Effectiveness of A Psycho-Education Model on The Quality of Life of Women with Anxiety and Depressive Disorders in Resource Poor Settings in Laikipia County, Kenya by Gladys Kabura Mwangi 13-0392 A dissertation presented to the School of Human & Social Sciences of Daystar University Nairobi, Kenya In partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY in Clinical Psychology May 2016 APPROVAL PAGE Daystar University Repository Library Archives Copy ii EFFECTIVENESS OF A PSYCHO-EDUCATION MODEL ON THE QUALITY OF LIFE OF WOMEN WITH ANXIETY AND DEPRESSIVE DISORDERS IN RESOURCE POOR SETTINGS IN LAIKIPIA COUNTY, KENYA by Gladys Kabura Mwangi 13-0392 In accordance with Daystar University policies, this dissertation is accepted in partial fulfillment of the requirements for the Doctor of Philosophy degree. Date: _____________________ Anne W. Mbwayo, Ph.D., Supervisor ____________________ ______________________ Emil Chandran, Ph.D., Supervisor _____________________ ______________________ Alice Munene, Psy.D., Coordinator, Ph.D. Clinical Psychology _____________________ _______________________ _____________________ Kennedy Ongaro, Ph.D., Dean, School of Human and Social Sciences Daystar University Repository Library Archives Copy ii i Copyright © 2016 by Gladys Kabura Mwangi DECLARATION EFFECTIVENESS OF A PSYCHO-EDUCATION MODEL ON THE QUALITY OF Daystar University Repository Library Archives Copy iv LIFE OF WOMEN WITH ANXIETY AND DEPRESSIVE DISORDERS IN RESOURCE POOR SETTINGS IN LAIKIPIA COUNTY, KENYA I declare that this research is my original work and has not been submitted to any other college or university for academic credit. Signed: ________________________ Date: ____________________________ Gladys Kabura Mwangi (13-0392) ACKNOWLEDGEMENTS I thank God the almighty for bringing me this far, for his strength, protection, comfort and provision in all seasons. Heartfelt gratitude goes to my supervisors. I would like to Daystar University Repository Library Archives Copy v profoundly thank Dr. Anne Mbwayo, who has selflessly worked to guide and offer me valuable insights and unwavering support throughout this entire process. I would also like to convey my sincere appreciation and gratitude to Professor Emil Chandran, for his kind understanding, direction, thoughtfulness and guidance through this process. I also wish to thank Dr. Alice Munene, for her valuable inputs during this process. A sincere thank you goes to Prof. Rebecca Oladipo for her guidance and assistance in ensuring that the study document met the required APA standards. I would also like to thank Mr. Peter Hetz, the Executive Director of the Laikipia Wildlife Forum (LWF), for allowing his community liaison staff to introduce me to the women’s Conservation Enterprise Groups (CEG). Heartfelt gratitude goes to my parents. To my late father, Bethuel Mwangi, who encouraged me to always reach for greater heights and to my mother Margaret Wanjiku for her unwavering support and encouragement. She has always urged me to strive towards achieving as much as the Lord would allow and help me in the education field. Sincere thanks to my entire family and specifically to my eldest sister Charity Mwangi for her prayers and moral support. Special appreciation goes to my children Michael Ndungu Njagui and Angela Wanjiku Njagui and to their dear father, Samuel Njagui, for all your love, support and encouragement that they have accorded me. Sam, I would never have completed this journey without you. May the Lord bless you in abundance. TABLE OF CONTENTS APPROVAL PAGE…………………………………………………………………… ii DECLARATION……………………………………………………………………….. iv ACKNOWLEDGEMENTS…………………………………………………………….. v TABLE OF CONTENTS ………………………………………………………………. vi LIST OF TABLES………………………………………………………………………. viii LIST OF FIGURES …………………………………………………………………….. ix Daystar University Repository Library Archives Copy vi LIST OF ABBREVIATIONS AND ACRONYMS…………………………………….. x ABSTRACT …………………………………………………………………................. xi DEDICATION………………………………………………………………………….. xiii CHAPTER ONE: INTRODUCTION AND BACKGROUND TO THE STUDY……… 1 1.1 Introduction ………………………………………………………………………… 1 1.2 Background to the Study………………………………………………………….… 1 1.3 Statement of the Problem…………………………………………………………… 9 1.4 Purpose of the Study…………………………………………………………........... 11 1.5 Objectives of the Study……………………………………………………………... 11 1.6 Research Questions…………………………………………………………............. 11 1.7 Null Hypotheses…………………………………………………………………….. 12 1.8 Justification of the Study…………………………………………………................. 12 1.9 Significance of the Study…………………………………………………………… 14 1.10 Assumptions of the Study………………………………………………................. 15 1.11 Scope of the Study………………………………………………………………….. 15 1.12 Limitations and Delimitations of the Study………………………………............... 15 1.13 Definition of Terms…………………………………………………………............. 16 1.14 Summary……………………………………………………………………………. 20 CHAPTER TWO: LITERATURE REVIEW……………………………………………. 21 2.1 Introduction…………………………………………………………………………... 21 2.2 Theoretical Framework………………………………………………………............. 21 2.2.1 Carl Roger’s Theory of Personality Related to Self-Concept…………………... 21 2.2.2 Morse’s Theory on Psycho-Education…………………………………………….. 24 2.3 General Literature Review……………………………………………………............ 25 2.4 Empirical Literature Review…………………………………………………............. 31 2.5 Conceptual Framework………………………………………………………………. 48 2.6 Discussion……………………………………………………………………………. 49 2.7 Summary……………………………………………………………………………... 50 CHAPTER THREE: RESEARCH METHODOLOGY…………………………………. 51 3.1 Introduction…………………………………………………………………………... 51 3.2 Research Design……………………………………………………………………… 51 3.3 The Study Site and Population……………………………………………………….. 52 3.4 Target Population…………………………………………………………………….. 54 3.5 Sample Size…………………………………………………………………………... 55 3.6 Sampling Techniques………………………………………………………………… 58 3.7 Recruitment Procedure……………………………………………………………….. 60 3.8 Inclusion and Exclusion Criteria……………………………………………………... 61 3.9 Data Collection Instruments………………………………………………………….. 61 3.10 Pretesting Exercise……………….………………………………………………… 65 3.11 Data Collection Procedures………………………………………………………… 65 3.12 Data Analysis Plan………………………………………………………………….. 67 3.13 Data Presentation…………………………………………………………………… 70 3.14 Data Management Plan………………………………………………………........... 70 Daystar University Repository Library Archives Copy vi i 3.15 Ethical Considerations……………………………………………………………… 71 3.16 Summary……………………………………………………………………………. 74 CHAPTER FOUR: DATA PRESENTATION, ANALYSIS AND INTERPRETATION 75 4.1 Introduction…………………………………………………………………………... 75 4.2 Presentation, Analysis and Interpretation According to Research Objectives………. 76 4.3 Summary of Key Findings…………………………………………………………… 108 4.4 Summary …………………………………………………………………………….. 113 CHAPTER FIVE: DISCUSSIONS, CONCLUSIONS AND RECOMMENDATIONS... 115 5.1 Introduction…………………………………………………………………………... 115 5.2 Discussion of Key Findings in Relation to Socio-Demographic Data……………….. 115 5.3 Discussion of Key Findings in Relation to the Research Objectives………………… 118 5.4 Conclusions…………………………………………………………………………... 125 5.5 Study Recommendations………………………………………………………........... 125 5.6 Recommendations for Further Research………………………………………........... 128 REFERENCES…………………………………………………………………………… 130 APPENDICES Appendix A: EUROHIS-8- Item- QOL-Index- English Version………………………….. 142 Appendix B: EUROHIS-8-Item-QOL-Index-Swahili Version.......…………………………. 144 Appendix C: Beck’s Depression Inventory /English Swahili Version…………………..... 144 Appendix D: Beck’s Anxiety Inventory- English Version…………………………………... 152 Appendix E: Beck’s Anxiety Inventory-Swahili Version…………………………………….. 153 Appendix F: Informed Consent Form Experimental Group…………………………….. 150 Appendix G: Informed Consent Form Control Group………………………………….... 152 Appendix H: Template to Guide Informed Consent- Maa Version................................... 158 Appendix I: Flow-Chart for Data Collection & Analysis………………………………... 159 Appendix J: Description of the Intervention/Minimum Package for Psycho-Education... 159 Appendix K: Map of Laikipia County (Source, LWF, 2013)…………………………….. 173 Appendix L: Approval from Nairobi Hospital Ethical Review Board (ERB)……………. 169 Appendix M: NACOSTI Research Permit……………………………………………...... 170 Appendix N: VITA GLADYS K. MWANGI……………………………………………………... 172 LIST OF TABLES Table 2.1: Quality of Life Domains………………………………….……………............. 29 Table 3.1: Target Population of Study-CE Groups in Laikipia County …… 54 Table 3.2: Sampling Frame: Laikipia North Conservation Enterprise Groups……… 56 Table 3.3: Sampling Unit……………………………………………………………………. 60 Table 4.1: Demographic Data……………………………………………………………... 78 Table 4.2: Socio-Demographic Variations of EG and CG at Baseline……………….. 80 Table 4.3: Correlation between Socio-Demographic Factors and Anxiety…………... 82 Table 4.4: Correlation between Socio-Demographic Factors and Depression……... 84 Table 4.5: Correlation between Socio-Demographic Factors and QoL……………… 86 Table 4.6: Regression Analysis and Anxiety………………………………………........... 87 Daystar University Repository Library Archives Copy vi ii Table 4.7: ANOVA tests for Socio-Demographic Factors Associated with Anxiety… 88 Table 4.8: Coefficients of Determination for Socio-demographic Factors Influencing Anxiety……………………………………………………………... 89 Table 4.9: Regression Analysis and Depression…………………………………………. 89 Table 4.10: ANOVA Tests and Depression……………………………………………….. 90 Table 4.11: Coefficients of Determination for Depression……………………………... 90 Table 4.12: Regression Analysis and QoL………………………………………………... 91 Table 4.13: ANOVA Tests and QoL………………………………………………………... 91 Table 4.14: Coefficients of Determination for QoL……………………………………… 92 Table 4.15: Prevalence of Anxiety in EG and CG…………………………………......... 94 Table 4.16: Prevalence of Depressive Symptoms for both EG and CG………………. 95 Table 4.17: Comorbid Symptoms of Anxiety and Depression for EG and CG………. 96 Table 4.18: Bi-variate Analysis of Comorbid Symptoms of Anxiety and Depression at Baseline for EG…………………………………………………………… 97 Table 4.19: Bi-variate Analysis on the Correlation between Comorbid Symptoms of Anxiety and Depression at Intervention/ Treatment Two for EG………. 98 Table 4.20: QoL Domain Scores for Both EG and CG at Baseline, after Treatments One and Two…………………………………………………………………… 100 Table 4.21: Time Series Testing the Overall Means of Anxiety and Depression after Psycho-Education Treatment……………………………………………….. 102 Table 4.22: Bi-Variate Analysis on the Correlation between Anxiety and QoL…… 102 Table 4.23: Bi-Variate Analysis on the Correlation between Depression and QoL… 103 Table 4.24: Levene's and T-test at Baseline……………………………………………… 105 Table 4.25: T-test after Psycho-Education Treatment /Intervention One…………..... 106 Table 4.26: T-test after Psycho-Education Treatment /Intervention Two…………….. 107 Table 4.27: ANOVA Tests to Measure Depressive and Anxiety symptoms in the Absence of the Psycho-Education Treatment for the Control Group… 108 Table 4.28: ANOVA Tests to Measure Depressive and Anxiety Symptoms after the Psycho-Education Treatment in the Experimental Group……………. 108 LIST OF FIGURES Figure 2.1: Quality of Life Model………………………………………………………….. 28 Figure 2.2: Conceptual Framework.……………………………..................................... 49 Figure 4.1: Trends of Anxiety, Depression and QoL Scores for EG & CG…………... 114 LIST OF ABBREVIATIONS & ACRONYMS BAI Beck’s Anxiety Inventory Daystar University Repository Library Archives Copy ix BDI Beck’s Depression Inventory CBNRM Community Based Natural Resource Management CBT Cognitive Behavioral Therapy CEG Conservation Enterprise Groups CMD Common Mental Health Disorders EUROHIS European Health Index Scale GDI Gender Development Index GOK Government of Kenya HDI Human Development Index IPT Inter-Personal Therapy MDG Millennium Development Goals MT Motivational Therapy PWID People Who Inject Drugs QoL Quality of Life YDI Youth Development Index WHO World Health Organization ABSTRACT The objective of this study was to determine if the psycho-education model adopted for this study was effective in treating anxiety and depressive symptoms among women in resource poor settings (RPS), with an intention of improving their Quality of Life (QoL). Two theories that guided this study were Morse’s (2004) theory of psycho-education which is premised on imparting cognitive and social skills to improve the respondents’ self-esteem and Carl Roger’s theory of the concept of self (1961), towards selfactualization.. The quasi-experimental research design was used for this study. The Daystar University Repository Library Archives Copy x target population for this study was 686 female members of Conservation Enterprise Groups (CEG) in Laikipia. However, the sampling frame constituted of 484 members of female CEG members in Laikipia North. A sample size of 200 for both the experimental (EG) and control group (CG) was selected at 80% power and 30% effective size. Standardised tools were used to collect data on anxiety, depression and Quality of Life (QoL). These included Beck’s Anxiety Inventory (BAI)-for anxiety and the Beck’s Depression Inventory (BDI)-for depression and the EUROHIS 8-item- QoL index (for QoL). The study implemented an eclectic model of psycho-education to treat anxiety and depressive symptoms. Data was analysed using SPSS Version 21.0. This study established the prevalence of depression as 26.7% and that of anxiety as 79.4% among women living in resource poor settings. It also showed that if these symptoms were not treated, they degenerated into severe symptoms, as evidenced in the CG, where the psycho-education treatment was not provided. T-tests and Chi-square tests conducted at the end of the studies showed that the psycho-education treatment resulted in statistically significant improvements in anxiety (P<0.005), depression (P<0.005) and QoL scores (P<0.005). There is however need for further research to establish other socio-cultural and environmental factors that contribute to high levels of anxiety and depression and leading to poor QoL among women in resource poor settings in Laikipia. Daystar University Repository Library Archives Copy xi DEDICATION This research is dedicated to all the Maa speaking women who despite the challenges of the harsh climatic conditions that they live in, they continue to have strength to move forward and make ends meet to support and nurture their families in the face of adversities. Daystar University Repository Library Archives Copy xi i Daystar University Repository Library Archives Copy at Baseline for EG…………………………………………………………… 97 Psycho-Education Treatment……………………………………………….. 102 Psycho-Education Treatment in the Experimental Group……………. 108