Using a person-generated mental health outcome measure in large clinical trials in Kenya and Pakistan: Self-perceived problem responses in diverse communities

Family concerns and relationship problems in anxious pregnant women and their associations with postnatal functional disability in Pakistan

OBJECTIVE

Expanding on existing research suggesting that strategies to reduce prenatal anxiety can decrease functional disability (e.g., difficulties in performing everyday activities and social participation), we examined if this effect varied by type of anxiety-producing problem (i.e., having family concerns and relationship problems versus other problems) reported during pregnancy. Further, we explored if perceived social support mediated this relationship.

METHODS

We used longitudinal data on 310 anxious Pakistani women who received any psychosocial intervention sessions as part of a program that was based on Cognitive Behavioral Therapy. The Psychological Outcome Profiles (PSYCHLOPS) was used to assess whether women had 'family concerns and relationship problems' or 'other problems.' The WHO Disability Assessment Schedule 2.0 assessed functional disability at six-weeks after delivery. Lack of support was measured using a 12-item Multi-dimensional Scale of Perceived Social Support. We employed linear regression to examine associations between types of problems reported during pregnancy and postnatal functional disability. Causal mediation analysis was used to assess whether postnatal social support mediated this relationship.

RESULTS

Of anxious pregnant women, 34% reported family concerns or relationship problems as primary problems in pregnancy. They were more likely to report higher functional disability at six-weeks after delivery than women who reported other problems (adjusted B = 2.40, 95% CI: 0.83-3.97). Lack of overall social support (Estimateindirect = 0.69, 95% CI: 0.04-1.38) and lack of support from friends (Estimateindirect = 0.62, 95% CI: 0.01-1.29) significantly mediated the relationship.

CONCLUSIONS

Findings suggest that complementing pre- and post-natal care with support programs and services that address family concerns and relationship problems, as well as enhancing social support is important to functional disability.

Self-reported problems and functional difficulties in anxious pregnant women in Pakistan: The use of a patient-generated mental health outcome measure

Anxiety during pregnancy affects women worldwide and is highly prevalent in Pakistan. The Psychological Outcome Profiles (PSYCHLOPS) questionnaire is an instrument used in therapy to assess patient-generated problems and the consequent functional difficulties. Using the PSYCHLOPS, we aimed to describe the type of problems and the consequent functional difficulties faced by anxious pregnant women in Pakistan. Secondarily, we sought to explore if a cognitive behavioral therapy (CBT)-based intervention brought about changes in the severity score for certain problems or functional difficulties. Anxious pregnant women were recruited from the Obstetrics/Gynecology Department of a tertiary hospital in Rawalpindi, Pakistan. Of 600 pregnant women randomized to receive a psychosocial intervention for prenatal anxiety delivered by non-specialist providers, 450 received ≥1 intervention session and were administered the PSYCHLOPS. Eight types of problems were identified; worries about the unborn baby's health and development (23%), concerns about family members (13%), and financial constraints (12%) were the most frequently reported primary problems. Severity scores between baseline and the last available therapy session indicated the largest decrease for relationship problems (mean = 2.4) and for concerns about family members (mean = 2.2). For functional difficulties, 45% of the participants reported difficulties in performing household chores, but the intervention showed the greatest decrease in severity scores for mental or emotional functional difficulties. Focus on certain types of patient-generated problems, e.g., relationship problems, could anchor therapy delivery in order to have the greatest impact. Tailored CBT-based intervention sessions have the potential to address important but neglected problems and functional difficulties in anxious pregnant women.

Notes from the youth mental health field: Using movement towards goals as a potential indicator of service change and quality improvement

The aim of this paper is to report our notes from the field on using movement toward goals at an aggregate level as an inference of service effectiveness. Analysis of routinely collected data from UK youth mental health services was conducted (N = 8,172, age M = 13.8, 67% female, 32% male) to explore the impact of including goal-based outcome data in combined calculations of standardized measures based on the principles of reliable change ("measurable change"). Due to the broad nature of standardized measures, inferred validity becomes diluted in any team or service level aggregate analysis. To make inferences that are closer to the person's interpretation of their difficulties, we argue that Idiographic Patient Reported Outcome Measures (I-PROMs) counterbalance these limitations. This is supported by our findings. The measurable change metric is the first step towards enabling national analysis of aggregated I-PROMs. I-PROMs, supplemented by standardized measures should be used to consider service evaluation.

In Their Own Words: Using Open-Ended Assessment to Identify Culturally Relevant Concerns among Kenyan Adolescents

Standardized assessment tools developed in western contexts may systematically miss certain problems that are considered important in non-western cultures. In this mixed-methods study, we used an open-ended assessment tool (the Top Problem Assessment; TPA) to identify culturally relevant concerns among low-income Kenyan youth. We then (a) applied thematic analysis to identify the most frequently reported problems and (b) examined the extent to which these problems were reflected in standardized mental health measures. Using the TPA, we identified common social, academic, and economic problems facing Kenyan youths. Specifically, 61% of the sample reported a social problem, 38% an academic problem, and 35% an economic problem. By contrast, the standardized assessments revealed that worrying and difficulty concentrating were the most commonly reported symptoms. However, the emotional and behavioral problems assessed via the standardized measures were only reported as top problems by 17% of the sample. Overall, our findings are consistent with the idea that standardized measures can miss certain culturally-salient concerns that can be acquired through open-ended assessments. We discuss how brief open-ended assessment tools could complement standardized measures, inform the development of culturally relevant standardized measures, and offer rich data about the experiences of people in understudied cultural contexts.

Problems after flight: understanding and comparing Syrians' perspectives in the Middle East and Europe

Background

Syrian refugees and asylum seekers (SRAs) face multiple stressors after flight, which may vary due to different geographic, economic, cultural and socio-political contexts in the host countries. Past research has recognised the importance of participants’ own perspectives. The aims of this multi-country study were to identify and compare self-reported problems of SRAs between various settings.

Methods

A semi-structured client-generated outcome measurement was used to collect data among adult SRAs in Jordan (N = 61), Turkey (N = 46) and Switzerland (N = 57) between September 2018 and November 2019. Answers were analysed following thematic analysis.

Results

Over half of the participants reported practical problems with an emphasis on camp-related problems (Jordan), finances (Turkey), employment (Jordan and Switzerland) and government regulations (Switzerland), followed by psychological, and social issues.

Conclusion

This study highlights the impact of local contextual factors on wellbeing. The findings emphasise that planning preventative procedures and mental health care services for SRAs need to consider local challenges affecting the population in specific countries.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10498-1.

Personalising Outcome Measurement in Substance Misuse Treatment: the Feasibility and Psychometrics of Two Individualised Outcome Measures

Individualised information in substance misuse treatment complements standardised outcome measures. However, few studies investigate the use of individualised measures and their robustness in terms of quantifying outcomes. In this study, we analysed the psychometrics and feasibility of two individualised outcome measures (PQ and PSYCHLOPS). We followed a cross-sectional methodology, administering the individualised measures and three additional standardised measures (TOP, a measure of psychological health within addiction services; PHQ-9; CORE-OM) to a sample of 93 patients entering substance misuse treatment in four clinical services. The results showed high levels of patient acceptability of the two individualised measures (response rates > 95%). The internal reliability was good for both PQ and PSYCHLOPS (Cronbach’s alpha, .79 and .72, respectively). Convergent validity of PQ with standardised measures was weak: Pearson’s r values for TOP (psychological health), PHQ-9 and CORE-OM were .21, .22 and .27, respectively. In contrast, convergent validity of PSYCHLOPS was moderate: r = .40, .39 and .50, respectively. Convergence between PQ and PSYCHLOPS was weak (r = .28). Experience of previous treatment episodes was associated with higher PQ and PSYCHLOPS scores; PSYCHLOPS but not PQ scores were higher among those opting to complete the questionnaires in written rather than verbal format. Our findings demonstrated that PQ and PSYCHLOPS are reliable and feasible individualised outcome measures for use in substance misuse treatment units, although the lack of strong convergent validity indicates that they may be measuring different underlying constructs. Optimal outcome measurement may involve combining individualised and standardised measures.

Global Mental Health: Interdisciplinary challenges for a field in motion

In recent years, efforts in Global Mental Health (GMH) have evolved alongside critical engagement with the field's claims and interventions. GMH has shifted its agenda and epistemological underpinnings, increased its evidence base, and joined other global policy platforms such as the Sustainable Development Goals. This editorial introduction to a thematic issue traces the recent shifts in the GMH agenda and discusses the changing construct of "mental health" as GMH moves away from a categorical biomedical model toward dimensional and transdiagnostic approaches and embraces digital technologies. We highlight persistent and emerging lines of inquiry and advocate for meaningful interdisciplinary engagement. Taken together, the articles in this special issue of Transcultural Psychiatry provide a snapshot of current interdisciplinary work in GMH that considers the socio-cultural and historical dimensions of mental health important and proposes reflexive development of interventions and implementation strategies.