 (15.8%) had an Axis I diagnosis alone, 11 (14.5%) had an Axis II diagnosis alone while 15 (19.7%) had both Axis I and II diagnoses, that is, co-morbidity. Exposure to erotica was statistically associated with both Axis I and II (p = 0.02 and p = 0.0003 respectively) and pre-occupation with thoughts about sex was associated with Axis II disorders (p = 0.01). Conclusions: Most of those with psychiatric morbidity targeted children and had antisocial or impulsive personality disorder. Awareness campaigns to enlighten the public of the fact that children are the most common victims and research to determine ways of treating and rehabilitating sexual offenders could reduce the vice.

Background: The prevalence and frequency of bullying in Nairobi public secondary schools in particular and in Kenyan schools in general is not known. Knowledge of the extent of the problem is essential in developing effective interventions.Aim: To study the prevalence and frequency of bullying in Nairobi public secondary schools, Kenya. Methods: A self-report sociodemographic questionnaire and the Olweus Bullying Questionnaire of 1991 were administered to 1 012 students from a stratified sample of public secondary schools in Nairobi.Results: Between 63.2% (640) and 81.8% (828) of students reported various types of bullying, both direct and indirect, with significant variations found for sex, age, class and year of study, whether in day or boarding school, and the place where bullied. Being bullied was significantly associated with becoming a bully, in turn.Discussion: Bullying is highly prevalent in Kenyan schools. Further studies are needed to characterise bullies and victims in terms of personality and environmental factors that may be associated with or conducive to bullying, as well as to determine the long-term prognosis for both bullies and victims. Further research is also required to determine the most appropriate intervention.Journal of Child and Adolescent Mental Health 2007, 19(1): 45–55

Objective : To establish the magnitude of psychiatric disorders among leprosy patients in western Kenya. Design : A cross-sectional descriptive study. Setting : Busia and Teso districts in western Kenya. Subjects : A sample of 152 male and female, adult leprosy patients. Results : The prevalence of psychiatric morbidity (PM) was 53.29%. The PM was positively correlated with physical disability and marital status but not with age, sex, education, type of leprosy, or duration of the illness. The prevalence of psychiatric morbidity was lower among Kenyan leprosy patients compared to studies carried out in India (56% to 78%). It was high compared to the rate of psychiatric morbidity in those seeking medical help in primary health care centres in Kenya, which was recently estimated to be 10%. Conclusion : The prevalence of PM in leprosy patients in western Kenya was lower than that in studies carried out in India. This could be attributed to de-institutionalisation and re-integration of leprosy sufferers back into their local communities. Since the rate was more than double that in the general Kenyan population and seemed to be related to presence of physical disability, an appraisal of psychiatric services offered to these patients is needed. East African Medical Journal Vol. 82(9) 2005: 452-456

Objectives: To describe the psychiatric services offered at Kenyatta National Hospital and the types of patients and cases seen at Kenyatta National Hospital. Design: A retrospective study based on case notes and other hospital records. Setting: Kenyatta National Hospital, Nairobi, Kenya Subjects: All patients seen in the various psychiatric clinics and those who attended the Patient Support Centre Unit in the hospital in the year 2002. Results: In the year 2002, 598,119 patients were treated at KNH out of which 6,878 (1.15%) were seen in the psychiatric clinics: 1,709 adults and 1,412 children were referred to the various psychiatric clinics. At the hospital's Patient Support Centre (PSC) 3,454 patients were seen, mostly for pre and post-HIV test counselling. Consultations from the wards accounted for 332 (9.6%) of the cases referred to PSC. The main diagnoses among the latter in order of frequency were alcohol related psychiatric disorders, acute and transient psychoses, depressive disorders, dissociative and conversion disorders and dementia. Conclusion: In view of the high load of acute and transient psychotic states, as well as substance related disorders, it is recommended that the hospital should establish acute wards for the comprehensive management of such patients. An alcohol and drug detoxification and rehabilitation centre should also be developed at the hospital. Services to those with HIV related disorders should also be improved. East African Medical Journal Vol.82(2) 2005: 80-85

Objectives: To determine the prevalence rate of post traumatic stress disorder (PTSD) and associated risk factors among motor vehicle accident (MVA) survivors attending the orthopaedic and trauma clinic at Kenyatta National Hospital, Nairobi. Design: A cross-sectional study. Setting: Kenyatta National Hospital, Nairobi. Subjects: One hundred and ninety seven adult males and sixty seven female patients. Method: The 264 patients were interviewed using a questionnaire to collect the sociodemographic data, the Self Rating Questionnaire (SRQ) and the Impact of Event Scale -Revised (IES-R). Diagnosis was made using the Diagnostic and Statistical Manual (DSM-IV). Results: The mean age was 34.63 ± 12.71 years (range 18-65). Overall, the prevalence rate of PTSD was 13.3%. None of the cases had been previously diagnosed as having PTSD. Females had a higher rate of 17.9% (n = 67), compared to the males 11.7% (n=197). The majority of those with PTSD (42.9%) were young, 20 - 29 years. Other risk factors were having post-primary education (62.9%), experiencing the first motor vehicle accident (14.1%), previous psychiatric illness, and other medical illnesses. The type of accident, role/status and immediate reactions to the accident were not significant. Conclusions: PTSD following motor vehicle accidents is common. Although the MVA survivors do develop significant rates of PTSD, it is not easy to identify those at risk but some of the parameters documented in this study may help. A multi disciplinary approach is therefore essential in the management of the RTA survivors at the orthopaedic and trauma clinics if their physical and psychological needs are to be adequately addressed East African Medical Journal Vol.81(7) 2004: 362-366

Objectives : To estimate the prevalence and pattern of substance use among patients attending primary health centres in urban and rural areas of Kenya. Design : A descriptive cross-sectional prevalence survey. Setting : Urban health centres of Jericho and Kenyatta University (KU) and rural health centres in Muranga district. Subjects : One hundred and fifty adult patients (seventy eight males and seventy two females) were included in the study. Intervention : Semi-structured questionnaires and the DSM IV diagnostic criteria were used to record the socio-demographic data and to determine substance dependence or abuse. Results : The substances commonly used in descending order of frequency were alcohol, tobacco, khat and cannabis. Only alcohol and tobacco were extensively used. Lifetime prevalence rates of alcohol use for the two urban health centres were 54% and 62% compared to 54% for the rural health centres. For tobacco the lifetime prevalence rates were 30% for Jericho, 28% for KU and 38% for Muranga. The differences between the rural and urban samples were not statistically significant. More males than females had used alcohol (average lifetime use 80.8% for males compared to 30.6% for females: p Conclusion : The rates of substance abuse were generally low with the exception of alcohol and tobacco. Socio-cultural factors might be responsible for the differences noted. It is suggested that preventive measures and education should be emphasised at the primary care level.