BackgroundThis study took place to enable the measurement of the effects on mental health of a psychosocial intervention in Rwanda. It aimed to establish the capacities of the Self-Reporting Questionnaire (SRQ-20) to screen for mental disorder and to assess symptom change over time in a Rwandan community setting.MethodsThe SRQ-20 was translated into Kinyarwanda in a process of forward and back-translation. SRQ-20 data were collected in a Rwandan setting on 418 respondents; a random subsample of 230 respondents was assessed a second time with a three month time interval. Internal reliability was tested using Cronbach's alpha. The optimal cut-off point was determined by calculating Receiver Operating Curves, using semi-structured clinical interviews as standard in a random subsample of 99 respondents. Subsequently, predictive value, likelihood ratio, and interrater agreement were calculated. The factor structure of the SRQ-20 was determined through exploratory factor analysis. Factorial invariance over time was tested in a multigroup confirmatory factor analysis.ResultsThe reliability of the SRQ-20 in women (α = 0.85) and men (α = 0.81) could be considered good. The instrument performed moderately well in detecting common mental disorders, with an area under the curve (AUC) of 0.76 for women and 0.74 for men. Cut-off scores were different for women (10) and men (8). Factor analysis yielded five factors, explaining 38% of the total variance. The factor structure proved to be time invariant.ConclusionsThe SRQ-20 can be used as a screener to detect mental disorder in a Rwandan community setting, but cut-off scores need to be adjusted for women and men separately. The instrument also shows longitudinal factorial invariance, which is an important prerequisite for assessing changes in symptom severity. This is a significant finding as in non-western post-conflict settings the relevance of diagnostic categories is questionable. The use of the SRQ-20 can be considered an alternative option for measuring the effect of a psychosocial intervention on mental health.Trial registrationNederlands Trial Register NTR1120.

BackgroundWar has serious and prolonged mental health consequences. It is argued that post-emergency mental health interventions should not only focus on psychological factors but also address the social environment. No controlled trials of such interventions exist. We studied the effect on mental health of a large scale psychosocial intervention primarily aimed at social bonding in post-genocide Rwanda. The programme is implemented at population level without diagnostic criteria for participation. It is open to any person older than 15 years, and enables participation of over 1500 individuals per year. We postulated that the mental health of programme participants would improve significantly relative to non-participants.Methods and FindingsWe used a prospective quasi-experimental study design with measurement points pre and post intervention and at 8 months follow-up. 100 adults from both sexes in the experimental condition entered the study; follow-up measurements were taken from 81. We selected a control group of 100 respondents with similar age, sex and symptom score distribution from a random community sample in the same region; of these, 73 completed the study. Mental health was assessed by use of the Self Reporting Questionnaire (SRQ-20), a twenty item instrument to detect common mental disorders in primary health care settings. Mean SRQ-20 scores decreased by 2.3 points in the experimental group and 0.8 in the control group (p = 0.033). Women in the experimental group scoring above cut-off at baseline improved with 4.8 points to below cut-off (p<0.001). Men scoring above cut-off at baseline showed a similar trend which was statistically non-significant. No adverse events were observed.ConclusionsA large scale psychosocial intervention primarily aimed at social bonding caused a lasting improvement of mental health in survivors of mass violence in Rwanda. This approach may have a similar positive effect in other post-conflict settings.Trial RegistrationNederlands Trial Register 1120

Background Refugees fleeing conflict often experience poor mental health due to experiences in their country of origin, during displacement, and in new host environments. Conditions in refugee camps and settlements, and the wider socio-political and economic context of refugees’ lives, create structural conditions that compound the effects of previous adversity. Mental health and psychosocial support services must address the daily stressors and adversities refugees face by being grounded in the lived reality of refugee’s lives and addressing issues relevant to them. Methods We undertook a rapid qualitative study between March and May 2019 to understand the local prioritisation of problems facing Congolese refugees living in two refugee settings in Uganda and Rwanda. Thirty free list interviews were conducted in each setting, followed by 11 key informant interviews in Uganda and 12 in Rwanda. Results Results from all interviews were thematically analysed following a deductive process by the in-country research teams. Free list interview findings highlight priority problems of basic needs such as food, shelter, and healthcare access; alongside contextual social problems including discrimination/inequity and a lack of gender equality. Priority problems relating to mental and psychosocial health explored in key informant interviews include discrimination and inequity; alcohol and substance abuse; and violence and gender-based violence. Conclusions Our findings strongly resonate with models of mental health and psychosocial wellbeing that emphasise their socially determined and contextually embedded nature. Specifically, findings foreground the structural conditions of refugees’ lives such as the physical organisation of camp spaces or refugee policies that are stigmatising through restricting the right to work or pursue education. This structural environment can lead to disruptions in social relationships at the familial and community levels, giving rise to discrimination/inequity and gender-based violence. Therefore, our findings foreground that one consequence of living in situations of pervasive adversity caused by experiences of discrimination, inequity, and violence is poor mental health and psychosocial wellbeing. This understanding reinforces the relevance of feasible and acceptable intervention approaches that aim to strengthening familial and community-level social relationships, building upon existing community resources to promote positive mental health and psychosocial wellbeing among Congolese refugees in these settings.

A distinguishing feature of the 1994 genocide against the Tutsi and the preceding 1990-1994 war in Rwanda was the social intimacy of the crimes committed. The legacy of this kind of violence includes distrust in social relations within communities and families, an increase of violence in everyday social interaction, transgressive sexual engagements, and a range of psychological problems. Many people feel nostalgia for their past social life, but are unable to change their current situation. In 2005, a community-based sociotherapy programme was introduced into this context of mental and social distress. The goal was to help people regain feelings of dignity and safety and to reduce distress. This paper is based on qualitative research, in particular, case studies. It explores how sociotherapy, as a specific form of peer group counselling, may facilitate the healing of suffering related to issues of sexuality, violence within the family and the breakdown of social connections on a community level.

Abstract:The 1994 genocide against the Tutsi in Rwanda and its aftermath led to large-scale individual traumatization, disruption of family structures, shifts in gender roles, and tensions in communities, which are all ongoing. Previous research around the world has demonstrated the transgenerational effects of mass violence on individuals, families and communities. In Rwanda, in light of recurrent episodes of violence in the past, attention to the potential 'cycle of violence' is warranted. The assumption that violence is passed from generation to generation was first formulated in research on domestic violence and child abuse, but is receiving increasing attention in conflict-affected societies. However, the mechanisms behind intergenerational transmission are still poorly understood. Based on qualitative research with 41 mothers and their adolescent children, we investigated how legacies of the 1994 genocide and its aftermath are transmitted to the next generation through processes in the family environment in Rwanda. Our findings reveal direct and indirect pathways of transmission. We also argue that intergenerational effects might best be described as heterotypic: genocide and its aftermath lead to multiple challenges in the children's lives, but do not necessarily translate into new physical violence. Further research is needed on how children actively engage with conflict legacies of the past.

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Exposure to intimate partner violence (IPV) is a common feature of women living in low- and middle-income countries. Several studies have shown a significant association between IPV against women and mental health in both developed and in low- and middle-income countries. In postconflict settings, the relationship between IPV and mental health is likely more complex, given the high levels of violence experienced by the population as a whole. In this cross-sectional study the authors explore the association between IPV and common mental health disorders (CMD), and more specifically, suicidal ideation, among inhabitants of postgenocide Rwanda. The authors use the concept of "mutual partner violence," thereby exploring the association between IPV and CMD in victims, perpetrators, and those who state they are both. Data of 241 married men and women were used. Symptoms suggestive of CMD were established by use of the Self-Reporting Questionnaire (SRQ-20), and physical intimate partner violence was measured using the Conflict Tactics Scale, Short Version (CTS2S). The authors applied multivariate logistic regressions with total SRQ-20 scores (above/below cutoff) and suicidal ideation as the outcome measures and corrected for age and gender. The study findings suggest that reported IPV is associated with CMD (odds ratio [OR] = 1.7, 95% confidence interval [95% CI] = 0.92-3.15) and suicidal ideation (OR = 1.6, 95% CI = 0.70-3.53). Those who state to be both victim and perpetrator (OR = 1.75, 95% CI = 0.82-3.72), or only perpetrator (OR = 3.13, 95% CI = 0.49-20.0), are more likely to report mental health problems than victims and people who do not report IPV. In a postconflict situation, perpetrators of IPV may suffer from mental health problems as much as, or even more than, victims. Longitudinal data are needed to clarify the complex relationship between CMD and IPV, especially if outcomes may also be related to other forms of violence experienced in the past.

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