Chingono, Rudo Meggie Samantha; (2023) The burden of poor mental health on parenting in mothers living with HIV in Zimbabwe. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

Background Mothers living with HIV are at increased risk of comorbidities, including mental health conditions. Mental health condition rates may be high yet often undiagnosed and untreated. This study aimed to assess the prevalence and factors associated with mental health conditions in mothers living with HIV and their association with parenting behaviour. Methods Firstly, the 8-item Shona Symptom Questionnaire (SSQ-8), which identifies the risk of common mental disorders (CMD), was validated in a sample of 264 primary care clinic attendees compared to a gold standard, using a receiver operating characteristic curve to identify the optimal cut point of 6. The next phase used data from 485 mothers living with HIV, participating in a cluster-randomised controlled trial evaluating parenting and income interventions, to explore the prevalence of and risk factors for CMD, defined as a 3-category ordinal variable (no CMD, CMD at one timepoint, CMD at both timepoints). I also investigated the association of CMD with parenting stress, parenting sense of competence and discipline. Lastly, a comprehensive parenting intervention was evaluated using mixed methods and guided by the MRC guidance to evaluate complex interventions. Results The SSQ-8 was found to have good validity when compared to the clinical assessments conducted by psychologists using the gold standard, Structured Clinical Interview for DSM-V (SCID). In the sample living with HIV, the optimal cut-off was ≥6 with an area under the curve of 89% (95% CI: 83%–93%). A quarter (N=127, 25.7%) of the 495 mothers in our sample experienced repeat CMD symptoms and a further 33.5% experienced CMD symptoms at one timepoint, with no difference by trial arm. Associated risk factors for CMD included food insecurity (aOR=2.23 (1.32, 3.78) p=0.003); domestic violence (aOR=3.12 (95% CI: 1.71, 5.70) p<0.001); mobility problems (aOR=2.71 (1.55, 4.72) p<0.001); increased pain and discomfort (aOR=1.61 (0.19, 2.43) p=0.015), low resilience (aOR=0.61 (0.42, 0.89) p=<0.010) and low postpartum bonding (aOR=3.13 (1.78, 5.52) p<0.001). CMD was associated with increased parenting stress. Mean parenting stress (total score) standard deviation scores (SD) were higher among mothers with repeat CMD symptoms (97.1, SD 15.0) compared to those with CMD symptoms at one timepoint (84.8, SD 14.8) and those without CMD symptoms (78.0, SD 12.8). Children of parents with repeat CMD were almost three times as likely to have been spanked >20 times as opposed to children with no CMD symptoms (14.2% vs 5.0%). A multivariate model found no association between repeat CMD symptoms and harsh discipline after adjusting for parenting stress. The process evaluation provided evidence that complex parenting interventions are feasible, but there is a need to foresee and address potential contextual and individual barriers to uptake. A major learning point was that future interventions targeting mothers living with HIV should consider lessons learnt from the CHIDO intervention and seek to comprehensively address risk factors not only affecting their parenting outcomes but their mental health. Conclusion The SSQ-8 has been shown to be valid for the use of screening common mental disorders in a population with high HIV prevalence. There is a high burden of mental health conditions in mothers living with HIV. These mothers have been shown to be at risk of experiencing depressive symptoms at different trajectories of their parenting journey, with several risk factors identified. Therefore, there is a need for interventions aimed at improving parenting and child outcomes and also to target addressing the risk factors associated with poor maternal mental health.

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