Conducting global mental health research: lessons learned from Kenya

Lessons learned from conducting mental health intervention research in schools in the global south: Our experiences in South Africa and Kenya

Most of the world's population of young people live in lower-and middle-income countries (LMICs; (Weine, Horvath Marques, Singh, & Pringle, 2020)), and these young people experience heightened rates of known risk factors for developing mental disorders such as poverty and exposure to trauma (Atwoli, Stein, Koenen, & McLaughlin, 2015). Access to professional psychological treatments is limited in LMICs due to structural barriers (e.g., a dearth of trained professionals) and cultural factors like stigma and beliefs about mental health and illness. Therefore, schools, which are widely attended, may be a good location for providing mental health interventions, and it is important that we develop and evaluate feasible, acceptable, effective, and scalable interventions for use in this context. Yet under 10% of clinical trials of psychotherapies (Venturo-Conerly, Eisenman, Wasil, Singla, & Weisz, 2022) have been conducted in LMICs. And there are particular challenges to conducting research in schools, as has been highlighted in the UK context by Moore et al. (2022). Building on that commentary, our aim herein is to share our learnings from conducting psychotherapy research in schools in Kenya and South Africa.

An arts-literacy intervention for adolescent depression and anxiety symptoms: outcomes of a randomised controlled trial of Pre-Texts with Kenyan adolescents

Background

Mental health problems are prevalent among youth in low-resource countries and are further compounded by stigma and limited access to traditional treatments. The need for scalable, accessible, and stigma-free mental health interventions is urgent. We developed and tested Pre-Texts, an arts-literacy intervention that targets adolescent depression and anxiety, in Kenya.

Methods

We conducted a universal RCT (Randomized Controlled Trial). Students from Kenyan high schools (N = 235, ages 13-19, 53.19% female) were randomized to either Pre-Texts or a study skills control intervention. Pre-Texts involves the use of a text-such an excerpt from a novel, a physics lesson, or a technical manual-to inspire art-making that is followed by collective reflection on the process of interpretation through artmaking. Participants met daily for a week in groups of 6-12 youths for 1-h sessions. Groups were facilitated by high school graduates trained as lay-providers. This study was pre-registered at the Pan African Clinical Trials Registry (PACTR; registration number: PACTR202111497122432). The trial took place between August 11th 2021 and December 18th 2021.

Findings

Pre-Texts produced a greater reduction in depression (d = 0.52, 95% CI [0.19, 0.84]) and anxiety (d = 0.51, 95% CI [0.20, 0.81]) symptoms from baseline to 1-month follow-up compared to the control group. Similarly, in a sub-sample of participants with elevated depression and anxiety symptoms, Pre-Texts produced a greater reduction in depression (d = 1.10, 95% CI [0.46, 1.75]) and anxiety (d = 0.54, 95% CI [-0.07, 1.45]) symptoms.

Interpretation

Our findings suggest that a brief arts-literacy intervention with challenging school material in a group setting, implemented as an afterschool program, can reduce depression and anxiety symptoms in adolescents in Sub-Saharan Africa. Future replication trials with larger sample sizes with extended follow-ups will help assess the strength and sustainability of these effects.

Funding

The study was funded by grants from the Mind, Brain, and Behaviour (MBB) Initiative at Harvard University and the Center for African Studies at Harvard University.

Peer-delivered Problem-solving Therapy for Adolescent Mental Health in Kenya: Adaptation for Context and Training of Peer-counselors

Peer-delivered interventions for adolescent mental health can help address poor access to mental health interventions. Questions remain about how interventions can be adapted for peer delivery and whether peers can be trained. In this study, we adapted problem solving therapy (PST) for peer-delivery with adolescents in Kenya and explored whether peer counselors can be trained in PST. We adapted treatment prior to and during training using the Cultural Adaptation and Contextualization for Implementation framework. Nine peer counselors (Ages 20-24) were selected and trained over 10 days. Peer competencies and knowledge were measured pre-post using a written exam, a written case study, and role plays rated using a standardized competency measure. We chose a version of PST used in India with secondary school adolescents originally delivered by teachers. All materials were translated into Kiswahili. Language and format were adapted to Kenyan adolescents as well as for delivery by peers with a focus on understandability and relevance (e.g., noting shared experience). Metaphors, examples, and visual materials were adapted for the context to reflect the culture and vernacular of Kenyan youth. Peer counselors were able to be trained in PST. Pre-post competencies and understanding of content showed improvements with peers minimally meeting patient needs (pre) on average to moderate/fully meeting patient needs (post). Post-training written exam score showed an average 90% correct. There is an adapted version of PST for Kenyan adolescents and peer delivery. Peer counselors can be trained to deliver a 5-session PST in a community context.

Testing pathways to scale: study protocol for a three-arm randomized controlled trial of a centralized and a decentralized ("Train the Trainers") dissemination of a mental health program for Kenyan adolescents

BACKGROUND

Providing care in Kenya to all youth in need is difficult because of a shortage of professional providers and societal stigma. Previous trials of the Anansi model, which involves delivering low-touch mental health interventions through a tiered caregiving model (including lay-providers, supervisors, and clinical experts), have shown its effectiveness for reducing depression and anxiety symptoms in school-going Kenyan adolescents. In this trial, we aim to assess two different scale-up strategies by comparing centralized implementation (i.e., by the organization that designed the Anansi model) against implementation through an implementing partner.

METHODS

In this three-arm trial, 1600 adolescents aged 13 to 20 years will be randomized to receive the Shamiri intervention from either the Shamiri Institute or an implementation partner or to be placed in the treatment as usual (TAU) control group. The implementation partner will be trained and supplied with protocols to ensure that the same procedures are followed by both implementors. Implementation activities will run concurrently for both implementors. The Shamiri intervention will be delivered by trained lay providers to groups of 10-15 adolescents over four weekly sessions which will take place in secondary schools in Machakos and Makueni counties in Kenya. The TAU group will receive the usual care offered by their respective schools. Outcomes will be assessed at baseline, midpoint (2 weeks), endpoint (4 weeks), and 1 month follow-up. The analysis will be based on an intent-to-treat approach. Mixed effects models will be used to assess trajectories over time of the primary outcomes (anxiety and depressive symptoms, mental well-being, perceived social support, and academic performance) and secondary outcomes for the intervention groups and the control group. Effect sizes will be computed for the mean differences of the intervention and control arms at midpoint, endpoint, and follow-up.

DISCUSSION

This trial will provide insight into the comparative effectiveness of different strategies for scaling a school-based mental health care model. Findings will also indicate areas for improved efficiency of the model to enhance its replicability by other implementors.

TRIAL REGISTRATION

Pan African Clinical Trials Registry (PACTR) (ID: PACTR202305589854478, Approved: 02/05/2023).

Screening depression and anxiety in Indigenous peoples: A global scoping review

Indigenous peoples' worldviews are intricately interconnected and interrelated with their communities and the environments in which they live. Their worldviews also manifest in a holistic view of health and well-being, which contrasts with those of the dominant western biomedical model. However, screening depression and/or anxiety in Indigenous peoples often occurs using standard western tools. Understandably, the cultural appropriateness of these tools has been questioned. The purpose of this scoping review was to map the literature that used any type of tool to screen depression or anxiety in Indigenous adults globally. A systematic scoping review method was used to search databases including, but not limited to, CINAHL, PubMed, Scopus and Google. Database-specific search terms associated with Indigenous peoples, depression and anxiety, and screening tools were used to identify literature. In addition, citation searches of related systematic reviews and relevant websites were conducted. The data set was limited to English language publications since database inception. Fifty-four publications met the review's inclusion criteria. Most studies were completed in community settings using standard western depression and anxiety screening tools. Thirty-three different tools were identified, with the Patient Health Questionnaire-9 being the most frequently used. The review's findings are concerning given repeated calls for culturally appropriate screening tools to be used with Indigenous peoples. Although there has been some work to cross-culturally adapt depression screening tools for specific Indigenous populations, clearly more clinicians and researchers need to be aware of, and use, culturally appropriate approaches to screening.

Risk Factors for the Mental Health of Adolescents from the Parental Perspective: Photo-Voice in Rural Communities of Ecuador

Mental health in adolescence is a very important topic worldwide, especially in rural areas. The implementation of Participatory Action Research (PAR) through the photo-voice method was a way to encourage adults to recognize problematic situations (at personal, family or community levels) that threaten the well-being of adolescents, but that in everyday life may go unnoticed by parents and caregivers. Our study aimed to identify risk factors for mental health in adolescents living in rural communities of Ecuador from the parental perspective through photographs and focus group discussions. The study sought to raise awareness of this issue at the family and community levels. The photo-voice method was conducted with the participation of 29 parents. The photographs and the collaborative construction of meanings allowed parents to have a better understanding about the importance of mental health and its benefit for adolescents. The principal risk factors mentioned by parents were stress, sleep deprivation, tiredness, poverty, difficulties in continuing education and alcohol consumption. In conclusion, we point out the importance of this intervention to explore the knowledge and understanding of the topic by parents as well as to communicate information that demystifies false beliefs around mental health.

Long-term health outcomes of adolescent character strength interventions: 3- to 4-year outcomes of three randomized controlled trials of the Shamiri program

BACKGROUND

Adolescents in low- and middle-income countries in need of mental health care often do not receive it due to stigma, cost, and lack of mental health professionals. Culturally appropriate, brief, and low-cost interventions delivered by lay-providers can help overcome these barriers and appear effective at reducing symptoms of depression and anxiety until several months post-intervention. However, little is known about whether these interventions may have long-term effects on health, mental health, social, or academic outcomes.

METHODS

Three previous randomized controlled trials of the Shamiri intervention, a 4-week, group-delivered, lay-provider-led intervention, have been conducted in Kenyan high schools. Shamiri teaches positively focused intervention elements (i.e., growth mindset and strategies for growth, gratitude, and value affirmation) to target symptoms of depression and anxiety and to improve academic performance and social relationships, by fostering character strengths. In this long-term follow-up study, we will test whether these mental health, academic, social, and character-strength outcomes, along with related health outcomes (e.g., sleep quality, heart-rate variability and activity level measured via wearables, HIV risk behaviors, alcohol and substance use), differ between the intervention and control group at 3-4-year follow-up. For primary analyses (Nanticipated = 432), youths who participated in the three previous trials will be contacted again to assess whether outcomes at 3-4-year-follow-up differ for those in the Shamiri Intervention group compared to those in the study-skills active control group. Multi-level models will be used to model trajectories over time of primary outcomes and secondary outcomes that were collected in previous trials. For outcomes only collected at 3-4-year follow-up, tests of location difference (e.g., t-tests) will be used to assess group differences in metric outcomes and difference tests (e.g., odds ratios) will be used to assess differences in categorical outcomes. Finally, standardized effect sizes will be used to compare groups on all measures.

DISCUSSION

This follow-up study of participants from three randomized controlled trials of the Shamiri intervention will provide evidence bearing on the long-term and health and mental health effects of brief, lay-provider-delivered character strength interventions for youth in low- and middle-income countries.

TRIAL REGISTRATION

PACTR Trial ID: PACTR202201600200783 . Approved on January 21, 2022.

Testing the effects of the Shamiri Intervention and its components on anxiety, depression, wellbeing, and academic functioning in Kenyan adolescents: study protocol for a five-arm randomized controlled trial

BACKGROUND

Treatments for youth mental disorders are a public health priority, especially in sub-Saharan Africa (SSA), where treatment options remain limited due to high cost, elevated stigma, and lack of trained mental health professionals. Brief, accessible, and non-stigmatizing community-based interventions delivered by lay providers may help address treatment needs in SSA. One such intervention, the Shamiri Intervention, consisting of three elements (growth mindset, gratitude, and value affirmation) has been tested in randomized controlled trials with school-going Kenyan adolescents. This three-element Shamiri Intervention has been shown to significantly reduce depression and anxiety symptoms and improve social support and academic performance relative to a control group. In this trial, we aim to investigate the effects of each element of the Shamiri Intervention.

METHODS

In this five-arm randomized controlled trial, we will test each of the intervention components (growth mindset, gratitude, and value affirmation) against the full Shamiri Intervention and against a study skills control intervention. Students (Nplanned = 1288) at participating secondary schools who are interested in participating in this universal intervention will be randomized in equal numbers into the five groups. The students will meet in groups of 8-15 students led by local high school graduate lay providers. These lay providers will receive a brief training, plus expert supervision once a week throughout the intervention delivery. Multi-level models will be used to compare trajectories over time of the primary outcomes (depressive symptoms, anxiety symptoms, academic performance, and wellness) and secondary outcomes in each intervention group to the control group. Multi-level models will also be used to compare trajectories over time of the primary outcomes (depressive symptoms, anxiety symptoms, academic performance, and wellness) and secondary outcomes of participants in the single-element interventions compared to the full Shamiri Intervention. Finally, effect sizes (calculated as mean gain scores) will be used to compare all groups on all measures.

DISCUSSION

This trial will shed light on the mechanisms and outcomes targeted by each individual intervention, helping prioritize which mental health interventions are most important to disseminate.

TRIAL REGISTRATION

PACTR Trial ID: PACTR202104716135752 . Approved on 4/19/2021.

Online single-session interventions for Kenyan adolescents: study protocol for a comparative effectiveness randomised controlled trial

BACKGROUND

Mental health problems are the leading cause of disability among adolescents worldwide, yet access to treatment is limited. Brief digital interventions have been shown to improve youth mental health, but little is known about which digital interventions are most effective.

AIMS

To evaluate the effectiveness of two digital single-session interventions (Shamiri-Digital and Digital-CBT (cognitive-behavioural therapy)) among Kenyan adolescents.

METHODS

We will perform a school-based comparative effectiveness randomised controlled trial. Approximately 926 Kenyan adolescents will be randomly assigned to one of three conditions: Shamiri-Digital (focused on gratitude, growth mindsets and values), Digital-CBT (focused on behavioural activation, cognitive restructuring and problem solving) or a study-skills control condition (focused on note-taking and essay writing skills). The primary outcomes include depressive symptoms (measured by the Patient Health Questionnaire-8), anxiety symptoms (Generalized Anxiety Disorder Screener-7) and subjective well-being (Short Warwick-Edinburgh Mental Well-being Scale). The secondary outcomes include acceptability, appropriateness, primary control and secondary control. Acceptability and appropriateness will be measured immediately post-intervention; other outcomes will be measured 2 weeks, 4 weeks and 12 weeks post-intervention.

RESULTS

We hypothesise that adolescents assigned to Shamiri-Digital and adolescents assigned to Digital-CBT will experience greater improvements (assessed via hierarchical linear models) than those assigned to the control group. We will also compare Shamiri-Digital with Digital-CBT, although we do not have a preplanned hypothesis.

CONCLUSIONS

Our findings will help us evaluate two digital single-session interventions with different theoretical foundations. If effective, such interventions could be disseminated to reduce the public health burden of common mental health problems.

TRIAL REGISTRATION NUMBER

PACTR202011691886690.