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AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20

Risk and protective factors for internalizing and externalizing outcomes among HIV-affected youth in Haiti a

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Michelle Li , Theresa Betancourt , Eddy Eustache , Catherine Oswald , Ermaze Louis , Joia ac

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Mukherjee , Pamela J. Surkan & Mary C. Smith Fawzi

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Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA b

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Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA c

Partners In Health-Haiti/Zanmi Lasante, Cange, Haiti

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Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA Published online: 07 May 2015.

To cite this article: Michelle Li, Theresa Betancourt, Eddy Eustache, Catherine Oswald, Ermaze Louis, Joia Mukherjee, Pamela J. Surkan & Mary C. Smith Fawzi (2015) Risk and protective factors for internalizing and externalizing outcomes among HIV-affected youth in Haiti, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 27:8, 995-999, DOI: 10.1080/09540121.2015.1020751 To link to this article: http://dx.doi.org/10.1080/09540121.2015.1020751

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AIDS Care, 2015 Vol. 27, No. 8, 995–999, http://dx.doi.org/10.1080/09540121.2015.1020751

Risk and protective factors for internalizing and externalizing outcomes among HIV-affected youth in Haiti Michelle Lia, Theresa Betancourtb, Eddy Eustachec, Catherine Oswaldc, Ermaze Louisc, Joia Mukherjeea,c, Pamela J. Surkand and Mary C. Smith Fawzia* a

Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA; bDepartment of Global Health and Population, Harvard School of Public Health, Boston, MA, USA; cPartners In Health-Haiti/Zanmi Lasante, Cange, Haiti; d Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

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(Received 8 September 2014; accepted 13 February 2015) The present study aims to: (1) estimate the levels of internalizing symptoms and externalizing behaviors among youth affected by HIV in central Haiti; and (2) examine the risk and protective factors associated with these outcomes to identify potential areas of intervention for HIV-affected youth. Baseline data for 492 youth affected by HIV (ages 10–17) and their 330 caregivers were collected for a pilot study of a psychosocial support intervention. Participants were recruited from a list of HIV-positive patients receiving care at Partners In Health/Zanmi Lasante clinic sites. Internalizing and externalizing behaviors were assessed using the Strengths and Difficulties Questionnaire. Demographic, economic, and social indicators were collected using a structured questionnaire administered by trained social workers. Youth affected by HIV in central Haiti displayed high levels of internalizing and, to a lesser degree, externalizing symptoms. Multivariate regression analysis demonstrated risk factors most strongly associated with internalizing symptoms (socioeconomic status, parental depressive symptoms) and externalizing behaviors (household living arrangements, such as living with a stepparent). Social support had a protective effect on externalizing behaviors for both caregiver (β = –0.03, p = 0.01) and self-report (β = –0.05, p < 0.0001). High levels of psychological distress were observed in this population, especially with respect to internalizing outcomes. Interventions should address the economic security, mental health, and access to antiretroviral therapy for families affected by HIV, as well as emphasize the importance of building supportive caregiver–child relationships to decrease the psychological symptoms and impact of other life stressors experienced by youth affected by HIV in Haiti and similar resource-limited settings. Keywords: HIV-affected; youth; adolescents; caregivers; mental health; Haiti

Introduction In Haiti, the most impoverished country in the Western Hemisphere, HIV prevalence among adults is estimated to be 2.1%, one of the highest rates outside of subSaharan Africa (UNAIDS, 2013). Improvement in access to antiretroviral therapy (ART) worldwide has transformed HIV into a manageable chronic illness with distinct long-term challenges for families affected by HIV (Deeks, Lewin, & Havlir, 2013). Given the stressors related to chronic illness, youth living with an HIVpositive parent may experience anxiety, anticipatory loss, and uncertainty about the future, especially in contexts of extreme poverty and food insecurity. Among youth in Haiti, the challenges of being affected by HIV and chronic poverty may be compounded by the ongoing impact of the trauma of the 2010 earthquake. The earthquake brought about an acute crisis within the context of chronic stressors, such as HIV and poverty (Farmer, 2011), potentially exacerbating mental health problems among youth in Haiti.

*Corresponding author. Email: [email protected] © 2015 Taylor & Francis

The present study aims to: (1) describe the mental health problems, such as internalizing and externalizing, among youth affected by HIV prior to the 2010 earthquake, demonstrating the chronic burden they experience in this context; and (2) examine risk and protective factors associated with internalizing and externalizing problems to inform the development of mental health interventions for this vulnerable population in Haiti and similar resource-limited settings.

Methods Participants and study procedures Study selection and procedures have been previously described (Smith Fawzi et al., 2010). Briefly, between February 2006 and September 2008, participants were recruited from six Partners In Health/Zanmi Lasante sites located in central Haiti that provide community-based directly observed therapy of ART. Eligibility criteria included being between the ages of 10 and 17 and

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affected by HIV, defined as at least one of the following: being HIV-positive; having at least one caregiver living with HIV; or having a caregiver who died of HIV/AIDS. Out of the 576 adolescents meeting eligibility criteria, 492 (85%) adolescents and their 330 caregivers accepted to participate in the study and provided informed consent/assent. Institutional Review Board approval was granted by the Zanmi Lasante Ethics Committee and Harvard Medical School.

symptoms). Theorized predictors associated in the bivariate analyses at p < 0.10 were selected for multivariate modeling. All models were additionally adjusted for adolescent age and gender. Hierarchical linear regression modeling controlling for clustering at the family level was performed using PROC MIXED in SAS version 9.1 (SAS Institute, Cary, NC).

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Results Study measures Adolescent internalizing symptoms and externalizing behaviors were measured by caregiver and self-report with Goodman’s Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997). The SDQ has been shown to perform as well as similar questionnaires (Goodman, 1997), and the emotional and conduct subscales have been shown to significantly correlate with the internalizing and externalizing problem scales of Achenbach’s Child Behavior Checklist (Goodman & Scott, 1999). Social support was assessed with Turner’s Provision of Social Relations Scale, including youth report of support from family and friends (Turner, Frankel, & Levin, 1983). Depressive symptomatology among caregivers was measured using the depression subscale of the Hopkins Symptoms Checklist (Derogatis, Lipman, Rickels, Uhlenhuth, & Covi, 1974). In addition, sociodemographic and economic characteristics included age, sex, household composition, average monthly income, food security, and access to a latrine, among other variables. The questionnaires were translated into Haitian Creole and were piloted to ensure clarity.

Data analysis The prevalence of psychological symptoms among youth was calculated, and independent sample t tests and paired t tests were used to compare mean differences between males and females and between caregivers and youth, respectively. Bivariate analyses were conducted to test associations between internalizing and externalizing problems, and hypothesized risk and protective factors (including household composition, social support, living in a rural area, food insecurity, and parental depressive

Internalizing and externalizing outcomes in adolescents Demographic and background characteristics of the 492 youth and their 330 caregivers have been described previously. For the youth, ages 10–17, 60% were 10–13 years of age and 51% were female. Seventy-three percent of caregivers were women and 38% never attended school (Smith Fawzi et al., 2010). Caregivers reported significantly higher externalizing problems in youth compared to self-report, and females indicated a higher level of internalizing compared to males on both reports (Tables 1 and 2). The most common internalizing symptoms reported by adolescents (marked “certainly true” on the SDQ) were: getting headaches, stomachaches (54%); having many fears (28%); and feeling unhappy (15%). Externalizing problems were less frequent – 16% of youth reported frequently getting very angry and 10% reported always being accused of lying or cheating (see Figure 1). Risk and protective factors associated with internalizing and externalizing Significant risk factors for internalizing problems in the self-report included older age (β = 0.13, p = 0.01), living without a parent (β = 1.29, p < 0.01), food insecurity (β = 0.89, p < 0.01), and parental depression (β = 0.56, p = 0.02). Perceived social support from relatives had a marginally protective effect (β = –0.43, p = 0.079). For caregiver report, being female (β = 0.43, p = 0.02), not having a latrine (β = 0.53, p = 0.04), and parental depressive symptoms (β = 1.23, p < 0.001) were significantly associated with internalizing problems. Older age was a protective factor associated with internalizing (β = –0.11, p < 0.01) and externalizing (β = –0.13, p < 0.01) according to caregiver report.

Table 1. Baseline SDQ scores, by report. Self-report (SDQ-S; n = 490)

Caregiver report (SDQ-C; n = 478)

Report

Mean

SD

Mean

SD

t statistic

Internalizing Externalizing

4.24 1.59

2.35 1.65

3.99 1.95

2.32 2.02

1.83 3.26*

Note: Values are the mean of subscale summary scores, ranging in severity from 0 (low) to 10 (high). *p < 0.05.

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Table 2. Baseline SDQ scores, by gender. Self-report (SDQ-S; n = 490)

Internalizing Externalizing

Caregiver report (SDQ-C; n = 478)

Males

Females

t statistic

Males

Females

t statistic

3.95 (2.25) 1.50 (1.55)

4.51 (2.42) 1.67 (1.74)

2.62** 1.09

3.75 (2.34) 1.91 (2.01)

4.24 (2.28) 1.97 (2.03)

2.37* 0.28

Note: Mean (standard deviation) are reported in each cell. *p < 0.05; **p < 0.01.

Prevalence of internalizing symptoms

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Is of ten unhappy , downhearted or tearf ul Is nerv ous in new situations Has many f ears and is easily scared Gets headaches, stomaches or sick 0

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Prevalence of externalizing symptoms Does not do as told Takes things that are not their own Fights a lot Is of ten accused of cheating or ly ing Gets v ery angry and of ten loses temper 0

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Figure 1. Prevalence of internalizing and externalizing symptoms (SDQ-S; n = 490).

Considering externalizing problems, living with a stepparent (β = 0.41, p = 0.05) and food insecurity (β = 0.39, p = 0.03) were significant risk factors according to self-report. Social support from friends and relatives demonstrated a significant protective effect on externalizing according to caregiver (β = –0.03, p < 0.014) and selfreport (β = –0.05, p

Risk and protective factors for internalizing and externalizing outcomes among HIV-affected youth in Haiti.

The present study aims to: (1) estimate the levels of internalizing symptoms and externalizing behaviors among youth affected by HIV in central Haiti;...
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