Assessing Children’s Psychological Wellbeing in Namibia:

Lessons for Research, Policy & Service Delivery

Mónica Ruiz-Casares, Ph.D.McGill University Health Center

1st ISCI ConferenceChicago, IL, June 27, 2007

Overview

I. Background informationa. Data sources & study overviewb. MH in Namibia: Situational analysis

II. Children & youth in Namibia: MH Associated Factors

a. Demographic factorsb. Social factors

III. Children & youth in Namibia: MH Indicatorsa. Depression in children & youthb. Juvenile suicide

IV. Moving forward: Lessons for research, policy & service delivery

I. Background Information

Sources of information

• Literature review & government statistics• Adults:

– Individual & group interviews

• Children & Youth: – Depression Inventory (CHH=33 + Schools=163)– Interviews (CHH)

• Open ended questions• Social networks• Life Changing Events• Suicide ideation

Namibia: Mental Health Situation Analysis

• South African legacy– Trauma-related illness

• Major challenges: – Unemployment

– Substance abuse

– Domestic violence

– Suicide and suicidal thinking

– HIV/AIDS

– Disabilities

Namibia: Estimated MH problems*

Frequency Percentage

Adults with serious MH disorder 21,500-32,500 2-3

Adults with common MH disorders 108,313 10

Children <15 years with serious MH problems

3,600-7,200 0,5-1

Children <15 years with learning/behavioral problems

6,600 1

* Not including HIV/AIDS & alcohol-related problems

Source: National Policy for MH, 2005

Namibia: MH Services

• Public services– Windhoek MH Care Center

(National Referral Hospital)

– Oshakati Psychiatric Unit (intermediate hospital)

– District Hospitals

– Some Health Care Centers & Clinics

• Private services– Private specialists

– Traditional Healers

Beds/MH Practitioners(per 100 000 population)

Freq.

Total psychiatric beds 1.5

Psychiatrists 0.2

Neurologists 0

Psychiatric Nurses 0

Social Workers 6

Psychologists 6

Source: National Policy for MH, 2005

Namibia: Mental Health Resources• Legislation

– Mental Health & Substance Abuse Policies (2005)

– National Therapeutic Drug Policy/Essential List of Drugs (1995)

– Orphan & Vulnerable Children Policy (2004)

– Mental Health Legislation (1973)

• Administration– Primary Health Care Directorate

• Disability Prevention & Rehabilitation Division

– National MH Programme

– Social Services Directorate

– Alcohol & Substance Abuse Programme

– National Inter-sectoral MH Action Group

II. Children & youth in Namibia: Mental Health Associated Factors

150000 100000 50000 0 50000 100000 150000

00-04

05-09

10-14

15-19

20-24

25-29

30-34

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40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

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95+

Figure 1. Namibia’s population pyramid (CBS, 2006).

MalesFemales

150000 100000 50000 0 50000 100000 150000

00-04

05-09

10-14

15-19

20-24

25-29

30-34

35-39

40-44

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65-69

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75-79

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85-89

90-94

95+

Figure 1. Namibia’s population pyramid (CBS, 2006).

150000 100000 50000 0 50000 100000 150000

00-04

05-09

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

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65-69

70-74

75-79

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90-94

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150000 100000 50000 0 50000 100000 150000

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05-09

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90-94

95+

Figure 1. Namibia’s population pyramid (CBS, 2006).

MalesFemales

Namibia population Pyramid (CBS, 2006)

Mental Health Associated Factors:DEMOGRAPHIC FACTORS

“To play the role of a mother, looking after children. Some of my friends and other girls feel unhappy when that happens. At the beginning, I did not accept it. People wanted to bury [my youngest brother] with my mother, [but] I decided to keep the baby. I struggled to raise him, [and] wondered if I would know how to do it right…”

Kavango, girl head since 16

Things that make you upset

Mental Health Associated Factors

SOCIAL FACTORS• Family Environment

– Fostering & Orphanhood

– Domestic violence & child abuse

• Stigma & discrimination• Stressful events

• Poverty

• Social Networks and Social Support

• Schooling/Work

OTHER FACTORS• Physical health

• Habits

• Spirituality/religion

• Personal systems of meaning

“When someone tells you “I love you” (…), that feels good.”

Kavango, girl head since 17

Things that make you happy

“My friends can make me happy when they give me advice.”

Caprivi, girl head since 11

III. Children & youth in Namibia:

Mental Health Indicators

Contextualizing MH measurement : Exploring local meaning• Withdrawal (‘Hide from visitors’)

• Not play with other children

• Insult without a reason

• Sadness (‘Sad face’)

• Fearful

• Do not show emotions

• Poor hygiene

• Changes in sleep and appetite

• Envy

• Poor school performance

Measuring depression in children & youth: Children’s Depression Inventory

CDI (Kovacs, 1977)Self-reported severity rating scale

27 items1 suicidal ideation item

7-17 yearsPrevious 2 weeksMultidimensional (depressive symptoms): 5 factor scales

Negative moodPersonal problemsIneffectivenessAnhedoniaNegative self-esteem

CDI-AdaptedSelf-reported severity rating scale

27 + 3 items1 suicidal ideation item (CHH)

7-17 + 18-21 yearsPrevious 2 weeksMultidimensional (overall α = .708;5 factor scales α = .16-.52)

2 forms (non/schooling)CHHs (N=33) + Schools (N=163)

Measuring depression in children & youth: School sample

Frequency (%) Schools

Sex* Female 81 (50.6)

Male 79 (49.4)

Current age (years) 9-12 43 (26.4)

13-17 81 (49.7)

18-21 39 (23.9)

Currently schooling 163 (100.0)

Orphanhood Non-orphans 89 (54.6)

Orphans (S/D) 74 (45.4)

Paternal O. 55 (33.7)

Maternal O. 42 (25.8)

Double O. 23 (14.1)

TOTAL participants 163

* 3 MV

Measuring depression in children & youth: Depression scores in Schools

Complete sample (N=163) μ=13.33, SD=6.00

CDI Normative (N=123) μ= 12.81, SD=6.190

7-12 (N=43) μ= 12.56, SD=6.001

13-17 (N=81) μ= 12.95, SD=6.320

Sch

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3 02 01 00

F i g u r e 1 . T o t a l C D I - A d a p t e d s c o r e s f o r c o n t r o l g r o u p a n d p a r t i c i p a n t s

2 5

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2 0

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F i g u r e 1 . T o t a l C D I - A d a p t e d s c o r e s f o r c o n t r o l g r o u p a n d p a r t i c i p a n t s

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Mean SD t dfSig. (2-tailed)

Sex* Female (n=81)

13.10 6.551-.216 158 .829

Male (n=79) 13.30 5.367

Orphanhood** Orphan (n=74)

13.57 6.693

.469 161 .640Non-orphan (n=89)

13.12 5.387

Mothertongue*** Caprivian (n=59)

13.59 6.672

.429 161 .669Kavango (n=104)

13.17 5.611

Mean SD F df Sig.

Age groups <12 (n=43) 12.56 6.001

1.960 2 .14413-17 (n=81) 12.95 6.320

18> (n=39) 14.95 5.088

Levene’s Test: Equal variances assumed *(Sig.=.225), **(Sig.=.161), *** (Sig=.363)

Comparing means (School sample)

Frequency (%) CHH

Sex* Female 21 (63.6)

Male 12 (36.4)

Current age (years) 9-12 3 (9.1)

13-17 8 (24.2)

18-21 22 (66.7)

Currently schooling 21 (63.6)

Orphanhood Non-orphans 3 (9.0)

Orphans (S/D) 30 (91)

Paternal O. 25 (75.8)

Maternal O. 26 (78.8)

Double O. 21 (63.6)

TOTAL participants 33

Measuring depression in children & youth: CHH

Means & variability of CDI scores in CHHs

CDI Compare(w/o suicide ideation)

CDI Complete (w/ suicide ideation)

Complete (N=33) μ=16.06, SD=4.84 μ= 16.45, SD=5.08

CDI Normative (N=11) μ= 15.09, SD=4.34 μ=15.45 , SD=4.45

7-12 (N=3) μ=17.00 , SD=6.557 μ= 17.33, SD=6.658

13-17 (N=8) μ= 14.38, SD=3.543 μ= 14.75, SD=3.694

Levene’s Test: Equal variances assumed *(Sig.=.668), **(Sig.=.220)L

Comparing means (CHHs)

Mean SD t dfSig.

(2-tailed)

Sex* Female (n=21) 16.43 5.192.572 31 .572

Male (n=12) 15.42 4.295

Orphanhood** Orphan (n=30) 16.23 4.987.642 31 .525

Non-orphan (n=3) 14.33 3.055

Mean SD F df Sig.

Mothertongue*** Caprivian/Kxoe (n=9) 17.22 4.738

6.261 2 .005Kavango (n=13) 18.31 4.498

Oshiwambo (n=11) 12.45 3.267

Age groups

<12 (n=3) 17.00 6.557

.637 2 .53613-17 (n=8) 14.38 3.543

18> (n=22) 16.55 5.096

Total CDI-Ad scores for control & CHHs

Sch

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F i g u r e 1 . T o t a l C D I - A d a p t e d s c o r e s f o r c o n t r o l g r o u p a n d p a r t i c i p a n t s

2 5

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μ=13.33

SD=6.00

μ=16.06, SD=4.84

* Equal variances assumed (Sig.=.211)

Significant difference (t= 2.460, Sig= .015) lost for normative group

Variability in Symptoms

CHH+ Somatic concerns*+ Disobedience*+ Difficulties doing

homework/chores*+ Decreased school

performance**+ Feeling sad+ Pessimism about the

future+ Other kids are better+ Tiredness

Schools+ Misbehavior+ Self-blame+ Loneliness

- Appetite- Social interest- Enough friends

* p<.01 ** p<.06

Juvenile Suicide Statistics (Namibian Police, April 2006)

Method2003 2004 2005

TotalMales Females Males Females Males Females

Hanging 12 5 7 4 5 4 37

Shooting 1 1 2 7 11

Overdose 2 2

Drowning 1 1

Poisoning 2 2

Total13 6 10 6 14 4

5319 16 18

“I have not talked about it [suicide] with anyone. I know

some social workers, but I would not feel comfortable talking to

them about it…”

Caprivi, boy head since 16

Suicidal ideation among CHHs

“After the death of my mother, I wanted to cause suicide, but (…) I got an advice from my friend. She told me: ‘If you want to cause suicide, look! You are having your young sister! Who is going to take care of your young sister? It would be better if some of these relatives of yours liked you, but they hate you. If you are going to cause suicide, there is no one who is going to take care of your sister’”

Caprivi, girl head since age 18

“I just think it in my heart…”: Suicidal ideation among CHHs

REASONS for SUICIDE• Poverty

• Conflict—“[I think about it] when someone makes me angry”

• Helplessness—“Sometimes I feel I am suffering a lot”.

REASONS NOT TO COMMIT SUICIDE

• Have to care for siblings—“There is no way I can leave my siblings” and “nobody would stay with my brother and my sister”.

• Hope of a better future—“I think that in the future I may get a good life” and “maybe I’ll do something good in the future”

• It is “wrong”—“I doubt; it is a bad thought…” and “I think about the Ten Commandments of God…”.

Limitations

• Small population/sample

• Absence of clinical diagnosis for comparison

• Cultural appropriateness of measure

• Self-report & administration

• Limited MH resources (ethics & follow-up)

IV. Moving forward:

Lessons for Research, Policy, & Service Delivery

Children’s advice to children

• “Stay together & care for each other”

• “Give positive advice & encourage each other to focus on schoolwork”

• “Be satisfied with what you have and don't think too much about being alone”

• “Trust in God and don't loose hope”

• “Avoid peer pressure, and abstain from alcohol, tobacco & sex”

“Advise families who are staying on their own to take school seriously and stay in good health.”

Omusati, boy head since 16

Children’s request to leaders

Children & Adolescent Mental Health: Lessons for Policy & Service Delivery1. Formulate mental health legislation

– Develop a child and adolescent mental health policy, services and training.

2. Barriers to care:– Stigma & public knowledge Public education– Poverty/Resources Training programs– Transportation– Language

3. Integrate mental health, general health and community care:– Promotion– Prevention– Treatment & Rehabilitation: “Continuum” of services

4. Training

Children & Adolescent Mental Health: Lessons for Research

1. Epidemiological studies of mental health in children & adolescents and associated disabilities

2. Culturally appropriate expressions of grief & healing practices (outcomes)

3. Cultural development/adaptation & translation of measures

4. Involve children in research!

“I learnt something important [today]: to ask, because you asked me how we are living. This helps me because (…) since my mother passed away, nobody has asked me this type of questions.”

Caprivi, boy head of household since age 17

Participants

Thank you! Merci!

monica.ruizcasares@mail.mcgill.ca