Rwandan Adolescents Research Articles

Experiences of peer educators in a high school sexual and reproductive health peer education programme in Rwanda

Background: To contribute to a reduction in teenage pregnancy among in-school adolescents in Rwanda, a sexual and reproductive health peer education programme (SRHPEP) was developed and implemented. Reflecting on the unique characteristics of this newly implemented programme, and understanding peer educators’ (PEs) and facilitators’ perspectives, can provide insights into the programme’s effectiveness and feedback to improve the programme in the future. This study explored the experiences of being a PE in the SRHPEP from the perspectives of PEs and facilitators. Design: Qualitative exploratory design. Setting: Data collection took placed in three public high schools in Rwanda. Method: Three focus group discussions (FGDs) with 22 PEs and 5 in-depth interviews with facilitators were conducted. Results: Thematic analysis identified the benefits of being a PE, including increased competence, enhanced relationships and an improved society’s understanding of sexual and reproductive health (SRH). PEs faced challenges, however, including bullying, limited resources and time constraints. A support system (comprising PEs themselves, facilitators and school leadership) and refresher training made being a PE easier. Study participants suggested allocating enough time, training larger numbers of PEs and the provision of contextually relevant educational materials to improve the programme. Conclusion: Findings from this study can be used to guide the development of future ways of strengthening the SRHPEP in schools. They can also help to ensure that PEs are adequately supported in their roles and the needs of the students are met.

Relationship between Volunteerism and Empathy among Adolescents in Rwanda

Purpose: The aim of the study was to assess the relationship between volunteerism and empathy among adolescents in Rwanda. Materials and Methods: This study adopted a desk methodology. A desk study research design is commonly known as secondary data collection. This is basically collecting data from existing resources preferably because of its low cost advantage as compared to a field research. Our current study looked into already published studies and reports as the data was easily accessed through online journals and libraries. Findings: The study indicated that engaging in volunteer activities enhances adolescents' empathy levels, as these experiences expose them to diverse social situations and perspectives. Adolescents who volunteer tend to develop a greater understanding and sensitivity towards the needs and emotions of others. This empathy growth is attributed to the direct interactions and responsibilities involved in volunteering, which foster emotional and cognitive empathy. Moreover, the sense of purpose and fulfillment derived from helping others further reinforces empathetic behaviors. Overall, volunteerism serves as a significant developmental tool in nurturing empathy among adolescents, promoting their social and emotional well-being. Implications to Theory, Practice and Policy: Social learning theory, empathy development theory and theory of planned behavior may be used to anchor future studies on assessing the relationship between volunteerism and empathy among adolescents in Rwanda. In practice, schools and community organizations should design volunteer programs that are both structured and reflective to maximize empathy development. Policymakers should prioritize integrating volunteerism into the educational curriculum as a key component of social-emotional learning.

Effect of a digital school-based intervention on adolescent family planning and reproductive health in Rwanda: a cluster-randomized trial.

We conducted a cluster-randomized hybrid effectiveness-implementation study of CyberRwanda, a digital family planning and reproductive health intervention for Rwandan adolescents. Sixty schools were randomized 1:1:1 to control or to one of two implementation models-self-service (self-guided access on tablets) or facilitated (peer-led clubs plus tablet access) with no masking. Eligible participants were aged 12-19 years, in secondary school levels 1 or 2, and willing to provide consent or assent/parental consent and contact information for follow-up. In 2021, 6,078 randomly selected adolescents were enrolled. At 24 months, 91.3% of participants were retained and included in the primary intention-to-treat analyses (control, n = 1,845; self-service, n = 1,849 and facilitated, n = 1,858). There were no adverse events related to the study. CyberRwanda did not affect the primary outcomes of modern contraceptive use (prevalence ratio (PR) = 1.04; 95% confidence interval (CI) = 0.76, 1.42), childbearing (PR = 1.33; 95% CI = 0.71, 2.50) and HIV testing (PR = 1.00; 95% CI = 0.91, 1.11) in the full sample. Significantly higher modern contraceptive use observed in the CyberRwanda facilitated arm in a prespecified analysis of sexually active participants suggests that longer-term evaluation is needed to examine effects as more of the study population becomes sexually active and has increased demand for contraception. ClinicalTrials.gov registration: NCT04198272 .

“Not just the consequences, but also the pleasurable sex”: a review of the content of comprehensive sexuality education for early adolescents in Rwanda

BackgroundResponding to adolescents’ educational needs in sexual and reproductive health and rights (SRHR) is central to their sexual health and achieved through school-based comprehensive sexuality education (CSE). In 2016, Rwanda introduced CSE through the competence-based curriculum in schools to enhance learners’ knowledge about sexuality, gender, and reproductive health issues, including HIV/AIDS. However, globally, the content of CSE is sometimes dissimilar, and little evidence surrounds its scope in many settings, including Rwanda. In addition, the extent to which CSE aligns with international guidelines has yet to be well known. This study assesses major areas of CSE for early adolescents in Rwanda, analyses how CSE correlates with international guidelines and makes recommendations accordingly.MethodsWe reviewed the Rwandan competence-based curriculum to map CSE competences for early adolescents and conducted semi-structured interviews with key informants (N = 16). Eleven of the 23 curriculum documents met the selection criteria and were included in the final review. We manually extracted data using a standard form in Microsoft Excel and analysed data using frequency tables and charts. Interviews were thematically analysed in NVivo 11 for Windows.FindingsWe found 58 CSE competences for early adolescents across various subjects, increasing with school grades. All recommended CSE areas were addressed but to a variable extent. Most competences fall under four recommended areas: sexual and reproductive health; human body and development; values, rights, and sexuality; and understanding gender. The least represented area is violence and staying safe. Of the 27 expected topics, there are two to six CSE competences for 13 topics, one CSE competence for each of the six others, and none for the eight remaining ones. Qualitative findings support these findings and suggest additional content on locally controversial but recommended areas of sexual pleasure, orientation, desire and modern contraceptive methods.ConclusionThis study explores the CSE content for early adolescents in Rwanda and how they align with sexuality education standards. Ensuring equal coverage of CSE areas and addressing missing topics may improve CSE content for this age group and foster their SRHR.

“She is courageous because she does not care what people think about her…”: attitudes toward adolescent contraception use among Rwandan family planning providers and adult female modern contraceptive users

IntroductionIn Rwanda, only 20% of sexually active unmarried young women use family planning as compared to 64% of married women. Adolescence is an important time of growth and development that often includes the initiation of sexual activity. Sexually active adolescents need support in accessing contraceptive services to prevent negative health outcomes. In sub-Saharan Africa, the adolescent population represents a large share of the total population and that proportion is predicted to expand over time. Adolescent contraceptive needs have largely been unmet, and with growing numbers, there is increased potential for negative health sequelae. Due to the low use of contraception by adolescents in Rwanda, and the growing population of adolescents, this study aims to explore the perspectives of family planning providers and adult modern contraceptive users on adolescent contraceptive use. Inclusion of adult community members in the study is a unique contribution, as research on adolescent contraceptive use in sub-Saharan Africa relies primarily on perspectives from adolescents and family planning providers.MethodsThis qualitative study in 2018 utilized 32 in-depth interviews with modern contraceptive users and eight focus group discussions with family planning providers. Respondents were from Musanze and Nyamasheke districts in Rwanda, the districts with the highest and lowest modern contraceptive use among married women, respectively. Coding was conducted in Atlas.ti.ResultsStigma regarding premarital sex results in barriers to adolescent access to contraceptive services. Family planning providers do provide services to adolescents; however, they often recommend secondary abstinence, offer a limited method selection, and accentuate risks associated with sexual activity and contraceptive use. Providers support adolescent clients by emphasizing the need for privacy, confidentiality, and expedient services, particularly through youth corners, which are spaces within health facilities designed to meet youth needs specifically. Modern contraceptive-using adult female community members advocate for youth access to contraception, however mothers have mixed comfort discussing sexual health with their own youth.ConclusionTo destigmatize premarital sexual activity, government efforts to initiate communication about this topic must occur at national and community levels with the goal of continued conversation within the family. The government should also train family planning providers and all health personnel interacting with youth on adolescent-friendly health services. Dialogue between community members and family planning providers about adolescent access to contraceptive services could also reduce barriers for adolescents due to community members’ generally supportive views on adolescent contraceptive use. Efforts to engage adolescent caregivers in how to talk to youth about sex could also contribute to expanded use.

Digital self-care for improved access to family planning and reproductive health services among adolescents in Rwanda: preliminary findings from a pilot study of CyberRwanda

Adolescents experience significant barriers, including stigma and discrimination, to accessing voluntary family planning and reproductive health (FP/RH) services in Rwanda. Self-care interventions have been shown to reduce social barriers to FP/RH care, but little is known about the effectiveness of digital self-care for adolescents, particularly in low-resource settings. This paper presents findings from a pilot study of CyberRwanda, a digital self-care intervention providing comprehensive sexuality education and confidential online ordering of contraceptives for school-aged youth in Rwanda through a rights-based approach. A mixed-methods pilot study was conducted from November 2019 to February 2020 to assess feasibility, acceptability, and engagement and to inform a future impact evaluation. Surveys were administered to a random sample of 158 students aged 12–19 years in three secondary schools. In-depth interviews were conducted with students, parents, teachers, pharmacists, district-level administrators, and youth centre staff. Descriptive statistics were calculated and qualitative data were analyzed using a thematic coding approach. One hundred and fifty-eight surveys and 28 interviews were conducted. Results revealed high demand for CyberRwanda in schools. Students were interested in engaging with the program and found the FP/RH content relevant to their needs. However, few purchased contraceptive products through the online ordering system. There are preliminary indications that CyberRwanda may improve access to FP/RH information. An extended implementation period and further research are needed to measure the long-term impacts of the program and evaluate whether this digital self-care intervention can increase uptake of contraceptive methods and reduce adolescent pregnancy among school-aged youth.

Design and impact evaluation of a digital reproductive health program in Rwanda using a cluster randomized design: study protocol

BackgroundRwandan adolescents have limited access to high-quality family planning and reproductive health (FP/RH) information and care to prevent unplanned pregnancy and HIV/STIs. In addition to the immediate implications for health and well-being, teenage pregnancy is a significant cause of school drop-out, limiting girls’ future potential and employment opportunities. This study introduces a direct-to-consumer digital education program that uses storytelling to deliver age-appropriate FP/RH information and economic empowerment training to adolescents. It also facilitates access to high-quality, youth-friendly FP/RH care and products. We evaluate two different school-based models of its implementation to understand how to optimize the uptake of contraception and HIV testing among adolescents.MethodsThe study consists of two distinct phases. The first formative intervention design phase, conducted from 2016 to 2019, used a human-centered design methodology to develop the intervention alongside over 600 Rwandan adolescents, their parents, teachers, and healthcare providers. Through this methodology, we sought to maximize the fit between evidence-based practices (uptake of modern contraception and HIV testing) and the implementation context of adolescents in Rwanda. The second phase is an impact evaluation, in which we will use a Hybrid Trial Type 2 Effectiveness-Implementation study design to determine the overall effectiveness of this digital intervention as well as the relative effectiveness of the two different school-based implementation models. This takes the form of a 3-arm cluster-randomized non-inferiority trial, with a sample of 6000 youth aged 12–19 in 60 schools across 8 districts in Rwanda. Primary outcome measures include use of modern contraception, delayed initiation of childbearing, and uptake of HIV testing.DiscussionThis study will yield insights into not only whether this digital intervention is successful in achieving the intended sexual and reproductive health outcomes, but also which mechanisms are likely to drive this effectiveness. The methodologies used are broadly applicable to the design, implementation, and evaluation of other behavior-based health programs in low and middle-income countries.Trial registrationClinicalTrials.gov Identifier: NCT04198272. Prospectively registered 13 December 2019.

Understanding Adolescent Sexual & Reproductive Health Behavior & Care Access in a Rwandan Community [36A

INTRODUCTION: The prevalent sexual norms and behaviors of rural Rwandan adolescents, including barriers to accessing and utilizing reproductive healthcare services, were explored qualitatively. METHODS: Focus groups were conducted with adolescents in the rural community of Kibogora, Rwanda. Participants included students from local secondary schools and adolescents not in school. Interview guides were adapted from validated World Health Organization guides. Trained midwives conducted focus groups in the local language. All were recorded, interpreted, transcribed and coded for themes. Interviewers were matched in gender with interviewees. Each subject completed a demographic survey with questions pertaining to sex and personal relationships. RESULTS: One hundred twenty-six adolescents (14-24 years) participated. Fourteen focus groups were conducted. Predominant themes include prevalence of transactional sex, need for sexual and reproductive health knowledge, need for increased access to condoms and services, fear of pregnancy and sexually transmitted infections, and confidentiality issues related to obtaining care. Adolescents correctly identify risks of having unsafe sex (infectious disease and pregnancy) but feel obtaining services is socially prohibitive. Adolescents consistently overestimate the number of sexually active peers when compared to the low number of adolescents reporting sexual activity on anonymous surveys. CONCLUSION: It is not only important to involve the local community, including adolescents, in designing and implementing any sexual and reproductive health educational program but it is also important to create safe and comfortable avenues for adolescents to access confidential services.

Individual-level factors associated with mental health in Rwandan youth affected by HIV/AIDS.

Prevention of mental disorders worldwide requires a greater understanding of protective processes associated with lower levels of mental health problems in children who face pervasive life stressors. This study aimed to identify culturally appropriate indicators of individual-level protective factors in Rwandan adolescents where risk factors, namely poverty and a history of trauma, have dramatically shaped youth mental health. The sample included 367 youth aged 10-17 in rural Rwanda. An earlier qualitative study of the same population identified the constructs "kwihangana" (patience/perseverance) and "kwigirira ikizere" (self-esteem) as capturing local perceptions of individual-level characteristics that helped reduce risks of mental health problems in youth. Nine items from the locally derived constructs were combined with 25 items from an existing scale that aligned well with local constructs-the Connor-Davidson Resilience Scale (CD-RISC). We assessed the factor structure of the CD-RISC expanded scale using exploratory factor analysis and determined the correlation of the expanded CD-RISC with depression and functional impairment. The CD-RISC expanded scale displayed high internal consistency (α = 0.93). Six factors emerged, which we labeled: perseverance, adaptability, strength/sociability, active engagement, self-assuredness, and sense of self-worth. Protective factor scale scores were significantly and inversely correlated with depression and functional impairment (r = -0.49 and r = - 0.38, respectively). An adapted scale displayed solid psychometric properties for measuring protective factors in Rwandan youth. Identifying culturally appropriate protective factors is a key component of research associated with the prevention of mental health problems and critical to the development of cross-cultural strength-based interventions for children and families.

Prevalence and incidence of clinically recognized cases of Type1 diabetes in children and adolescents in Rwanda, Africa.

To determine prevalence and incidence estimates for clinically recognized cases of Type1 diabetes from the Life For a Child Program (LFAC) with onset<26years in six representative districts, and the capital, of Rwanda. Cases were identified from the LFAC registry and visits to district hospitals. Denominators were calculated from district-level population surveys. Period prevalence data were collected from 1 August 2011 to 31 July 2012 and annual incidence rates were calculated, retrospectively, for 2004-2011. Ninety-five percent confidence intervals (95% CI) were calculated using a Poisson distribution. The prevalence of known Type1 diabetes in seven districts in Rwanda for ages<26years was 16.4 [95% CI 14.6-18.4]/100000 and for<15years was 4.8 [3.5-6.4]/100000. Prevalence was higher in females (18.5 [15.8-21.4]/100000) than males (14.1 [11.8-16.7]/100000; P=0.01) and rates increased with age. The annual incidence rate for those<26years was stable between 2007 and 2011 with a mean incidence over that time of 2.7 [2.0-3.7]/100000 (<15years=1.2 [0.5-2.0]/100000). Incidence rates were higher in females than males and peaked in males at ages 17 and 22years and in females at age 18years. Our report of known Type1 diabetes cases shows lower incidence and prevalence rates in Rwanda than previously reported in the USA and most African countries. Incidence of recognized cases has increased over time, but has recently stabilized. However, the likelihood of missed cases due to death before diagnosis and misdiagnosis is high and therefore more definitive studies are needed.

Long-term Effectiveness of Combination Antiretroviral Therapy and Prevalence of HIV Drug Resistance in HIV-1–infected Children and Adolescents in Rwanda

To determine the long-term outcomes of treatment and prevalence of genotypic drug resistance in children and adolescents on combination antiretroviral therapy. A cross-sectional study (September 2009 to October 2010) in which clinical, immunologic and virologic outcomes were assessed at a single-study visit and through patient records in a cohort of HIV-infected children and adolescents. Risk factors for clinical and immunologic responses and virologic outcome were evaluated using logistic regression, and the accuracy of clinical and immunologic criteria in identifying virologic failure was assessed. Four hundred twenty-four patients were enrolled with a median age of 10.8 years (range: 1.7-18.8) and a median duration on combination antiretroviral therapy of 3.4 years (range: 1.0-8.1). Thirty-three percent were stunted and 17% underweight. Eighty-four percent (95% confidence interval: 79-87) of children >5 years had CD4 ≥350 cells/mm and in 74% (95% confidence interval: 62-84) of younger children CD4% was ≥25. CD4 values and age at combination antiretroviral therapy initiation were independently associated with CD4 outcomes; 124 (29%) had HIV-1 RNA ≥1000 copies/mL, with no significant predictors. Sensitivity for weight-for-age and height-for-age and CD4 cells (<350/mm) remained under 50% (15-42%); CD4 cells showed the best specificity, ranging from 91% to 97%. Of 52 samples tested, ≥1 mutations were observed in 91% (nucleoside reverse transcriptase inhibitors) and 95% (non-nucleoside reverse transcriptase inhibitors); 1 to 2 thymidine analogue-associated mutations were detected in 16 (31%) and ≥3 thymidine analogue-associated mutations in 7 (13%). Nearly 1 in 3 children showed virologic failure, and >10% of the subgroup of children with treatment failure in whom genotyping was performed demonstrated multiple HIV drug resistance mutations. Neither clinical condition nor CD4 cells were good indicators for treatment failure.

THOUGHT FIELD THERAPY EFFICACY FOLLOWING LARGE SCALE TRAUMATIC EVENTS

Thought Field Therapy Efficacy Following Large Scale Traumatic Events: Description of Four Studies Thought Field Therapy (TFT) has been shown to reduce symptoms of Posttraumatic Stress (PTS) with trauma survivors in four studies in Africa. In a 2006 preliminary study, orphaned Rwandan adolescents, who reported ongoing trauma symptoms since the 1994 genocide, were treated with TFT. A 2008 Randomized Controlled Trial (RCT) examined the efficacy of TFT treatments facilitated by Rwandan Community leaders in reducing PTS symptoms in adult survivors of the 1994 genocide. Results of the 2008 study were replicated in a second RCT in Rwanda in 2009. A fourth RCT in Uganda (in preparation for submission) demonstrated significant differences in a third community leader-administered TFT treatment. The studies described here suggest that one-time, community leader-facilitated TFT interventions may be beneficial with protracted PTS in genocide survivors.

Factors that Hinder Parents from the Communicating of Sexual Matters with Adolescents in Rwanda

Parent-adolescent communication about sexual matters is one of the means that encourages adolescents to adopt responsible sexual behaviour. However, parents do not discuss sexual matters with adolescents and those who discuss to some extent; little information about sexuality is provided. This study, was, therefore aimed to find out the factors that hindered parents from communicating with their adolescent children on sexual matters. A descriptive, cross sectional study employing both quantitative and qualitative approaches was utilized. Simple random sampling was used to select households of parents/caretakers with adolescents and face to face interviews were used to collect data in February 2011. Out of 388 respondents, majority (81%) reported that they do not discuss sexual matters with the adolescents due to socio-demographic, cultural, individual and socio-environmental factors/barriers. Being male (p=0.04), parents’ age over 44 years (OR&lt; 1 at 95% CI), lower levels of education (≤primary) and income (farming and remittance) was significantly associated with “not communicating” sexual matters with the adolescents (p&lt;0.05). These findings strengthen the need for continued sensitization of parents/caretakers to involve themselves in discussing sexual matters with the adolescents. Furthermore, guidance of parents/caretakers on how to approach the subject of sexuality and sustenance of discussions with the adolescents is paramount.Key words: Communication, Sexual matters, Parents/ Caretakers, Adolescents

Living Situation Affects Adherence to Combination Antiretroviral Therapy in HIV-Infected Adolescents in Rwanda: A Qualitative Study

IntroductionAdherence to combination antiretroviral therapy (cART) is vital for HIV-infected adolescents for survival and quality of life. However, this age group faces many challenges to remain adherent. We used multiple data sources (role-play, focus group discussions (FGD), and in-depth interviews (IDI)) to better understand adherence barriers for Rwandan adolescents. Forty-two HIV positive adolescents (ages 12–21) and a selection of their primary caregivers were interviewed. All were perinatally-infected and received (cART) for ≥12 months. Topics discussed during FGDs and IDIs included learning HIV status, disclosure and stigma, care and treatment issues, cART adherence barriers.ResultsMedian age was 17 years, 45% female, 45% orphaned, and 48% in boarding schools. We identified three overarching but inter-related themes that appeared to influence adherence. Stigma, perceived and experienced, and inadvertent disclosure of HIV status hampered adolescents from obtaining and taking their drugs, attending clinic visits, carrying their cARTs with them in public. The second major theme was the need for better support, in particular for adolescents with different living situations, (orphanages, foster-care, and boarding schools). Lack of privacy to keep and take medication came out as major barrier for adolescents living in congested households, as well the institutionalization of boarding schools where privacy is almost non-existent. The third important theme was the desire to be ‘normal’ and not be recognized as an HIV-infected individual, and to have a normal life not perturbed by taking a regimen of medications or being forced to disclose where others would treat them differently.ConclusionsWe propose better management of HIV-infected adolescents integrated into boarding school, orphanages, and foster care; training of school-faculty on how to support students and allow them privacy for taking their medications. To provide better care and support, HIV programs should stimulate caregivers of HIV-infected adolescents to join them for their clinic visits.

Validating the Center for Epidemiological Studies Depression Scale for Children in Rwanda

We assessed the validity of the Center for Epidemiological Studies Depression Scale for Children (CES-DC) as a screen for depression in Rwandan children and adolescents. Although the CES-DC is widely used for depression screening in high-income countries, its validity in low-income and culturally diverse settings, including sub-Saharan Africa, is unknown. The CES-DC was selected based on alignment with local expressions of depression-like problems in Rwandan children and adolescents. To examine criterion validity, we compared CES-DC scores to depression diagnoses on a structured diagnostic interview, the Mini International Neuropsychiatric Interview for Children (MINI KID), in a sample of 367 Rwandan children and adolescents aged 10 through 17 years. Caregiver and child or adolescent self-reports endorsing the presence of local depression-like problems agahinda kenshi (persistent sorrow) and kwiheba (severe hopelessness) were also examined for agreement with MINI KID diagnosis. The CES-DC exhibited good internal reliability (α = .86) and test-retest reliability (r = .85). The area under the receiver operating characteristic curve for the CES-DC was 0.825 when compared to MINI KID diagnoses, indicating a strong ability to distinguish between depressed and nondepressed children and adolescents in Rwanda. A cut point of≥30 corresponded with a sensitivity of 81.9% and a specificity of 71.9% in this referred sample. MINI KID diagnosis was well aligned with local expressions of depression-like problems. The CES-DC demonstrates good psychometric properties for clinical screening and evaluation in Rwanda, and should be considered for use in this and other low-resource settings. Population samples are needed to determine a generalizable cut point in nonreferred samples.

A question of maturity: The participation, decision-making and rights of children in the context of HIV/AIDS

This article examines international, regional and national sources of law with respect to the rights of children and considers how a strict age of majority affects adolescents' access to health care. Using Rwanda as a case study, this article outlines how a high age of majority, combined with mandatory parental consent, creates barriers for Rwandan adolescents to prevent human immunodeficiency virus (HIV) transmission, learn their status and receive treatment for the disease. It further examines the relevant legal and policy framework of the Rwandan Government in order to suggest successful methods to gauge a child's maturity level for Rwanda and other countries. The article argues for the improvement of adolescents' level of participation in making health decisions, and thereby also increasing their access to HIV/acquired immune deficiency syndrome (AIDS) services.

Ten years after the genocide: Trauma confrontation and posttraumatic stress in Rwandan adolescents

A decade after the 1994 Rwandan genocide, we interviewed a total of 68 Rwandan orphans about their war experiences and posttraumatic stress disorder (PTSD) symptoms. The two samples comprised youth living either in a child-headed household (CHH) or in an orphanage. All had been exposed to extreme levels of violence and 41% had witnessed the murder of their own mother or father. Of the sample, 44% had PTSD. PTSD vulnerability was greater for youth who at the time of the study lived in CHH than those in an orphanage; it was also higher in those aged 8 to 13 during the outbreak of the genocide than those aged 3 to 7 at the time. Furthermore, a significant relationship was found between the number of traumatic experiences and subsequent stress responses.