(WITHDRAWN) Is There an Association between Poverty Measures and Adverse Mental, Emotional, and Behavioral (MEB) Disorders Among Children and Adolescents (1-19 Years) in Sub-Saharan Africa (SSA)? a Systematic Review

Background: Although poverty is most prevalent in SSA and may have a detrimental impact on MEB health, the link between poverty and adverse MEB health outcomes among children/adolescents is not well established. Understanding the relationship between poverty and MEB disorders could complement the global efforts in effectively addressing mental health among children/adolescents and their development in SSA. This review seeks to address this gap by describing the common measures of poverty and MEB health outcomes, and assess if there is an association between poverty and MEB disorders across studies conducted in SSA.

Methods: Search questions and a search strategy was developed and implemented in five electronic databases including PubMed/MEDLINE, EMBASE, SCOPUS, The Web of Science, and ProQuest databases between the years 2003 and 2019. The search identified peer-reviewed observational and intervention studies reporting on the relationship between poverty and MEBH outcomes among children/adolescents in SSA. Studies were included if they were: 1) conducted in SSA, 2) quantitatively assessed in part or in full the relationship between poverty and MEB disorders, 3) included samples with children/ adolescents (ages 1-19), and 4) reported MEB health outcomes. Data extracted from studies included study design, measures of poverty and MEB disorders, effect sizes and results.

Results: Out of 19 studies included, 14 were correlational and five were intervention studies. Among correlational studies, 13 were cross-sectional, while intervention studies included three were randomized control trials (RCT), one case control and one cohort study. Selected studies were conducted in Kenya, Nigeria, Rwanda, South Africa, Uganda and Zimbabwe. Common measures of poverty are socioeconomic status (n=15) and food insecurity (n=8). Common measures of MEB disorders include depressive symptoms (n=12), internalizing and externalizing behaviors (n=8), post-traumatic stress disorder (n=5) and common mental health disorders (n=9) as a broad category. Despite the variations in poverty measures and MEB disorders, in most correlational studies (n=9), living in poor household was associated with greater risk of MEBH disorders. Conversely, economic empowerment and poverty alleviation intervention studies reduced material and relational poverty which resulted in the reduced risk of MEB disorders among children/adolescents.

Conclusion and implications: Correlational study findings consistently link a range of poverty dimensions with a range of MEB disorders among children/adolescents in SSA. Intervention study findings suggest that economic empowerment and poverty alleviation programs can effectively reduce the likelihood of having MEB disorders children/adolescents. Future research needs to dis-aggregate the patterns of comorbidity between different MEB disorders and provide a more detailed exploration of the interrelationship between biological, personal, social, and economic factors that impact children/adolescent MEB health outcomes in poor communities of SSA. Adopting multiple dimensional measures of poverty, where different dimensions or indicators of poverty are sequentially added to regression models to assess how much each strengthens or weakens the association could strengthen evidence in future studies. Finally, there is a need to qualitatively assess the complex local realities that yield essential differences within and between different SSA country contexts to support theory development.