Utilization Patterns of Community-based Mental Health Services Among school-going Adolescent girls in Southwestern Uganda.

ABSTRACT OF THE DISSERTATION Globally an estimated 20% of children and adolescents experience a disabling mental illness (Belfer, 2008). Mental health disorders are the second leading cause of disease burden and the eleventh leading cause in older adolescents (15-19 years). Yet, children and adolescents are over-represented in low-resourced countries and settings often characterized by violence, wars, diseases, physical and sexual abuse, all of which are associated with poor mental health functioning (Kieling et al., 2011; Naker, 2005). Moreover, in LMICs the treatment gap is about 93% of individuals without access to mental health services with virtually no coverage of evidence-based interventions (Chisholm et al., 2016). Yet, psychosocial interventions are the most studied and effective treatments available (Singla et al., 2017; Patel et al., 2018). In addition, even within this group of children and adolescents, gender seems to be a critical factor that influences the utilization of mental health services. Girls more than their male counterparts are more likely to report mental health challenges (Nolen-Hoeksema, 2002; Petroni et al., 2015). This stems from gender-related inequalities, including physical and emotional abuse, poverty, social isolation, and educational disadvantage, which increase their vulnerability to depression and stress (Kågesten et al., 2016; Reiss, 2013; Rhodes et al., 2014). Taken as a whole, untreated mental illnesses have significant social, economic, and political disruptions to individuals, families, communities, and nations. This is because untreated mental disorders significantly impact a child\u27s growth, educational achievement, and ability to live a happy and healthy life. Therefore, promoting evidence-based psychosocial interventions is a promising approach to increase access to mental health services among adolescents in low-resource settings. This dissertation project aimed to improve understanding of patterns of mental health service utilization among 1260 adolescent girls from 47 public secondary schools in a low-resource country, Uganda, as well as examining the Andersen model’s constructs associated with mental health utilization by addressing gaps in the literature. It had four specific aims including, 1) to explore the short-term impact of an evidence-based MH intervention on depressive symptoms among 1260 school-going adolescent girls in southern Uganda; 2) to document the prevalence of depressive symptom severity and describe their characteristics among a sub-sample of school-going adolescent girls in southern Uganda participating in a community based mental health intervention; 3) to describe the patterns of mental health service utilization and explore how predisposing, enabling, and need factors are associated with mental health service utilization among school-going adolescent girls in southern Uganda participating in a community based mental health intervention; and 4) to explore pathways between predisposing, enabling, and need factors and how the pathways vary by patterns of mental health service utilization. Data from two waves, 2017-2018 of the Suubi4her study were used. Suubi4Her is a three-arm cluster randomized controlled trial design (Youth Development Accounts (YDA) only, YDA + Multiple Family Group (MFG), Usual Care) in 47 secondary schools in the southwestern region of Uganda. The sample consisted of 1,260 adolescent girls (ages 14–17 at enrollment) enrolled in the first two classes (senior one and senior two). I used descriptive statistics to document depressive symptom severity and describe their characteristics. At baseline, the results showed that about 41% of adolescent girls evidenced mild to severe symptoms. Similarly, the findings indicated that at 12-months post-intervention initiation, participants had a significant decline in depressive symptoms compared to the baseline (M=18 vs M=13, P\u3c.001). A three-level mixed-effects model was conducted to examine the effect of an evidence-based intervention on depressive symptoms. The results indicate that at 12-months post-intervention initiation, the intervention was effective in reducing depressive symptoms between the treatment and control conditions. Furthermore, the results revealed that exposure to violence, low levels of asset ownership, and low quality of social support relationships were risk factors for depressive symptoms. To identify the heterogeneity of mental health utilization, Latent Class Analysis (LCA) was utilized. Logistic regression analysis was conducted to assess the association between predisposing, enabling, need factors and patterns of mental health utilization. Using LCA, two groups were identified: low attendants and high attendants. In addition, two family-level factors, the number of adults and the number of children in the family, were associated with an increase in the utilization of mental health services. A structural equation model (SEM) was utilized to investigate the relationship across mental health utilization patterns from predisposing to need factors through enabling factors. The SEM found that enabling and predisposing factors were directly associated with need factors. The study also found that the quality of social support relationships mediated the relationship between exposure to violence and depressive symptoms. This relationship was different for participants in the low attendants\u27 group compared to participants in the high attendants’ group, indicating the potential effect of the intervention in enhancing social support among intervention participants. Findings suggest that mental health utilization is heterogeneous among adolescent girls and that enhancing family support systems is critical to promote mental health utilization among adolescent girls. In addition, results also imply that an evidence-based psychosocial intervention may be a promising tool in addressing depressive symptoms among adolescents. Additionally, results suggest that enhancing intervention factors such as social support that buffer against violence and enhance social connectedness could be useful to alleviate depressive symptoms. Therefore, in addition to material support, strategies to improve the support and care for adolescents, especially in low-resource settings, should focus on strengthening family support systems to enhance adolescents’ psychological well-being