The Mental Health Education Gap among Primary Care Providers in Rural Nepal

Mental Health Literacy and Education of Complementary Medicine Practitioners: A Cross-Sectional Study

An estimated 42% of Australians who consult complementary medicine (CM) practitioners have a mental health diagnosis. Preparedness of CM practitioners in managing such diagnoses is currently unknown. A cross-sectional survey of 257 CM practitioners who reported caring for people with a mental health diagnosis. Practitioners' mental health literacy, educational needs, and confidence in the assessment, management, and treatment of mental health-including suicide risk-were analysed. Most (59.1%) participants had no formal qualifications in mental health and 44.3% indicated they had not completed any training in psychological therapies. Only 20% were trained in mindfulness-based techniques or goal setting. Over 50% reported their undergraduate qualification contained insufficient mental health content to prepare them for clinical practice. Over one-half had attended continuing professional education on mental health. Practitioners reported greater confidence in assessing, managing, and treating mental wellbeing over complex mental health disorders and suicide risk. These findings uncovered a deficit in the CM practitioner's surveyed mental health education. As these CM practitioners are a primary point of contact for patients with mental health diagnoses, there is a critical need to expedite skills development in this workforce to support the delivery of safe and effective primary mental health care.

Attitudes toward depression among rural primary healthcare providers in hunan areas, China: a cross sectional study

BACKGROUND

Mental health services are not sufficient for depression patients in rural areas of China, training in mental health knowledge for primary healthcare providers has been encouraged, but the effect of this encouragement has rarely been reported.

METHODS

A cross-sectional survey was conducted in primary healthcare facilities that sought to include all the primary healthcare providers (registered physicians and nurses) in two cities in Hunan province, China by administering questionnaires that covered depression symptoms, typical depression cases, and the Revised Depression Attitude Questionnaire.

RESULTS

In total, 315 primary healthcare providers agreed to participate in the study and finished the questionnaires, of which 12.1% had training in depression. In addition, 62.9% of the rural primary healthcare providers were able to recognize most general depression symptoms, and 8.3% were able to recognize all general depression symptoms. The primary healthcare providers in the survey held a neutral to slightly negative attitude towards depression as indicated by their professional confidence (mean scores 16.51 ± 4.30), therapeutic optimism/pessimism (mean scores 29.02 ± 5.98), and general perspective (mean scores 18.12 ± 3.12) scores. Fewer rural primary healthcare providers knew (28.3%) or applied (2.9%) psychological intervention in the clinic.

CONCLUSIONS

Our study indicated that primary healthcare providers knew about general depression symptoms, but lacked psychological intervention skills and held low confidence in and pessimistic attitudes toward depression care. We therefore speculate that existing psychological training for primary healthcare providers is insufficient in quantity and quality, making the need to explore more effective types of training urgently.

A network meta-analysis of 12,116 individuals from randomized controlled trials in the treatment of depression after acute coronary syndrome

BACKGROUND

Post-acute coronary syndrome (ACS) depression is a common but not well understood complication experienced by ACS patients. Research on the effectiveness of various therapies remains limited. Hence, we sought to conduct a network meta-analysis to assess the efficacy of different interventions for post-ACS depression in improving patient outcomes.

METHODS AND FINDINGS

Three electronic databases were searched for randomised controlled trials describing different depression treatment modalities in post-ACS patients. Each article was screened based on inclusion criteria and relevant data were extracted. A bivariate analysis and a network meta-analysis was performed using risk ratios (RR) and standardized mean differences (SMD) for binary and continuous outcomes, respectively. A total of 30 articles were included in our analysis. Compared to standard care, psychosocial therapy was associated with the greatest reduction in depression scores (SMD:-1.21, 95% CI: -1.81 to -0.61, p<0.001), followed by cognitive behavioural therapy (CBT) (SMD: -0.75, 95% CI: -0.99 to -0.52, p<0.001), antidepressants (SMD: -0.73, 95% CI: -1.14 to -0.31, p<0.001), and lastly, combination therapy (SMD: -0.15, 95% CI: -0.28 to -0.03, p = 0.016). No treatment modalities was found to be more effective in reducing depression scores when compared to one another. Additional analysis showed that these treatment modalities did not have significant impact on the overall mortality, cardiac mortality and recurrent myocardial infarction.

CONCLUSION

This network meta-analysis found that the treatment effect of the various psychological modalities on depression severity were similar. Future trials on psychological interventions assessing clinical outcomes and improvement in adherence to ACS-specific interventions are needed.

Implementing Collaborative Care in Low-Resource Government, Research, and Academic Settings in Rural Nepal

The collaborative care model (CoCM) is a strategy of integrating behavioral health into primary care to expand access to high-quality mental health services in areas with few psychiatrists. CoCM is multifaceted, and its implementation is accelerating in high-resource settings. However, in low-resource settings, it may not be feasible to implement all CoCM components. Guidance is lacking on CoCM implementation when only some of its components are feasible. In this column, the authors used a cost-benefit approach to refine strategies for addressing common implementation challenges, incorporating the authors' experiences in what was gained and what was lost at each implementation step in three CoCM programs in diverse clinical settings in rural Nepal.

Cluster Analysis Algorithm in the Analysis of College Students' Mental Health Education

With the rapid development of curricula, a large number of studies are emerging to assist in the development of curricula. But in an information society, in the face of rapid learning and increased life expectancy, students face the pressure not to forget; the mental health status as a result of our curricula is closely related to our learning. The research and application of the integration algorithm plays an important role in the analysis of the mental health education system. The purpose of this work is to study the application analysis algorithm in the students' context. This work applies the integration analysis algorithm to students' mental health analysis and identifies students' mental health problems using the integration analysis algorithm so that students are well informed and guided. Based on the system engineering method, using the data mining clustering method, a detailed analysis and research on the mental health of college students is done. In this work, a method of student behavior analysis and statistical tools are used to collect mental health data to find common features of different groups of students, in order to better visualize and investigate the mental health of these students on a scientific basis. The results of this study are as follows: a general analysis algorithm application on the analysis of students' mental health education system allows for an effective understanding of scientific data. FCM and FCM algorithms based on the density of information entropy characteristics were used to investigate the effect of mental health factors on the results of the study and the practicality of the algorithm used, which provided an effective method for the prevention of student mental problems. Assisting the school in formulating corresponding new methods of early prevention and intervention of college students' psychological disorders will create a good and healthy atmosphere for college students' study and life. The research results provide a reliable basis for managing and cultivating students.

Collaborative care model for depression in rural Nepal: a mixed-methods implementation research study

INTRODUCTION

Despite carrying a disproportionately high burden of depression, patients in low-income countries lack access to effective care. The collaborative care model (CoCM) has robust evidence for clinical effectiveness in improving mental health outcomes. However, evidence from real-world implementation of CoCM is necessary to inform its expansion in low-resource settings.

METHODS

We conducted a 2-year mixed-methods study to assess the implementation and clinical impact of CoCM using the WHO Mental Health Gap Action Programme protocols in a primary care clinic in rural Nepal. We used the Capability Opportunity Motivation-Behaviour (COM-B) implementation research framework to adapt and study the intervention. To assess implementation factors, we qualitatively studied the impact on providers' behaviour to screen, diagnose and treat mental illness. To assess clinical impact, we followed a cohort of 201 patients with moderate to severe depression and determined the proportion of patients who had a substantial clinical response (defined as ≥50% decrease from baseline scores of Patient Health Questionnaire (PHQ) to measure depression) by the end of the study period.

RESULTS

Providers experienced improved capability (enhanced self-efficacy and knowledge), greater opportunity (via access to counsellors, psychiatrist, medications and diagnostic tests) and increased motivation (developing positive attitudes towards people with mental illness and seeing patients improve) to provide mental healthcare. We observed substantial clinical response in 99 (49%; 95% CI: 42% to 56%) of the 201 cohort patients, with a median seven point (Q1:-9, Q3:-2) decrease in PHQ-9 scores (p<0.0001).

CONCLUSION

Using the COM-B framework, we successfully adapted and implemented CoCM in rural Nepal, and found that it enhanced providers' positive perceptions of and engagement in delivering mental healthcare. We observed clinical improvement of depression comparable to controlled trials in high-resource settings. We recommend using implementation research to adapt and evaluate CoCM in other resource-constrained settings to help expand access to high-quality mental healthcare.

Mental health education in undergraduate medical curricula across Nepalese universities

BACKGROUND

Mental and substance use disorders account for 30 % of the non-fatal disease burden and 10 % of the overall disease burden but the treatment gap is daunting. With just one psychiatrist per 200,000 populations in Nepal, the only convincing way to improve access to the services quickly is by mobilizing non-specialized medical practitioner. A robust mental health component within the training curriculum of general medical doctors could produce medical graduates with adequate knowledge and skills to deliver basic mental health service. We reviewed the mental health curricula for medical students of all the medical universities in Nepal.

METHODS

Information on existing mental health curricula was collected from the faculty of the respective universities with respect to content coverage, teaching methods and evaluation patterns. The mental health curricula were described in relation to teaching duration, duration of clinical rotation, duration of internship, and the relative weight of mental health in examination marks. Teaching methods were classified broadly as passive and active. Assessment methods were documented. Content coverage of the curricula was evaluated with respect to history taking and general physical examination, the priority mental health conditions, topics on behavioural sciences, and child mental health or other topics.

RESULTS

The duration of teaching on mental health in general medical doctor training in Nepalese medical universities ranges from 25 to 92 h. All medical universities have a relative focus on the priority mental neurological and substance use disorders. The clinical rotation on mental health is mostly two weeks, except in one university where it can be extended up to 4 weeks with an elective clinical rotation. The relative weight of summative assessment ranges from 0.21 to 2.5 % total marks of the entire training.

CONCLUSIONS

Considerable disparities exist in course content, teaching/learning modalities and assessments for mental health across Nepalese medical universities. The relative proportion of mental health in medical curricula as well as teaching/learning and assessments are far below ideal in these universities. These findings suggest a need for increasing time allocation, adopting newer teaching learning methods, and also having a mandatory clinical rotation during training and during internship.

Mental health capacity building in Mali by training rural general practitioners and raising community awareness

Introduction

despite the high prevalence and significant burden of mental disorders, they remain grossly under-diagnosed and undertreated. In low-income countries, such as Mali, integrating mental health services into primary care is the most viable way of closing the treatment gap. This program aimed to provide a mental health training intervention to rural general practitioners (GPs), to organize community awareness activities, and to evaluate the impact on mental health knowledge and through the number of new patients diagnosed with mental disorders and managed by these general practitioners.

Methods

a pre-test/post-test design and the monthly monitoring of the number of new patients diagnosed with mental disorders by the trained GPs were used to evaluate the effect of the training interventions (two face-to-face group training workshops followed by individual follow-up supervisions) and of the community awareness activities.

Results

the mean knowledge score of the 19 GPs who completed the initial 12-day group training raised from 24.6/100 at baseline, to 61.5/100 after training (p<0.001), a 150% increase. Among them, sixteen completed the second 6-day group training with a mean score increasing from 50.2/100 to 70.1/100 (p<0.001), a 39.6% improvement. Between July 2018 and June 2020, 2,396 new patients were diagnosed with a mental disorder by the 19 GPs who took part in the program.

Conclusion

despite limited data regarding the effect of the community awareness component at this stage, the findings from this study suggest that the training intervention improved GPs' knowledge and skills, resulting in a significant number of new patients being identified and managed.

Cross-cultural adaptation of motivational interviewing for use in rural Nepal

Background

Motivational Interviewing (MI) has a robust evidence base in facilitating behavior change for several health conditions. MI focuses on the individual and assumes patient autonomy. Cross-cultural adaptation can face several challenges in settings where individualism and autonomy may not be as prominent. Sociocultural factors such as gender, class, caste hinder individual decision-making. Key informant perspectives are an essential aspect of cross-cultural adaptation of new interventions. Here, we share our experience of translating and adapting MI concepts to the local language and culture in rural Nepal, where families and communities play a central role in influencing a person’s behaviors.

Methods

We developed, translated, field-tested, and adapted a Nepali MI training module with key informants to generate insights on adapting MI for the first time in this cultural setting. Key informants were five Nepali nurses who supervise community health workers. We used structured observation notes to describe challenges and experiences in cross-cultural adaptation. We conducted this study as part of a larger study on using MI to improve adherence to HIV treatment.

Results

Participants viewed MI as an effective intervention with the potential to assist patients poorly engaged in care. Regarding patient autonomy, they initially shared examples of family members unsuccessfully dictating patient behavior change. These discussions led to consensus that every time the family members restrict patient's autonomy, the patient complies temporarily but then resumes their unhealthy behavior. In addition, participants highlighted that even when a patient is motivated to change (e.g., return for follow-up), their family members may not “allow” it. Discussion led to suggestions that health workers may need to conduct MI separately with patients and family members to understand everyone’s motivations and align those with the patient’s needs.

Conclusions

MI carries several cultural assumptions, particularly around individual freedom and autonomy. MI adaptation thus faces challenges in cultures where such assumptions may not hold. However, cross-cultural adaptation with key informant perspectives can lead to creative strategies that recognize both the patient’s autonomy and their role as a member of a complex social fabric to facilitate behavior change.

Unrecognized geriatric depression in the emergency Department of a Teaching Hospital in Nepal: prevalence, contributing factors, and metric properties of 5 item geriatric depression scale in this population

BACKGROUND

Depression is prevalent but poorly recognized in the Emergency Department (ED). We aimed to identify the frequency of unrecognized geriatric depression and its possible determinants in the ED using the 15-item geriatric depression scale (GDS). We also aimed to explore the performance of the shorter, five-item GDS as compared to the 15-item GDS.

METHODS

This was a cross-sectional study of the ED patients ≥ 60 years. The previously validated Nepali version of GDS-15 screened the sample into "no", "mild-moderate" and "severe" depression using cutoff values of 4/5, and 8/9 respectively. Demographic and socioeconomic factors, comorbidities and health seeking behaviors were studied and the relation was assessed with binary (Chi-square and Kruskal-Wallis test) and multinomial regression analysis. The performance of GDS-5 was compared with the GDS-15 as standard. Cronbach's alpha was calculated to investigate reliability. Validity was assessed by calculating sensitivity, specificity, positive predictive value, negative predictive value, Spearman's correlation, receiver operating characteristic curve, and kappa coefficient.

RESULTS

Two hundred eighty patients were enrolled with an overall prevalence of unrecognized depression of 45.7% [104 (81.3%) mild-moderate depression, and 24 (18.8%) severe depression]. The mean age of the sample was 71.36 with female predominance (61%), and 82.5% were illiterate. In the binary analysis, those who had more pain, visited the ED more often, had musculoskeletal diseases and sleep problems, mobility problems, visited local healers previously, and who reported self-perceived "heart and mind" disease showed statistically significant differences among the three categories. In multinomial regression analysis, visits to local healers, sleep problems and frequency of pain were significantly related to depression. The sensitivity, specificity, area under curve and Spearman's correlation of GDS-5 were 75.8%, 96%, 0.919, and 0.827 respectively. Cronbach's alpha for GDS-5 was low (0.416), therefore a new version was proposed which improved the sensitivity to 90.6% and Cronbach's alpha to 0.623.

CONCLUSIONS

Unrecognized geriatric depression was highly prevalent which urges the need for ED-based interventions for screening and referral. The proposed brief GDS-5 correlated well with the GDS-15 with better validity and internal reliability and offers a more expeditious form of screening for geriatric depression in emergency settings in Nepal.

Treatment recommendations made by a consultant psychiatrist to improve the quality of care in a collaborative mental health intervention in rural Nepal

BACKGROUND

The Collaborative Care Model (CoCM) for mental healthcare, where a consulting psychiatrist supports primary care and behavioral health workers, has the potential to address the large unmet burden of mental illness worldwide. A core component of this model is that the psychiatrist reviews treatment plans for a panel of patients and provides specific clinical recommendations to improve the quality of care. Very few studies have reported data on such recommendations. This study reviews and classifies the recommendations made by consulting psychiatrists in a rural primary care clinic in Nepal.

METHODS

A chart review was conducted for all patients whose cases were reviewed by the treatment team from January to June 2017, after CoCM had been operational for 6 months. Free text of the recommendations were extracted and two coders analyzed the data using an inductive approach to group and categorize recommendations until the coders achieved consensus. Cumulative frequency of the recommendations are tabulated and discussed in the context of an adapted CoCM in rural Nepal.

RESULTS

The clinical team discussed 1174 patient encounters (1162 unique patients) during panel reviews throughout the study period. The consultant psychiatrist made 214 recommendations for 192 (16%) patients. The most common recommendations were to revisit the primary mental health diagnosis (16%, n = 34), add or increase focus on counselling and psychosocial support (9%, n = 20), increase the antidepressant dose (9%, n = 20), and discontinue inappropriate medications (6%, n = 12).

CONCLUSIONS

In this CoCM study, the majority of treatment plans did not require significant change. The recommendations highlight the challenge that non-specialists face in making an accurate mental health diagnosis, the relative neglect of non-pharmacological interventions, and the risk of inappropriate medications. These results can inform interventions to better support non-specialists in rural areas.

Self-perceived competencies in the diagnosis and treatment of mental health disorders among general practitioners in Lima, Peru

AIM

To assess the self-perceived competencies in diagnosing and treating patients with mental health disorders, among recently graduated general practitioners (GPs) from Lima, Peru.

METHODS

A cross-sectional study was performed in April 2017 at a General Practitioner's meeting held for those who were going to perform the social service, by the Peruvian College of Physicians in Lima. Attendees were invited to answer a questionnaire that evaluated their self-perception of competence in diagnosing and treating four different mental health disorders; major depression, anxiety disorder, alcohol dependence, and schizophrenia.

RESULTS

Out of 434 evaluated GPs, the following percentages were self-perceived as competent in their adequate diagnosis of depression (70.5%), anxiety (73.3%), alcohol dependence (67.6%), and schizophrenia (62.0%). Concerning pharmacological treatment, these percentages were 46.6, 47.5, 39.0 and 37.6%, respectively. Referring to all the studied mental disorders, 41.6% of participants self-perceived competence in providing an adequate diagnosis, 36.1% in providing non-pharmacological treatment, and 20.1% in providing pharmacological treatment.

CONCLUSION

The rate of adequate self-perceived competences was higher for diagnosis than for treatment of patients with mental health disorders. These results highlight the importance of designing and implementing interventions to improve medical education so as to develop the skills necessary to confront mental health disorders.

Prevalence of geriatric depression in the Kavre district, Nepal: Findings from a cross sectional community survey

BACKGROUND

The increasing elderly population worldwide is likely to increase mental health problems such as geriatric depression, which has mostly been studied in high-income countries. Similar studies are scarce in low-and-middle-income-countries like Nepal.

METHODS

A cross-sectional, population-based, door-to-door survey was conducted in randomly selected rural and urban population clusters of the Kavre district, Nepal. Trained nurses (field interviewers) administered structured questionnaires that included a validated Nepali version of the Geriatric Depression Scale short form (GDS-15) for identifying geriatric depression among the elderly (≥60 years) participants (N = 460). Those scoring ≥6 on GDS-15 were considered depressed. Logistic regression analysis explored the associations of geriatric depression with regard to socio-demographic information, life style, family support and physical well-being.

RESULTS

Of the total 460 selected elderly participants, 439 (95.4%) took part in the study. More than half of them were females (54.2%). The mean age was 70.9 (± 8.6) years. Approximately half (50.6%) were rural inhabitants, the majority (86.1%) were illiterate, and about three-fifths (60.1%) were living with their spouses. The gender-and-age adjusted prevalence of geriatric depression was 53.1%. Geriatric depression was significantly associated with rural habitation (AOR 1.6), illiteracy (AOR 2.1), limited time provided by families (AOR 1.8), and exposure to verbal and/or physical abuse (AOR 2.6).

CONCLUSION

Geriatric depression is highly prevalent in Kavre, Nepal. The findings call for urgent prioritization of delivery of elderly mental health care services in the country.

Considering culture, context and community in mhGAP implementation and training: challenges and recommendations from the field

BACKGROUND

Major efforts are underway to improve access to mental health care in low- and middle-income countries (LMIC) including systematic training of non-specialized health professionals and other care providers to identify and help individuals with mental disorders. In many LMIC, this effort is guided by the mental health Gap Action Programme (mhGAP) established by the World Health Organization, and commonly centres around one tool in this program: the mhGAP-Intervention Guide.

OBJECTIVE

To identify cultural and contextual challenges in mhGAP training and implementation and potential strategies for mitigation.

METHOD

An informal consultative approach was used to analyze the authors' combined field experience in the practice of mhGAP implementation and training. We employed iterative thematic analysis to consolidate and refine lessons, challenges and recommendations through multiple drafts. Findings were organized into categories according to specific challenges, lessons learned and recommendations for future practice. We aimed to identify cross-cutting and recurrent issues.

RESULTS

Based on intensive fieldwork experience with a focus on capacity building, we identify six major sets of challenges: (i) cultural differences in explanations of and attitudes toward mental disorder; (ii) the structure of the local health-care system; (iii) the level of supervision and support available post-training; (iv) the level of previous education, knowledge and skills of trainees; (v) the process of recruitment of trainees; and (vi) the larger socio-political context. Approaches to addressing these problems include: (1) cultural and contextual adaptation of training activities, (2) meaningful stakeholder and community engagement, and (3) processes that provide support to trainees, such as ongoing supervision and Communities of Practice.

CONCLUSION

Contextual and cultural factors present major barriers to mhGAP implementation and sustainability of improved services. To enable trainees to effectively apply their local cultural knowledge, mhGAP training needs to: (1) address assumptions, biases and stigma associated with mental health symptoms and problems; (2) provide an explicit framework to guide the integration of cultural knowledge into assessment, treatment negotiation, and delivery; and (3) address the specific kinds of problems, modes of clinical presentations and social predicaments seen in the local population. Continued research is needed to assess the effectiveness these strategies.

Designing and implementing an integrated non-communicable disease primary care intervention in rural Nepal

Low-income and middle-income countries are struggling with a growing epidemic of non-communicable diseases. To achieve the Sustainable Development Goals, their healthcare systems need to be strengthened and redesigned. The Starfield 4Cs of primary care-first-contact access, care coordination, comprehensiveness and continuity-offer practical, high-quality design options for non-communicable disease care in low-income and middle-income countries. We describe an integrated non-communicable disease intervention in rural Nepal using the 4C principles. We present 18 months of retrospective assessment of implementation for patients with type II diabetes, hypertension and chronic obstructive pulmonary disease. We assessed feasibility using facility and community follow-up as proxy measures, and assessed effectiveness using singular 'at-goal' metrics for each condition. The median follow-up for diabetes, hypertension and chronic obstructive pulmonary disease was 6, 6 and 7 facility visits, and 10, 10 and 11 community visits, respectively (0.9 monthly patient touch-points). Loss-to-follow-up rates were 16%, 19% and 22%, respectively. The median time between visits was approximately 2 months for facility visits and 1 month for community visits. 'At-goal' status for patients with chronic obstructive pulmonary disease improved from baseline to endline (p=0.01), but not for diabetes or hypertension. This is the first integrated non-communicable disease intervention, based on the 4C principles, in Nepal. Our experience demonstrates high rates of facility and community follow-up, with comparatively low lost-to-follow-up rates. The mixed effectiveness results suggest that while this intervention may be valuable, it may not be sufficient to impact outcomes. To achieve the Sustainable Development Goals, further implementation research is urgently needed to determine how to optimise non-communicable disease interventions.

Transition to active learning in rural Nepal: an adaptable and scalable curriculum development model

BACKGROUND

Traditional medical education in much of the world has historically relied on passive learning. Although active learning has been in the medical education literature for decades, its incorporation into practice has been inconsistent. We describe and analyze the implementation of a multidisciplinary continuing medical education curriculum in a rural Nepali district hospital, for which a core objective was an organizational shift towards active learning.

METHODS

The intervention occurred in a district hospital in remote Nepal, staffed primarily by mid-level providers. Before the intervention, education sessions included traditional didactics. We conducted a mixed-methods needs assessment to determine the content and educational strategies for a revised curriculum. Our goal was to develop an effective, relevant, and acceptable curriculum, which could facilitate active learning. As part of the intervention, physicians acted as both learners and teachers by creating and delivering lectures. Presenters used lecture templates to prioritize clarity, relevance, and audience engagement, including discussion questions and clinical cases. Two 6-month curricular cycles were completed during the study period. Daily lecture evaluations assessed ease of understanding, relevance, clinical practice change, and participation. Periodic lecture audits recorded learner talk-time, the proportion of lecture time during which learners were talking, as a surrogate for active learning. Feedback from evaluation and audit results was provided to presenters, and pre- and post-curriculum knowledge assessment exams were conducted.

RESULTS

Lecture audits showed a significant increase in learner talk-time, from 14% at baseline to 30% between months 3-6, maintained at 31% through months 6-12. Lecture evaluations demonstrated satisfaction with the curriculum. Pre- and post-curriculum knowledge assessment scores improved from 50 to 64% (difference 13.3% ± 4.5%, p = 0.006). As an outcome for the measure of organizational change, the curriculum was replicated at an additional clinical site.

CONCLUSION

We demonstrate that active learning can be facilitated by implementing a new educational strategy. Lecture audits proved useful for internal program improvement. The components of the intervention which are transferable to other rural settings include the use of learners as teachers, lecture templates, and provision of immediate feedback. This curricular model could be adapted to similar settings in Nepal, and globally.

Delivering Collaborative Care in Rural Settings: Integrating Remote Teleconsultation and Local Supervision in Rural Nepal

The collaborative care model can deliver high-quality mental health care. In rural regions, clinical supervision is conducted remotely rather than in person. The authors implemented a remote teleconsultation model in rural Nepal, where the consulting psychiatrist is over 30 hours away. This column describes strategies for several challenges: poor mental health competencies and high turnover among primary care providers; need for urgent consultations; psychiatrist discomfort with lack of direct patient contact; unreliable electricity, technological tools, documentation, and delivery of treatment recommendations; on-site clinicians' low motivation to accept psychiatrist recommendations; and mismatch between the psychiatrist's recommendations and the site's capacity to implement them.

Modeling Health Disparities and Outcomes in Disenfranchised Populations

The Health Disparities and Outcomes (HDO) model originally created to explain the complexity of obtaining healthcare in rural settings has been revised and updated using emerging theoretical models of adversity and inequity and two decades of empirical work by the authors. With a strong orientation to explaining population-based health inequities, the HDO is applied to individuals with Serious Mental Illness (SMI), to explain their high rates of morbidity and mortality compared to the general population. Individual-, community-, and system-level factors that reflect an understanding of life-long risk, accrued hazards associated with multiple and intersecting disadvantages, and difficulty obtaining healthcare that meets accepted standards are described. The revised HDO can be applied to populations with disproportionate health challenges to identify multi-level factors that affect illness trajectory and overall health outcomes.

Competencies for Global Mental Health: Developing Training Objectives for a Post-Graduate Fellowship for Psychiatrists

BACKGROUND

Despite an increase in psychiatry trainees' interest in global mental health (GMH), there is a lack of relevant training competencies developed using educational frameworks that incorporate viewpoints from high- and low-income countries. Objective: The aim of this study was to determine competencies for a two-year post-graduate GMH fellowship for psychiatrists utilizing Kern's six-step process as a theoretical framework for curriculum development. Methods: We conducted a targeted needs assessment via key informant interviews with a purposive sample of stakeholders (n = 19), including psychiatry trainees, generalist clinicians, medical directors, psychiatrists, researchers, and GMH educators from high- and low-resource settings in the United States and abroad. We analyzed data using a template method of thematic analysis. Findings: We tabulated learning objectives across 20 domains. Broadly, clinical objectives focused on providing supervision for short-term, evidence-based psychotherapies and on identifying red flags and avoiding harmful medication use among vulnerable populations such as children and the elderly. Non-clinical objectives focused on social determinants of health, education, and clinical supervision as part of capacity-building for non-specialists, engagement in a systems-wide project to improve care, and ethical and equitable partnerships that involve reciprocal and bidirectional education. Several competencies were also relevant for global health work in general. Conclusions: A theory-informed framework for curriculum development and a diverse set of key informants can provide educational objectives that meet the priorities of the trainees and the clinical sites in both low- and high-income settings. Limitations of this study include a small sample size and a focus on clinical needs of specific sites, both of which may affect generalizability. Given the focus on training specialists (psychiatrists), the low-resource sites highlighted the importance of educating and supervising their permanent, generalist clinicians, rather than providing direct, independent patient care.

Competencies for Global Mental Health: Developing Training Objectives for a Post-Graduate Fellowship for Psychiatrists

Background:

Despite an increase in psychiatry trainees’ interest in global mental health (GMH), there is a lack of relevant training competencies developed using educational frameworks that incorporate viewpoints from high- and low-income countries.

Objective:

The aim of this study was to determine competencies for a two-year post-graduate GMH fellowship for psychiatrists utilizing Kern’s six-step process as a theoretical framework for curriculum development.

Methods:

We conducted a targeted needs assessment via key informant interviews with a purposive sample of stakeholders (n = 19), including psychiatry trainees, generalist clinicians, medical directors, psychiatrists, researchers, and GMH educators from high- and low-resource settings in the United States and abroad. We analyzed data using a template method of thematic analysis.

Findings:

We tabulated learning objectives across 20 domains. Broadly, clinical objectives focused on providing supervision for short-term, evidence-based psychotherapies and on identifying red flags and avoiding harmful medication use among vulnerable populations such as children and the elderly. Non-clinical objectives focused on social determinants of health, education, and clinical supervision as part of capacity-building for non-specialists, engagement in a systems-wide project to improve care, and ethical and equitable partnerships that involve reciprocal and bidirectional education. Several competencies were also relevant for global health work in general.

Conclusions:

A theory-informed framework for curriculum development and a diverse set of key informants can provide educational objectives that meet the priorities of the trainees and the clinical sites in both low- and high-income settings. Limitations of this study include a small sample size and a focus on clinical needs of specific sites, both of which may affect generalizability. Given the focus on training specialists (psychiatrists), the low-resource sites highlighted the importance of educating and supervising their permanent, generalist clinicians, rather than providing direct, independent patient care.

Translating mental health diagnostic and symptom terminology to train health workers and engage patients in cross-cultural, non-English speaking populations

Although there are guidelines for transcultural adaptation and validation of psychometric tools, similar resources do not exist for translation of diagnostic and symptom terminology used by health professionals to communicate with one another, their patients, and the public. The issue of translation is particularly salient when working with underserved, non-English speaking populations in high-income countries and low- and middle-income countries. As clinicians, researchers, and educators working in cross-cultural settings, we present four recommendations to avoid common pitfalls in these settings. We demonstrate the need for: (1) harmonization of terminology among clinicians, educators of health professionals, and health policymakers; (2) distinction in terminology used among health professionals and that used for communication with patients, families, and the lay public; (3) linkage of symptom assessment with functional assessment; and (4) establishment of a culture of evaluating communication and terminology for continued improvement.

Collaborative Care for Mental Health in Low- and Middle-Income Countries: A WHO Health Systems Framework Assessment of Three Programs

The collaborative care model is an evidence-based intervention for behavioral and other chronic conditions that has the potential to address the large burden of mental illness globally. Using the World Health Organization Health Systems Framework, the authors present challenges in implementing this model in low- and middle-income countries (LMICs) and discuss strategies to address these challenges based on experiences with three large-scale programs: an implementation research study in a district-level government hospital in rural Nepal, one clinical trial in 50 primary health centers in rural India, and one study in four diabetes clinics in India. Several strategies can be utilized to address implementation challenges and enhance scalability in LMICs, including mobilizing community resources, engaging in advocacy, and strengthening the overall health care delivery system.

Partnerships in mental healthcare service delivery in low-resource settings: developing an innovative network in rural Nepal

BACKGROUND

Mental illnesses are the largest contributors to the global burden of non-communicable diseases. However, there is extremely limited access to high quality, culturally-sensitive, and contextually-appropriate mental healthcare services. This situation persists despite the availability of interventions with proven efficacy to improve patient outcomes. A partnerships network is necessary for successful program adaptation and implementation.

PARTNERSHIPS NETWORK

We describe our partnerships network as a case example that addresses challenges in delivering mental healthcare and which can serve as a model for similar settings. Our perspectives are informed from integrating mental healthcare services within a rural public hospital in Nepal. Our approach includes training and supervising generalist health workers by off-site psychiatrists. This is made possible by complementing the strengths and weaknesses of the various groups involved: the public sector, a non-profit organization that provides general healthcare services and one that specializes in mental health, a community advisory board, academic centers in high- and low-income countries, and bicultural professionals from the diaspora community.

CONCLUSIONS

We propose a partnerships model to assist implementation of promising programs to expand access to mental healthcare in low- resource settings. We describe the success and limitations of our current partners in a mental health program in rural Nepal.

Developing a scalable training model in global mental health: pilot study of a video-assisted training Program for Generalist Clinicians in Rural Nepal

BACKGROUND

In low- and middle-income countries, mental health training often includes sending few generalist clinicians to specialist-led programs for several weeks. Our objective is to develop and test a video-assisted training model addressing the shortcomings of traditional programs that affect scalability: failing to train all clinicians, disrupting clinical services, and depending on specialists.

METHODS

We implemented the program -video lectures and on-site skills training- for all clinicians at a rural Nepali hospital. We used Wilcoxon signed-rank tests to evaluate pre- and post-test change in knowledge (diagnostic criteria, differential diagnosis, and appropriate treatment). We used a series of 'Yes' or 'No' questions to assess attitudes about mental illness, and utilized exact McNemar's test to analyze the proportions of participants who held a specific belief before and after the training. We assessed acceptability and feasibility through key informant interviews and structured feedback.

RESULTS

For each topic except depression, there was a statistically significant increase (Δ) in median scores on knowledge questionnaires: Acute Stress Reaction (Δ = 20, p = 0.03), Depression (Δ = 11, p = 0.12), Grief (Δ = 40, p < 0.01), Psychosis (Δ = 22, p = 0.01), and post-traumatic stress disorder (Δ = 20, p = 0.01). The training received high ratings; key informants shared examples and views about the training's positive impact and complementary nature of the program's components.

CONCLUSION

Video lectures and on-site skills training can address the limitations of a conventional training model while being acceptable, feasible, and impactful toward improving knowledge and attitudes of the participants.

Recommendations from primary care providers for integrating mental health in a primary care system in rural Nepal

BACKGROUND

Globally, access to mental healthcare is often lacking in rural, low-resource settings. Mental healthcare services integration in primary care settings is a key intervention to address this gap. A common strategy includes embedding mental healthcare workers on-site, and receiving consultation from an off-site psychiatrist. Primary care provider perspectives are important for successful program implementation.

METHODS

We conducted three focus groups with all 24 primary care providers at a district-level hospital in rural Nepal. We asked participants about their concerns and recommendations for an integrated mental healthcare delivery program. They were also asked about current practices in seeking referral for patients with mental illness. We collected data using structured notes and analyzed the data by template coding to develop themes around concerns and recommendations for an integrated program.

RESULTS

Participants noted that the current referral system included sending patients to the nearest psychiatrist who is 14 h away. Participants did not think this was effective, and stated that integrating mental health into the existing primary care setting would be ideal. Their major concerns about a proposed program included workplace hierarchies between mental healthcare workers and other clinicians, impact of staff turnover on patients, reliability of an off-site consultant psychiatrist, and ability of on-site primary care providers to screen patients and follow recommendations from an off-site psychiatrist. Their suggestions included training a few existing primary care providers as dedicated mental healthcare workers, recruiting both senior and junior mental healthcare workers to ensure retention, recruiting academic psychiatrists for reliability, and training all primary care providers to appropriately screen for mental illness and follow recommendations from the psychiatrist.

CONCLUSIONS

Primary care providers in rural Nepal reported the failure of the current system of referral, which includes sending patients to a distant city. They welcomed integrating mental healthcare into the primary care system, and reported several concerns and recommendations to increase the likelihood of successful implementation of such a program.