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Agudelo-Hernández F, Plata-Casas L, Vélez Botero H, Salazar Vieira LM, Moreno Mayorga B. [Mental Health Gap Action Programme: a theoretical model of barriers to implementation by health personnel in Chocó, ColombiaPrograma de Ação para Reduzir as Lacunas em Saúde Mental: modelo teórico das barreiras de implementação por profissionais de saúde de Chocó, Colômbia]. Rev Panam Salud Publica 2024; 48:e49. [PMID: 38779536 PMCID: PMC11110682 DOI: 10.26633/rpsp.2024.49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 03/19/2024] [Indexed: 05/25/2024] Open
Abstract
Objectives Mental, neurological, and substance use (MNS) disorders have a high prevalence in Colombia and there is a treatment gap. The World Health Organization (WHO) Mental Health Gap Action Programme (mhGAP) has various components. The mhGAP 2.0 Intervention Guide, aimed at improving primary health care, is a guide for the assessment and management of MNS disorders based on clinical decision-making protocols. The objective of this study was to determine the barriers that may hinder the program implementation process. Methods A qualitative study with content analysis was conducted in three phases: i) study preparation, organization, and presentation; ii) open coding, categorization, and abstraction of contents; and iii) information analysis. The study included semi-structured interviews with 21 people involved in the provision of mental health services in Chocó (Colombia): five medical doctors, seven nurses, and three psychologists, as well as six professionals working in the administrative area of the department's health secretariats. The perceptions of these stakeholders were explored. Open-ended questions were asked to explore experiences with the process, as well as the barriers identified in practice. Results Four different thematic categories were identified: intersectoral action, long-standing challenges, opportunities, and suitability of tools. Conclusions A theoretical model of barriers to implementation of the mhGAP program was constructed, based on stakeholder perceptions. Controlling barriers is perceived as a possible way to contribute significantly to population health.
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Affiliation(s)
- Felipe Agudelo-Hernández
- Facultad de Ciencias de la Salud Universidad de Manizales Caldas Colombia Facultad de Ciencias de la Salud, Universidad de Manizales, Caldas, Colombia
| | - Laura Plata-Casas
- Ministerio de Salud y Protección Social Bogotá Colombia Ministerio de Salud y Protección Social, Bogotá, Colombia
| | - Helena Vélez Botero
- Universidad Nacional de Colombia Bogotá Colombia Universidad Nacional de Colombia, Bogotá, Colombia
| | - Luz María Salazar Vieira
- Universidad Nacional de Colombia Bogotá Colombia Universidad Nacional de Colombia, Bogotá, Colombia
| | - Bibian Moreno Mayorga
- Ministerio de Salud y Protección Social Bogotá Colombia Ministerio de Salud y Protección Social, Bogotá, Colombia
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Müller MR, Ortega F. Mental Health Collaborative Care in Brazil and the Economy of Attention: Disclosing Barriers and Therapeutic Negotiations. Cult Med Psychiatry 2024:10.1007/s11013-024-09852-w. [PMID: 38652342 DOI: 10.1007/s11013-024-09852-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/12/2024] [Indexed: 04/25/2024]
Abstract
The introduction of mental health collaborative care (MHCC) is one of the strategies to scale up access to mental health care in primary health care in Brazil. This article investigates an experience of mental health collaborative care in the city of Rio de Janeiro, Brazil. It is a qualitative study involving interviews with physicians and mental health professionals working in primary health care units located in the northern part of the city of Rio de Janeiro, Brazil. The aim is to examine the various strategies and negotiations that primary health care professionals deploy to identify mental distress and plan health care interventions. We discuss the results within the economy of attention framework. We argue that divergences in diagnostic design and therapeutic planning carried out by professionals and users or observed in MHCC meetings illustrate the health-disease-care seeking phenomenon as a negotiated process, entangled in complex interactions. Our results evince that those interactions are not always evident and configure 'what is at stake' in mental suffering. The incorporation of cultural and structural determinants in collaborative care may enable the expansion of mental health initiatives sensitive to local needs and realities.
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Affiliation(s)
- Manuela Rodrigues Müller
- Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro (FCM-UERJ), Rio de Janeiro, Brazil
| | - Francisco Ortega
- Catalan Institution for Research and Advanced Studies (ICREA), Barcelona, Spain.
- Medical Anthropology Research Center, Universitat Rovira i Virgili, Av. Catalunya 35, 43002, Tarragona, Spain.
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Mutahi J, Kangwana B, Khasowa D, Muthoni I, Charo O, Muli A, Kumar M. Integrating Mental Health Management into Empowerment Group Sessions for Out-of-School Adolescents in Kenyan Informal Settlements: A Process Paper. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:223. [PMID: 38397712 PMCID: PMC10888709 DOI: 10.3390/ijerph21020223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 12/28/2023] [Accepted: 12/29/2023] [Indexed: 02/25/2024]
Abstract
This article presents processes for developing contextualized training procedures to better appreciate partnership, capacity-building experiences, and specific implementation challenges and opportunities for mental and public health teams. The program enrolled 469 out-of-school adolescents to participate in the integration of youth mental health into health and life-skill safe spaces. The teams utilized various methods to achieve process outcomes of restructuring and adapting curricula, training youth mentors, and assessing their self-efficacy before integrating the intervention for 18 months. The Coronavirus (COVID-19) pandemic became an additional unique concern in the preliminary and the 18-month implementation period of the program. This necessitated innovation around hybrid training and asynchronous modalities as program teams navigated the two study locations for prompt training, supervision, evaluation, and feedback. In conclusion, out-of-school adolescents face a myriad of challenges, and a safe space program led by youth mentors can help promote mental health. Our study demonstrated how best this can be achieved. We point to lessons such as the importance of adapting the intervention and working cohesively in teams, building strong and trusting partnerships, learning how to carry out multidisciplinary dialogues, and continuous supervision and capacity building. This article aimed to document the processes around the design and implementation of this innovative intervention and present a summary of lessons learned.
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Affiliation(s)
- Joan Mutahi
- Department of Psychiatry, School of Medicine, College of Health Sciences, University of Nairobi, Nairobi P.O. Box 30197-00100, Kenya; (J.M.); (D.K.)
| | - Beth Kangwana
- Population Council–Kenya-Avenue 5, 3rd Floor Rose Ave, Nairobi P.O. Box 17643-00500, Kenya; (B.K.); (A.M.)
| | - Dorcas Khasowa
- Department of Psychiatry, School of Medicine, College of Health Sciences, University of Nairobi, Nairobi P.O. Box 30197-00100, Kenya; (J.M.); (D.K.)
| | - Irene Muthoni
- Integrated Education for Community Empowerment, Nairobi P.O. Box 7631-00300, Kenya;
| | - Oliver Charo
- Rapid Effective Participatory Action in Community Theatre Education and Development, Nakuru P.O. Box 15614-20100, Kenya;
| | - Alfred Muli
- Population Council–Kenya-Avenue 5, 3rd Floor Rose Ave, Nairobi P.O. Box 17643-00500, Kenya; (B.K.); (A.M.)
| | - Manasi Kumar
- Department of Psychiatry, School of Medicine, College of Health Sciences, University of Nairobi, Nairobi P.O. Box 30197-00100, Kenya; (J.M.); (D.K.)
- Institute for Excellence in Health Equity, New York University Grossman School of Medicine, US-550 First Avenue New York, New York, NY 10016, USA
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Praptomojati A, Icanervilia AV, Nauta MH, Bouman TK. A systematic review of Culturally Adapted Cognitive Behavioral Therapy (CA-CBT) for anxiety disorders in Southeast Asia. Asian J Psychiatr 2024; 92:103896. [PMID: 38199202 DOI: 10.1016/j.ajp.2023.103896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 12/19/2023] [Accepted: 12/23/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND Cognitive Behavioral Therapy (CBT) has been proven an effective treatment for anxiety disorders. However, CBT still dominantly uses concepts and constructs rooted in Western cultures, and most research focuses on Western populations. It is unsure how this translates to non-Western cultures like Southeast Asia. AIMS Our objective is to explore which types of cultural adaptations in CBT have been implemented for anxiety disorders in Southeast Asia and their effectiveness. METHODS We systematically searched PubMed, PsycINFO, Embase, CENTRAL, GARUDA, and Google Scholar for CA-CBT for anxiety disorders in local communities in Southeast Asian countries. Data were analyzed using a narrative approach distinguishing between peripheral and core component adaptations. PROSPERO database preregistration number was CRD42022336376. RESULTS Seven studies (one randomized controlled trial, three quasi-experimental studies, and three case reports) were selected. Two studies made cultural adaptations in multiple components. Two studies modified core treatment components by incorporating local values in the CBT restructuring process. Three studies conducted cultural adaptation on peripheral treatment components: adaptation to materials and semantics, cultural examples and themes, and session structure. Three studies did not provide detailed information. One RCT study showed better improvement for those who got CA-CBT than those in treatment as usual (TAU). CONCLUSION The findings suggest some components to consider when conducting cultural adaptation. We could not establish the degree of superiority of CA-CBT over non-CA-CBT nor identify components with the most influence due to the limited number of studies found. Employing standard documentation in reporting trials is also important to increase transparency.
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Affiliation(s)
- Ardian Praptomojati
- Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, Grote Kruisstraat 2/1, 9712 TS Groningen, the Netherlands; Faculty of Psychology, Universitas Gadjah Mada, Jl. Sosio Humaniora Bulaksumur, 55281 Yogyakarta, Indonesia.
| | - Ajeng Viska Icanervilia
- Department of Health Sciences, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, the Netherlands; Department of Radiology, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, RSUP. Dr. Sardjito, Jl. Kesehatan 1, Sekip, 55284 Yogyakarta, Indonesia; Clinical Epidemiology and Biostatistics Unit (CEBU), Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Gedung Litbang FK-KMK UGM Lantai 1, Jl. Medika, Senolowo, Mlati, Sleman, Yogyakarta, Indonesia
| | - Maaike H Nauta
- Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, Grote Kruisstraat 2/1, 9712 TS Groningen, the Netherlands
| | - Theo K Bouman
- Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, Grote Kruisstraat 2/1, 9712 TS Groningen, the Netherlands
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Iheanacho T, Chu C, Aguocha CM, Nwefoh E, Dike C. Integrating mental health into primary care in Nigeria: Implementation outcomes and clinical impact of the HAPPINESS intervention. Glob Ment Health (Camb) 2024; 11:e9. [PMID: 38390244 PMCID: PMC10882178 DOI: 10.1017/gmh.2024.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 12/18/2023] [Accepted: 12/28/2023] [Indexed: 02/24/2024] Open
Abstract
Background The Health Action for Psychiatric Problems In Nigeria including Epilepsy and SubstanceS (HAPPINESS) intervention is a multicomponent, community-based, mobile technology-supported intervention that integrates mental health into primary health care centers in Nigeria using the World Health Organization's Mental Health Gap Action Programme-Intervention Guide (mhGAP-IG). This study evaluates its implementation and patient-level clinical impact using a quasi-experimental design (single cohort with pre- and post-measures). Findings The HAPPINESS intervention implementation demonstrated high feasibility with 84% adoption rate (% of participating primary health centers that completed its roll out) and 81% fidelity (% of clinicians who completed required intervention components according to the protocol). Retention rate in care at 12 months was 86%. Among patients with complete clinical records analyzed (n = 178), there was a statistically significant reduction in 9-item Patient Health Questionnaire scores from baseline (Md = 9.5) to 6 months (Md = 3.0) post-intervention (z = 80.5, p < 0.001), with a large effect size (r = 0.8) and statistically significant reduction in Brief Psychiatric Rating Scale scores from baseline (Md = 36.0) to 6 months (Md = 17.0) post-intervention (z = 128.5, p < 0.001), with a large effect size (r = 0.9). Implications Mobile technology-enhanced, mhGAP-IG-based efforts to scale-up mental health services in Nigeria are feasible and effective.
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Affiliation(s)
| | - Casey Chu
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
| | | | - Emeka Nwefoh
- Department of Medicine, Imo State University, Owerri, Nigeria
- CBM International, Abuja, Nigeria
| | - Charles Dike
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
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Purgato M, Prina E, Ceccarelli C, Cadorin C, Abdulmalik JO, Amaddeo F, Arcari L, Churchill R, Jordans MJ, Lund C, Papola D, Uphoff E, van Ginneken N, Tol WA, Barbui C. Primary-level and community worker interventions for the prevention of mental disorders and the promotion of well-being in low- and middle-income countries. Cochrane Database Syst Rev 2023; 10:CD014722. [PMID: 37873968 PMCID: PMC10594594 DOI: 10.1002/14651858.cd014722.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
BACKGROUND There is a significant research gap in the field of universal, selective, and indicated prevention interventions for mental health promotion and the prevention of mental disorders. Barriers to closing the research gap include scarcity of skilled human resources, large inequities in resource distribution and utilization, and stigma. OBJECTIVES To assess the effectiveness of delivery by primary workers of interventions for the promotion of mental health and universal prevention, and for the selective and indicated prevention of mental disorders or symptoms of mental illness in low- and middle-income countries (LMICs). To examine the impact of intervention delivery by primary workers on resource use and costs. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, Global Index Medicus, PsycInfo, WHO ICTRP, and ClinicalTrials.gov from inception to 29 November 2021. SELECTION CRITERIA Randomized controlled trials (RCTs) of primary-level and/or community health worker interventions for promoting mental health and/or preventing mental disorders versus any control conditions in adults and children in LMICs. DATA COLLECTION AND ANALYSIS Standardized mean differences (SMD) or mean differences (MD) were used for continuous outcomes, and risk ratios (RR) for dichotomous data, using a random-effects model. We analyzed data at 0 to 1, 1 to 6, and 7 to 24 months post-intervention. For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥ 0.80 large clinical effects. We evaluated the risk of bias (RoB) using Cochrane RoB2. MAIN RESULTS Description of studies We identified 113 studies with 32,992 participants (97 RCTs, 19,570 participants in meta-analyses) for inclusion. Nineteen RCTs were conducted in low-income countries, 27 in low-middle-income countries, 2 in middle-income countries, 58 in upper-middle-income countries and 7 in mixed settings. Eighty-three RCTs included adults and 30 RCTs included children. Cadres of primary-level workers employed primary care health workers (38 studies), community workers (71 studies), both (2 studies), and not reported (2 studies). Interventions were universal prevention/promotion in 22 studies, selective in 36, and indicated prevention in 55 RCTs. Risk of bias The most common concerns over risk of bias were performance bias, attrition bias, and reporting bias. Intervention effects 'Probably', 'may', or 'uncertain' indicates 'moderate-', 'low-', or 'very low-'certainty evidence. *Certainty of the evidence (using GRADE) was assessed at 0 to 1 month post-intervention as specified in the review protocol. In the abstract, we did not report results for outcomes for which evidence was missing or very uncertain. Adults Promotion/universal prevention, compared to usual care: - probably slightly reduced anxiety symptoms (MD -0.14, 95% confidence interval (CI) -0.27 to -0.01; 1 trial, 158 participants) - may slightly reduce distress/PTSD symptoms (SMD -0.24, 95% CI -0.41 to -0.08; 4 trials, 722 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD -0.69, 95% CI -1.08 to -0.30; 4 trials, 223 participants) Indicated prevention, compared to usual care: - may reduce adverse events (1 trial, 547 participants) - probably slightly reduced functional impairment (SMD -0.12, 95% CI -0.39 to -0.15; 4 trials, 663 participants) Children Promotion/universal prevention, compared to usual care: - may improve the quality of life (SMD -0.25, 95% CI -0.39 to -0.11; 2 trials, 803 participants) - may reduce adverse events (1 trial, 694 participants) - may slightly reduce depressive symptoms (MD -3.04, 95% CI -6 to -0.08; 1 trial, 160 participants) - may slightly reduce anxiety symptoms (MD -2.27, 95% CI -3.13 to -1.41; 1 trial, 183 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD 0, 95% CI -0.16 to -0.15; 2 trials, 638 participants) - may slightly reduce anxiety symptoms (MD 4.50, 95% CI -12.05 to 21.05; 1 trial, 28 participants) - probably slightly reduced distress/PTSD symptoms (MD -2.14, 95% CI -3.77 to -0.51; 1 trial, 159 participants) Indicated prevention, compared to usual care: - decreased slightly functional impairment (SMD -0.29, 95% CI -0.47 to -0.10; 2 trials, 448 participants) - decreased slightly depressive symptoms (SMD -0.18, 95% CI -0.32 to -0.04; 4 trials, 771 participants) - may slightly reduce distress/PTSD symptoms (SMD 0.24, 95% CI -1.28 to 1.76; 2 trials, 448 participants). AUTHORS' CONCLUSIONS The evidence indicated that prevention interventions delivered through primary workers - a form of task-shifting - may improve mental health outcomes. Certainty in the evidence was influenced by the risk of bias and by substantial levels of heterogeneity. A supportive network of infrastructure and research would enhance and reinforce this delivery modality across LMICs.
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Affiliation(s)
- Marianna Purgato
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
- Cochrane Global Mental Health, University of Verona, Verona, Italy
| | - Eleonora Prina
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Caterina Ceccarelli
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Camilla Cadorin
- Department of Neurosciences, Biomedicine and Movement Sciences, Verona, Italy
| | | | - Francesco Amaddeo
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | | | - Rachel Churchill
- Cochrane Common Mental Disorders, Centre for Reviews and Dissemination, University of York, York, UK
| | - Mark Jd Jordans
- Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Crick Lund
- King's Global Health Institute, Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Davide Papola
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
- Cochrane Global Mental Health, University of Verona, Verona, Italy
| | - Eleonora Uphoff
- Cochrane Common Mental Disorders, Centre for Reviews and Dissemination, University of York, York, UK
| | - Nadja van Ginneken
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK
| | - Wietse Anton Tol
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Corrado Barbui
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
- Cochrane Global Mental Health, University of Verona, Verona, Italy
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Heltne UM, Sarkadi A, Lien L, Dybdahl R. Training non-specialists in teaching recovery techniques (TRT) to help traumatised children in humanitarian settings: a qualitative analysis of experiences gained from 20 years of practice. Int J Equity Health 2023; 22:187. [PMID: 37697272 PMCID: PMC10494337 DOI: 10.1186/s12939-023-01999-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 08/25/2023] [Indexed: 09/13/2023] Open
Abstract
BACKGROUND Although several manuals and guidelines have been developed to enhance the quality of task-sharing interventions, it remains challenging to train non-professional personnel in mental health and psychosocial support. Practitioners must translate general recommendations into practical applications to make them relevant in demanding contexts. However, limited research exists on practical experiences with standardised programmes in the field. AIM To explore how experiences gained from the training of first-line health providers in a low-threshold intervention for children with trauma symptoms may guide implementation of such interventions in local communities in low-income countries. METHOD We summarise 20 years of experience in the training of first-line health providers, teachers, and school counsellors in providing a low-threshold intervention. The intervention is called teaching recovery techniques (TRT), developed by the Children and War Foundation (CAW). Field notes containing notes from trainings and oral, informal feedback from participants are analysed using thematic analysis, a method well-suited for identifying, analysing, and reporting patterns, or themes, within data in qualitative research. FINDINGS The analysis showed three main themes/ challenges: (1) Who can conduct the TRT intervention? (2) What form and content should the training take? (3) How can the intervention be used in a responsible way to follow the 'do no harm' principle? We discuss the implications of the findings for trainings in scalable interventions and further research.
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Affiliation(s)
| | | | - Lars Lien
- National Competence Services for Concurrent Addiction and Mental Disorders, Brummundal, Norway
| | - Ragnhild Dybdahl
- Centre for Crisis Psychology, University of Bergen, Bergen, Norway
- Norwegian Institute of Public Health, Oslo, Norway
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Perry AE, Zawadzka M, Lapinski P, Moore K, Rychlik J, Nowak B. Cultural adaptation of a UK evidence-based problem-solving intervention to support Polish prisoners at risk of suicidal behaviour: a cross-sectional survey using an Ecological Validity Model. BMJ Open 2023; 13:e069252. [PMID: 37423634 DOI: 10.1136/bmjopen-2022-069252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/11/2023] Open
Abstract
OBJECTIVE To complete a cultural adaptation of a UK evidence-based problem-solving intervention to support Polish prisoners at risk of suicidal behaviour. DESIGN A cross-sectional survey participatory design using an Ecological Validity Model. SETTING The study was a collaboration between: the Academy of Justice, in Warsaw, the University of Lodz, two Polish prisons (ZK Raciborz and ZK Klodzko) and the University of York (UK). METHODS The adaptation process included an examination of the use of language, metaphors and content (ie, culturally appropriate and syntonic language), the changing of case study scenarios (relevance and acceptability) and maintenance of the theoretical underpinning of the problem-solving model (intervention comprehensibility and completeness). Four stages used: (1) a targeted demonstration for Polish prison staff, (2) a wider audit of the skills with Polish prison staff and students, (3) forward and back-translation of the adapted package, and (4) two iterative consultations with participants from stages (1) and (2) and prison officers from two Polish prisons. PARTICIPANTS Self-selecting volunteer participants included: targeted prison staff (n=10), prison staff from the wider Polish penitentiary system (n=39), students from the University of Lodz (n=28) and prison officers from two Polish prisons (n=12). MAIN OUTCOMES AND MEASURES Acceptability and feasibility of the training package, reported in a series of knowledge user surveys. RESULTS The recognised benefits of using the skills within the training package included: enhancing communication, reflective development, collaborative working, changing behaviour, empowering decision-making, relevance to crisis management situations and use of open-ended questions. The skills were endorsed to be used as part of future penitentiary training for prison officers in Poland. CONCLUSIONS The skills had widespread appeal for use across the Polish penitentiary system. The materials were deemed relevant while adhering to the comprehensibility of the intervention. Further evaluation of the intervention should be explored using a randomised controlled trial design.
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Affiliation(s)
- Amanda E Perry
- Department of Health Sciences, University of York, York, UK
| | | | - Piotr Lapinski
- Department of Occupational Therapy, University of Physical Education in Warsaw, Faculty of Rehabilitation, Warsaw, Poland
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Rabbani F, Akhtar S, Nafis J, Khan S, Siddiqi S, Merali Z. Addition of mental health to the lady health worker curriculum in Pakistan: now or never. HUMAN RESOURCES FOR HEALTH 2023; 21:29. [PMID: 37072767 PMCID: PMC10112305 DOI: 10.1186/s12960-023-00814-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 04/03/2023] [Indexed: 05/03/2023]
Abstract
The technical advisory group of the World Health Organization (Geneva, Switzerland) has suggested person-centered and community-based mental health services in response to the long-term and far-reaching mental health impacts of the COVID-19 pandemic. Task shifting is a pragmatic approach to tackle the mental health treatment gap in low- and middle-income countries. Pakistan is dismally resourced to address the mental health challenges. Pakistan's government has established a lady health worker's program (LHW-P) which can be effectively utilized to provide some basic mental health services at community doorsteps. However, lady health workers' current curriculum does not include mental health as a subject. WHO's Mental Health Gap Intervention Guide (mhGAP-IG) Version 2.0 for mental, neurological, and substance use disorders in non-specialist health settings can be adapted and utilized to be included as part of the LHW-P curriculum in Pakistan. Thus, the historical lack of access to mental health support workers, counsellors, and specialists can be addressed. Additionally, this will also help to reduce the stigma associated with seeking mental health care outside the boundaries of home, mostly at a huge cost.
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Affiliation(s)
- Fauziah Rabbani
- Brain and Mind Institute, Aga Khan University, Karachi, Pakistan.
- Department of Community Health Sciences, Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, Pakistan.
| | - Samina Akhtar
- Department of Community Health Sciences, Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, Pakistan
| | - Javeria Nafis
- Department of Community Health Sciences, Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, Pakistan
| | - Shahid Khan
- Population and Public Health Stream, Aga Khan University, Stadium Road, Karachi, Pakistan
| | - Sameen Siddiqi
- Department of Community Health Sciences, Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, Pakistan
| | - Zul Merali
- Brain and Mind Institute, Aga Khan University, Karachi, Pakistan
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Kokole D, Mercken L, Anderson P, Mejía-Trujillo J, Perez-Gomez A, Bustamante I, Piazza M, Natera Rey G, Arroyo M, Pérez De León A, Bautista Aguilar N, Medina Aguilar PS, Schulte B, O'Donnell A, de Vries H, Jané-Llopis E. Country and policy factors influencing the implementation of primary care-based alcohol screening: A comparison of Colombia, Mexico and Peru. Glob Public Health 2023; 18:2207410. [PMID: 37156224 DOI: 10.1080/17441692.2023.2207410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Researchers and practitioners recognise the importance of context when implementing healthcare interventions, but the influence of wider environment is rarely mapped. This paper identifies the country and policy-related factors potentially explaining the country differences in outcomes of an intervention focused on improving detection and management of heavy alcohol use in primary care in Colombia, Mexico and Peru. Qualitative data obtained through interviews, logbooks and document analysis are used to explain quantitative data on number of alcohol screenings and screening providers in each of the countries. Existing alcohol screening standards in Mexico, and policy prioritisation of primary care and consideration of alcohol as a public health issue in Colombia and Mexico positively contributed to the outcome, while the COVID-19 pandemic had a negative impact. In Peru, the context was unsupportive due to a combination of: political instability amongst regional health authorities; lack of focus on strengthening primary care due to the expansion of community mental health centres; alcohol considered as an addiction rather than a public health issue; and the impact of COVID-19 on healthcare. We found that wider environment-related factors interacted with the intervention implemented and can help explain country differences in outcomes.
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Affiliation(s)
- Daša Kokole
- Department of Health Promotion, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, Netherlands
| | - Liesbeth Mercken
- Department of Health Promotion, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, Netherlands
- Department of Health Psychology, Open University, Heerlen, Netherlands
| | - Peter Anderson
- Department of Health Promotion, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, Netherlands
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | | | - Ines Bustamante
- School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Lima, Perú
| | - Marina Piazza
- School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Lima, Perú
| | | | - Miriam Arroyo
- Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz, Ciudad de México, Mexico
| | | | | | | | - Bernd Schulte
- Department of Psychiatry and Psychotherapy, Centre for Interdisciplinary Addiction Research (ZIS), University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Amy O'Donnell
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Hein de Vries
- Department of Health Promotion, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, Netherlands
| | - Eva Jané-Llopis
- Department of Health Promotion, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, Netherlands
- ESADE, Universitat Ramon Llull, Barcelona, Spain
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Regalado ICR, Lindquist AR, Cardoso R, Longo E, Lencucha R, Hunt M, Thomas A, Bussières A, Boruff JT, Shikako K. Knowledge translation in rehabilitation settings in low, lower-middle and upper-middle-income countries: a scoping review. Disabil Rehabil 2023; 45:376-390. [PMID: 35188861 DOI: 10.1080/09638288.2022.2030415] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
PURPOSE This review aims to identify the barriers and facilitators to knowledge use and Knowledge Translation (KT) strategies in rehabilitation in low, lower-middle, and upper-middle-income countries (LMICs). MATERIALS AND METHODS A scoping review of studies of KT in rehabilitation in LMICs contexts using the Arksey and O'Malley Framework was conducted. A comprehensive search of MEDLINE and 10 other databases was undertaken to identify studies conducted primarily in LMICs. RESULTS From the initial 15.606 titles identified; 27 articles were included for final analysis. Our analysis identified the following themes: Professional culture and context; KT interventions; and the conceptualization and application of KT and Evidence Based Practice (EBP). Individual-level barriers to KT included lack of skills, knowledge about EBP and English language, lack of motivation, and decision-making power. Facilitators to KT included positive attitudes and motivation. Organization-level barriers included lack of time, lack of financial resources, limited access to scientific journals, and applicability of research to rural settings. Facilitators included adequate financial and physical resources, a supportive management environment, and the existence of training and continuing education programs. CONCLUSION This review identified common and unique barriers and facilitators to KT in LMICs when compared to KT studies conducted in high-income settings.IMPLICATIONS FOR REHABILITATIONKnowledge Translation from academic institutions to rehabilitation clinical practice in low and upper-middle-income countries is important to support evidence-based practice and patient outcomes.Barriers at the individual level include professionals' ability to understand English and knowledge of the evidence-based practice.Organization-level barriers included lack of time to access and implement new practices, lack of financial and personal resources, limited access to scientific journals, and applicability of research to rural settings.Training and continuing education programs are needed to support rehabilitation professionals' efforts to achieve the application of evidence-based practice in clinical practice.
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Affiliation(s)
- I C R Regalado
- Department of Physiotherapy, Federal University of Rio Grande do Norte-UFRN, Avenida Senador Salgado Filho, Natal, Brazil
| | - A R Lindquist
- Department of Physiotherapy, Federal University of Rio Grande do Norte-UFRN, Avenida Senador Salgado Filho, Natal, Brazil
| | - R Cardoso
- School of Physical and Occupational Therapy, McGill University, Montreal, Canada
| | - E Longo
- Department of Health of Children, Federal University of Rio Grande do Norte-UFRN/FACISA, Santa Cruz, Brazil
| | - R Lencucha
- School of Physical and Occupational Therapy, McGill University, Montreal, Canada
| | - M Hunt
- School of Physical and Occupational Therapy, McGill University, Montreal, Canada
| | - A Thomas
- School of Physical and Occupational Therapy, McGill University, Montreal, Canada
| | - A Bussières
- School of Physical and Occupational Therapy, McGill University, Montreal, Canada
| | - J T Boruff
- School of Physical and Occupational Therapy, McGill University, Montreal, Canada
| | - K Shikako
- School of Physical and Occupational Therapy, McGill University, Montreal, Canada
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O'Donnell A, Anderson P, Schmidt C, Braddick F, Lopez-Pelayo H, Mejía-Trujillo J, Natera G, Arroyo M, Bautista N, Piazza M, Bustamante IV, Kokole D, Jackson K, Jane-Llopis E, Gual A, Schulte B. Tailoring an evidence-based clinical intervention and training package for the treatment and prevention of comorbid heavy drinking and depression in middle-income country settings: the development of the SCALA toolkit in Latin America. Glob Health Action 2022; 15:2080344. [PMID: 35867541 PMCID: PMC9310809 DOI: 10.1080/16549716.2022.2080344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Effective interventions exist for heavy drinking and depression but to date there has been limited translation into routine practice in global health systems. This evidence-to-practice gap is particularly evident in low- and middle-income countries. The international SCALA project (Scale-up of Prevention and Management of Alcohol Use Disorders and Comorbid Depression in Latin America) sought to test the impact of multilevel implementation strategies on rates of primary health care-based measurement of alcohol consumption and identification of depression in Colombia, Mexico, and Peru. OBJECTIVE To describe the process of development and cultural adaptation of the clinical intervention and training package. METHODS We drew on Barrero and Castro's four-stage cultural adaption model: 1) information gathering, 2) preliminary adaption, 3) preliminary adaption tests, and 4) adaption refinement. The Tailored Implementation in Chronic Diseases checklist helped us identify potential factors that could affect implementation, with local stakeholder groups established to support the tailoring process, as per the Institute for Healthcare Improvement's Going to Scale Framework. RESULTS In Stage 1, international best practice guidelines for preventing heavy drinking and depression, and intelligence on the local implementation context, were synthesised to provide an outline clinical intervention and training package. In Stage 2, feedback was gathered from local stakeholders and materials refined accordingly. These materials were piloted with local trainers in Stage 3, leading to further refinements including developing additional tools to support delivery in busy primary care settings. Stage 4 comprised further adaptions in response to real-world implementation, a period that coincided with the onset of the COVID-19 pandemic, including translating the intervention and training package for online delivery, and higher priority for depression screening in the clinical pathway. CONCLUSION Our experience highlights the importance of meaningful engagement with local communities, alongside the need for continuous tailoring and adaptation, and collaborative decision-making.
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Affiliation(s)
- Amy O'Donnell
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Peter Anderson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK.,Department of Health Promotion, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Christiane Schmidt
- Centre of Interdisciplinary Addiction Research (ZIS), Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fleur Braddick
- Addictions Unit, Psychiatry Department, Hospital Clínic, Barcelona, Spain
| | - Hugo Lopez-Pelayo
- Addictions Unit, Psychiatry Department, Hospital Clínic, Barcelona, Spain.,Red de Trastornos Adictivos, Instituto Carlos III. Sinesio Delgado, Madrid, Spain.,Institut d'Investigacions Biomèdiques August Pi Sunyer (IDIBAPS); Rosselló, Barcelona, Spain
| | | | - Guillermina Natera
- Instituto Nacional de Psiquiatría Ram´on de la Fuente, Ciudad de México, Mexico
| | - Miriam Arroyo
- Instituto Nacional de Psiquiatría Ram´on de la Fuente, Ciudad de México, Mexico
| | - Natalia Bautista
- Instituto Nacional de Psiquiatría Ram´on de la Fuente, Ciudad de México, Mexico
| | - Marina Piazza
- School of Public Health and Administration, Universidad Peruana Cayetano Heredia, San Martin de Porres, Peru
| | - Ines V Bustamante
- School of Public Health and Administration, Universidad Peruana Cayetano Heredia, San Martin de Porres, Peru
| | - Daša Kokole
- Department of Health Promotion, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Katherine Jackson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Eva Jane-Llopis
- Department of Health Promotion, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands.,Institute for Mental Health Policy Research, Toronto, Ontario, Canada.,Univ. Ramon Llull, ESADE, Barcelona, Spain
| | - Antoni Gual
- Institut d'Investigacions Biomèdiques August Pi Sunyer (IDIBAPS); Rosselló, Barcelona, Spain
| | - Bernd Schulte
- Centre of Interdisciplinary Addiction Research (ZIS), Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Nyongesa V, Kathono J, Mwaniga S, Yator O, Madeghe B, Kanana S, Amugune B, Anyango N, Nyamai D, Wambua GN, Chorpita B, Kohrt BA, Ahs JW, Idele P, Carvajal L, Kumar M. Cultural and contextual adaptation of mental health measures in Kenya: An adolescent-centered transcultural adaptation of measures study. PLoS One 2022; 17:e0277619. [PMID: 36520943 PMCID: PMC9754261 DOI: 10.1371/journal.pone.0277619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 10/31/2022] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION There is paucity of culturally adapted tools for assessing depression and anxiety in children and adolescents in low-and middle-income countries. This hinders early detection, provision of appropriate and culturally acceptable interventions. In a partnership with the University of Nairobi, Nairobi County, Kenyatta National Hospital, and UNICEF, a rapid cultural adaptation of three adolescent mental health scales was done, i.e., Revised Children's Anxiety and Depression Scale, Patient Health Questionnaire-9 and additional scales in the UNICEF mental health module for adolescents. MATERIALS AND METHODS Using a qualitative approach, we explored adolescent participants' views on cultural acceptability, comprehensibility, relevance, and completeness of specific items in these tools through an adolescent-centered approach to understand their psychosocial needs, focusing on gender and age-differentiated nuances around expression of distress. Forty-two adolescents and 20 caregivers participated in the study carried out in two primary care centers where we conducted cognitive interviews and focused group discussions assessing mental health knowledge, literacy, access to services, community, and family-level stigma. RESULTS We reflect on process and findings of adaptations of the tools, including systematic identification of words adolescents did not understand in English and Kiswahili translations of these scales. Some translated words could not be understood and were not used in routine conversations. Response options were changed to increase comprehensibility; some statements were qualified by adding extra words to avoid ambiguity. Participants suggested alternative words that replaced difficult ones and arrived at culturally adapted tools. DISCUSSION Study noted difficult words, phrases, dynamics in understanding words translated from one language to another, and differences in comprehension in adolescents ages 10-19 years. There is a critical need to consider cultural adaptation of depression and anxiety tools for adolescents. CONCLUSION Results informed a set of culturally adapted scales. The process was community-driven and adhered to the principles of cultural adaptation for assessment tools.
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Affiliation(s)
| | - Joseph Kathono
- Department of Psychiatry, University of Nairobi, Nairobi, Kenya
- Nairobi Metropolitan Services, Nairobi, Kenya
| | - Shillah Mwaniga
- Nairobi Metropolitan Services, Nairobi, Kenya
- Vrije University, Amsterdam, Netherlands
| | - Obadia Yator
- Department of Psychiatry, University of Nairobi, Nairobi, Kenya
| | - Beatrice Madeghe
- Department of Food and Nutrition Sciences, University of Nairobi, Nairobi, Kenya
| | | | | | - Naomi Anyango
- Department of Mental Health, Ministry of Health, Kenya
| | | | - Grace Nduku Wambua
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Bruce Chorpita
- University of California, Los Angeles, United States of America
| | - Brandon A. Kohrt
- Division of Global Mental Health, Department of Psychiatry and Behavioral Science, The George Washington University, Washington, District of Columbia, United States of America
| | - Jill W. Ahs
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Solna, Sweden
- Department of Health Care Sciences, Swedish Red Cross University College, Huddinge, Sweden
| | - Priscilla Idele
- UN Secretariat, New York, New York, United States of America
| | - Liliana Carvajal
- Division of Data, Analytics, Planning and Monitoring, Data and Analytics Section, UNICEF, New York, New York, United States of America
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Manasi Kumar
- Department of Psychiatry, University of Nairobi, Nairobi, Kenya
- Brain and Mind Institute, Aga Khan University, Nairobi, Kenyau
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Will increasing access to mental health treatment close India's mental health gap? SSM - MENTAL HEALTH 2022. [DOI: 10.1016/j.ssmmh.2022.100184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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15
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Girase B, Parikh R, Vashisht S, Mullick A, Ambhore V, Maknikar S. India's policy and programmatic response to mental health of young people: A narrative review. SSM - MENTAL HEALTH 2022. [DOI: 10.1016/j.ssmmh.2022.100145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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16
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Ribic E, Sikira H, Dzubur Kulenovic A, Pemovska T, Russo M, Jovanovic N, Radojicic T, Repisti S, Milutinović M, Blazevska B, Konjufca J, Ramadani F, Jerotic S, Savic B. Perceived sustainability of psychosocial treatment in low- and middle-income countries in South-Eastern Europe. BJPsych Open 2022; 8:e156. [PMID: 35968901 PMCID: PMC9438482 DOI: 10.1192/bjo.2022.539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND DIALOG+ is an evidence-based, generic, cost-saving and easily deliverable psychosocial intervention, adaptable to clinicians' personal manner of interaction with patients. It was implemented in mental health services in five low- and middle-income countries in South-Eastern Europe during a 12-month randomised-controlled trial (IMPULSE) to improve the effectiveness of out-patient treatment for people with psychotic disorders. AIMS To investigate barriers and facilitators to the perceived sustainability of DIALOG+ that has been successfully implemented as a part of the IMPULSE project. METHOD Three months after the IMPULSE trial's end, perceived sustainability of the DIALOG+ intervention was assessed via a short survey of clinicians and patients who took part in the trial. Quantitative data collected from the survey were analysed using descriptive statistics; content analysis assessed qualitative survey data. The views and experiences of key informants (patients, clinicians and healthcare policy influencers) regarding the sustainability and scale-up of DIALOG+ were further explored through semi-structured interviews. These data were explored using framework analysis. RESULTS Clinicians mostly appreciated the comprehensiveness of DIALOG+, and patients described DIALOG+ meetings as empowering and motivating. The barrier most commonly identified by key informants was availability of financial resources; the most important facilitators were the clinically relevant structure and comprehensiveness of the DIALOG+ intervention. CONCLUSIONS Participants showed a willingness to sustain the implementation of DIALOG+. It is important to maintain collaboration with healthcare policy influencers to improve implementation of DIALOG+ across different levels of healthcare systems and ensure availability of resources for implementing psychosocial interventions such as DIALOG+.
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Affiliation(s)
- Emina Ribic
- Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Hana Sikira
- Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | | | - Tamara Pemovska
- Unit for Social and Community Psychiatry, Queen Mary University of London, London, UK; and WHO Collaborating Centre for Mental Health Services Development, Bart's and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Manuela Russo
- Unit for Social and Community Psychiatry, Queen Mary University of London, London, UK
| | - Nikolina Jovanovic
- Unit for Social and Community Psychiatry, Queen Mary University of London, London, UK; and Newham Centre for Mental Health, London, UK
| | | | | | | | | | - Jon Konjufca
- Department of Psychology, University of Prishtina 'Hasan Prishtina', Prishtina, Kosovo, Albania; and University of Prishtina, Kosovska Mitrovica, Serbia
| | - Fjolla Ramadani
- Department of Psychology, University of Prishtina 'Hasan Prishtina', Prishtina, Kosovo, Albania
| | - Stefan Jerotic
- Department of Psychiatry, University Clinical Center of Serbia, Belgrade, Serbia; and Department of Psychiatry, Clinic for Psychiatry, Clinical Centre of Serbia, Belgrade, Serbia
| | - Bojana Savic
- University Clinical Center of Serbia, Belgrade, Serbia
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Fine SL, Kane JC, Spiegel PB, Tol WA, Ventevogel P. Ten years of tracking mental health in refugee primary health care settings: an updated analysis of data from UNHCR's Health Information System (2009-2018). BMC Med 2022; 20:183. [PMID: 35570266 PMCID: PMC9109385 DOI: 10.1186/s12916-022-02371-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 04/08/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND This study examines mental, neurological, and substance use (MNS) service usage within refugee camp primary health care facilities in low- and middle-income countries (LMICs) by analyzing surveillance data from the United Nations High Commissioner for Refugees Health Information System (HIS). Such information is crucial for efforts to strengthen MNS services in primary health care settings for refugees in LMICs. METHODS Data on 744,036 MNS visits were collected from 175 refugee camps across 24 countries between 2009 and 2018. The HIS documented primary health care visits for seven MNS categories: epilepsy/seizures, alcohol/substance use disorders, mental retardation/intellectual disability, psychotic disorders, severe emotional disorders, medically unexplained somatic complaints, and other psychological complaints. Combined data were stratified by 2-year period, country, sex, and age group. These data were then integrated with camp population data to generate MNS service utilization rates, calculated as MNS visits per 1000 persons per month. RESULTS MNS service utilization rates remained broadly consistent throughout the 10-year period, with rates across all camps hovering around 2-3 visits per 1000 persons per month. The largest proportion of MNS visits were attributable to epilepsy/seizures (44.4%) and psychotic disorders (21.8%). There were wide variations in MNS service utilization rates and few consistent patterns over time at the country level. Across the 10 years, females had higher MNS service utilization rates than males, and rates were lower among children under five compared to those five and older. CONCLUSIONS Despite increased efforts to integrate MNS services into refugee primary health care settings over the past 10 years, there does not appear to be an increase in overall service utilization rates for MNS disorders within these settings. Healthcare service utilization rates are particularly low for common mental disorders such as depression, anxiety, post-traumatic stress disorder, and substance use. This may be related to different health-seeking behaviors for these disorders and because psychological services are often offered outside of formal health settings and consequently do not report to the HIS. Sustained and equitable investment to improve identification and holistic management of MNS disorders in refugee settings should remain a priority.
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Affiliation(s)
- Shoshanna L Fine
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Baltimore, MD, 21205, USA.
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Jeremy C Kane
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Epidemiology, Columbia Mailman School of Public Health, New York, NY, USA
| | - Paul B Spiegel
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Wietse A Tol
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Athena Research Institute, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Arq International, Diemen, the Netherlands
| | - Peter Ventevogel
- Public Health Section, Division of Resilience and Solutions, United Nations High Commissioner for Refugees, Geneva, Switzerland
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An evaluation of mental health capacity building among Community Rehabilitation Officers in Malawi: A mixed-methods case study. SSM - MENTAL HEALTH 2022. [DOI: 10.1016/j.ssmmh.2022.100108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Chu C, Roxas N, Aguocha CM, Nwefoh E, Wang K, Dike C, Iheanacho T. Integrating mental health into primary care: evaluation of the Health Action for Psychiatric Problems In Nigeria including Epilepsy and SubstanceS (HAPPINESS) pilot project. BMC Health Serv Res 2022; 22:333. [PMID: 35279154 PMCID: PMC8917687 DOI: 10.1186/s12913-022-07703-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 02/28/2022] [Indexed: 11/29/2022] Open
Abstract
Background The Health Action for Psychiatric Problems In Nigeria including Epilepsy and SubstanceS (HAPPINESS) project trains non-specialist and primary health care workers in Imo State, Nigeria. This project adapted the World Health Organization’s Mental Health Gap Action Programme-Intervention Guide (mhGAP-IG), emphasizing stigma reduction among trainees. This convergent mixed-methods proof-of-concept study evaluates the HAPPINESS pilot project mhGAP-IG training’s impact on mental illness stigma among trainees and barriers, facilitators, and opportunities to consider for project improvement. Methods Trainees (n = 13) completed a 43-item questionnaire before and after their 5-day training to assess perceptions of mental disorders and attitudes towards people with mental illness. These responses were analyzed using paired-sample t-tests for four subscales of the questionnaire: acceptance of socializing with people with mental illness, normalizing activities and relationships with people with mental illness, supernatural causation of mental illness, and endorsement of a biopsychosocial approach to mental illness. Semi-structured key informant interviews (n = 11) with trainees, trainers, and local health officials who participated in or supported the HAPPINESS project were thematically analyzed to understand their experiences and perspectives of the project’s barriers, facilitators, and opportunities. Results Trainees showed significant improvements on socializing, normalizing, and supernatural causation subscales of the stigma questionnaire (p < 0.05). No significant effect was seen on the biopsychosocial subscale; however, evidence of biopsychosocial beliefs was found in interview responses. Key informant interviews revealed that the HAPPINESS project enhanced trainees’ diagnostic and treatment abilities, mental health awareness, and empathy towards patients. Misinformation, stigma, inadequate funding, and lack of road access to clinics were identified as barriers to mental health care integration into general care in Imo State. Respondents also suggested ways that the HAPPINESS project could be improved and expanded in the future. Conclusions This study adds to the limited evidence on the implementation of mhGAP-IG in Nigeria. Using mixed methods, it evaluates how mhGAP-IG can impact perceptions and knowledge of stigma among primary care trainees. It also highlights barriers, facilitators, and opportunities to consider for project growth. Future efforts should focus on clinical support, supervision, health outcomes, as well as scaling up and assessing the cost-effectiveness of the HAPPINESS project intervention. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07703-1.
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Competency-based mental health supervision: evidence-based tool needs for the humanitarian context. Glob Ment Health (Camb) 2022; 9:221-222. [PMID: 36618752 PMCID: PMC9806983 DOI: 10.1017/gmh.2022.23] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 03/21/2022] [Accepted: 03/28/2022] [Indexed: 01/11/2023] Open
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What matters in mental health care? A co-design approach to developing clinical supervision tools for practitioner competency development. Glob Ment Health (Camb) 2022; 9:491-498. [PMID: 36618724 PMCID: PMC9807002 DOI: 10.1017/gmh.2022.53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 08/27/2022] [Accepted: 09/20/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Specialised mental health (MH) care providers are often absent or scarcely available in low resource and humanitarian settings (LRHS), making MH training and supervision for general health care workers (using task-sharing approaches) essential to scaling up services and reducing the treatment gap for severe and common MH conditions. Yet, the diversity of settings, population types, and professional skills in crisis contexts complicate these efforts. A standardised, field tested instrument for clinical supervision would be a significant step towards attaining quality standards in MH care worldwide. METHODS A competency-based clinical supervision tool was designed by Médecins Sans Frontières (MSF) for use in LRHS. A systematic literature review informed its design and assured its focus on key clinical competencies. An initial pool of behavioural indicators was identified through a rational theoretical scale construction approach, tested through waves of simulation and reviewed by 12 MH supervisors in seven projects where MSF provides care for severe and common MH conditions. RESULTS Qualitative analysis yielded two sets of competency grids based on a supervisee's professional background: one for 'psychological/counselling' and another for 'psychiatric/mhGAP' practitioners. Each grid features 22-26 competencies, plus optional items for specific interventions. While the structure and content were assessed as logical by supervisors, there were concerns regarding the adequacy of the tool to field reality. CONCLUSIONS Humanitarian settings have specific needs that require careful consideration when developing capacity-building strategies. Clinical supervision of key competencies through a standardised instrument represents an important step towards ensuring progress of clinical skills among MH practitioners.
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Kumar M, Chu W, Gellatly R, Wambua GN, Becker KD, Chorpita BF. Identified needs of peripartum adolescents in Sub-Saharan Africa from 2013 to 2021: a mapping of domains for strengthening psychosocial interventions. Curr Opin Psychol 2021; 45:101291. [PMID: 35016086 DOI: 10.1016/j.copsyc.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 12/01/2021] [Accepted: 12/06/2021] [Indexed: 11/16/2022]
Abstract
Adolescent pregnancy and early motherhood pose significant socioeconomic and health risks in Sub-Saharan Africa, leading to considerable morbidity and mortality. To learn more about the needs of this population, we reviewed 24 articles featuring 21 samples covering 12,490 adolescents from 14 countries. Our coding revealed that adolescent mothers were studied more (85.7% of samples) than pregnant adolescents (61.9%). We summarized needs as per six categories. Resource needs were most prevalent, reported by 100% of samples, followed by ecology (85.7%), mental health (76.2%), medical (61.9%), other (61.9%), and education (33.3%). The most frequently reported resource needs were low income and unemployment. Low social support, low family functioning, and exposure to negative cultural norms were ecological needs prevalent in most samples. Among mental health concerns, depression was the most commonly reported problem, whereas other problems, such as anxiety, substance use, and suicidality, were reported much less frequently. HIV-positive status was the most frequently reported medical concern. Intervention developers should consider the range of challenges when designing psychosocial services for this population.
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Affiliation(s)
- Manasi Kumar
- Department of Psychiatry, University of Nairobi, Kenya.
| | - Wendy Chu
- Department of Psychology, University of South Carolina, USA
| | - Resham Gellatly
- Department of Psychology, University of California, Los Angeles, USA
| | - Grace Nduku Wambua
- Faculty of Behavioural and Movement Sciences, Clinical Psychology, Vrije Universiteit, Netherlands
| | | | - Bruce F Chorpita
- Department of Psychology, University of California, Los Angeles, USA
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Singh A, Nemiro A, Malik A, Guimond MF, Nduwimana E, Likindikoki S, Annan J, Tol WA. Cultural adaptation of a scalable psychological intervention for Burundian refugee adolescents in Tanzania: a qualitative study. Confl Health 2021; 15:73. [PMID: 34579750 PMCID: PMC8477522 DOI: 10.1186/s13031-021-00391-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 06/25/2021] [Indexed: 11/26/2022] Open
Abstract
Background There is an urgent need for evidence-based, scalable, psychological interventions to improve the mental health of adolescents affected by adversity in low-resource settings. Early Adolescents Skills for Emotions (EASE) was developed by the WHO as a brief, transdiagnostic, group intervention for early adolescents exhibiting internalising problems, delivered by trained and supervised lay providers. This study describes the cultural adaptation of EASE for Burundian adolescents living in Mtendeli refugee camps in Tanzania. Methods A phased approach to adaptation of the EASE intervention and its implementation, was adopted and comprised of: (1) a desk review to synthesize existing research on mental health issues in conflict-affected Burundian communities, (2) a rapid qualitative assessment involving free listing and key informant interviews with multiple stakeholders, (3) cognitive interviews with end users, and (4) a two-part adaptation workshop involving the implementing partner staff, members of the refugee community and mental health experts. We applied the Bernal framework to systematically document and track adaptations across eight dimensions of the intervention. Results Problems associated with worry, stress, sadness, shame and fear were identified as amongst the most critical mental health concerns, alongside a range of experiences of different forms of violence (such as gender-based violence, violence when fleeing from their homes) and associated problems. Problems associated with violence that included past experiences of fleeing as well as ongoing problems of gender-based violence in the camp. The most significant adaptations that were required included providing options for low literacy of participants, safety planning to address the high prevalence of sexual violence, simplification of strategies for the benefit of the end users and of lay facilitators, and implementation changes to consider involvement of refugee incentive workers. A majority of changes were across dimensions of language, people, metaphors, content, methods and context, while there were fewer changes regarding the goals and concepts of EASE. Conclusions The approach to adaptation of a psychological intervention suggested both minor and major required changes. Adaptations based on the findings of this study are anticipated to enhance relevance and acceptability of the EASE intervention and its delivery for camp-residing Burundian refugees in Tanzania. Supplementary Information The online version contains supplementary material available at 10.1186/s13031-021-00391-4.
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Affiliation(s)
- Aneeha Singh
- International Rescue Committee, 122 E 42nd Street, New York, NY, 1068, USA
| | - Ashley Nemiro
- International Rescue Committee, 122 E 42nd Street, New York, NY, 1068, USA
| | | | | | - Estella Nduwimana
- International Organization for Migration, Kabondo Ouest, Av. Ririkumutima, 13, Bujumbura, Burundi
| | - Samuel Likindikoki
- Muhimbili University of Health and Allied Sciences, United Nations Road, Dar es Salaam, Tanzania
| | - Jeannie Annan
- International Rescue Committee, 122 E 42nd Street, New York, NY, 1068, USA
| | - Wietse A Tol
- Section of Global Health, Department of Public Health, CSS, Øster Farimagsgade 5, bg 9, DK-1014, Copenhagen K, Denmark. .,HealthRight International, 14 E 4th Street, New York, NY, 10012, USA. .,Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, 624 N. Broadway, 8th Floor, Baltimore, MD, 21205, USA.
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Task sharing in psychotherapy as a viable global mental health approach in resource-poor countries and also in high-resource settings. GLOBAL HEALTH JOURNAL 2021. [DOI: 10.1016/j.glohj.2021.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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25
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Elias L, Singh A, Burgess RA. In search of 'community': a critical review of community mental health services for women in African settings. Health Policy Plan 2021; 36:205-217. [PMID: 33543248 DOI: 10.1093/heapol/czaa140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2020] [Indexed: 11/14/2022] Open
Abstract
Community is deemed a central resource for the improvement of health, across disciplines, contexts and conditions. However, what is meant by this term is rarely critically explored. In Global Mental Health, considerable efforts in recent years have been directed towards scaling up 'community' approaches, with variable success, creating the need to better understand approaches to its use. Our study contributes to this need, through a critical review of studies engaging with the term 'community' in relation to women's mental health services in African settings. Our review explored 30 peer-reviewed articles from the past 15 years, which were systematically evaluated for quality of evidence. Studies were then analysed using a blend of conventional and directed content analysis to unpack perspectives on the term's use in intervention and phenomenological studies. We identified four broad categories of community: (1) place (shared geographical location or institutional affiliation), (2) practice (belongingness to a shared activity or profession), (3) symbols (meanings and experiences associated with shared community life) and (4) identity (diagnostic identity around a mental health condition). Analysis identified community of place as the most common primary focus of interest across the sample, with 80% of papers referencing this dimension. We noted that in studies where communities of practice were the focus, this was in relation to leveraging local knowledge to inform or support service delivery of intervention programmes, often designed by outsiders. Implications for future policy and mental health services research are discussed.
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Affiliation(s)
- Lauren Elias
- Institute for Global Health, University College London, 30 Guilford Street, London WC1N 1EH, UK
| | - Aneeha Singh
- International Research and Exchanges Board (South & South East Asia Centre), 1275 K Street, NW, Suite 600 Washington, DC 20005, USA
| | - Rochelle A Burgess
- Institute for Global Health, University College London, 30 Guilford Street, London WC1N 1EH, UK.,Research Associate, Department of Social Work, University of Johannesburg, South Africa
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Keynejad R, Spagnolo J, Thornicroft G. WHO mental health gap action programme (mhGAP) intervention guide: updated systematic review on evidence and impact. EVIDENCE-BASED MENTAL HEALTH 2021; 24:ebmental-2021-300254. [PMID: 33903119 PMCID: PMC8311089 DOI: 10.1136/ebmental-2021-300254] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/22/2021] [Accepted: 03/29/2021] [Indexed: 01/08/2023]
Abstract
QUESTION There is a large worldwide gap between the service need and provision for mental, neurological and substance use disorders. WHO's Mental Health Gap Action Programme (mhGAP) intervention guide (IG), provides evidence-based guidance and tools for assessment and integrated management of priority disorders. Our 2017 systematic review identified 33 peer-reviewed studies describing mhGAP-IG implementation in low-income and middle-income countries. STUDY SELECTION AND ANALYSIS We searched MEDLINE, Embase, PsycINFO, Web of Knowledge, Scopus, CINAHL, LILACS, ScieELO, Cochrane, PubMed databases, 3ie, Google Scholar and citations of our review, on 24 November 2020. We sought evidence, experience and evaluations of the mhGAP-IG, app or mhGAP Humanitarian IG, from any country, in any language. We extracted data from included papers, but heterogeneity prevented meta-analysis. FINDINGS Of 2621 results, 162 new papers reported applications of the mhGAP-IG. They described mhGAP training courses (59 references), clinical applications (n=49), research uses (n=27), contextual adaptations (n=13), economic studies (n=7) and other educational applications (n=7). Most were conducted in the African region (40%) and South-East Asia (25%). Studies demonstrated improved knowledge, attitudes and confidence post-training and improved symptoms and engagement with care, post-implementation. Research studies compared mhGAP-IG-enhanced usual care with task-shared psychological interventions and adaptation studies optimised mhGAP-IG implementation for different contexts. Economic studies calculated human resource requirements of scaling up mhGAP-IG implementation and other educational studies explored its potential for repurposing. CONCLUSIONS The diverse, expanding global mhGAP-IG literature demonstrates substantial impact on training, patient care, research and practice. Priorities for future research should be less-studied regions, severe mental illness and contextual adaptation of brief psychological interventions.
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Affiliation(s)
- Roxanne Keynejad
- Department of Health Service and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Jessica Spagnolo
- Département des Sciences de la Santé Communautaire, Université de Sherbrooke, Sherbrooke, Quebec, Canada
- Centre de recherche Charles-Le Moyne - Saguenay-Lac-Saint-Jean sur les innovations en santé, Campus de Longueuil, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Graham Thornicroft
- Department of Health Service and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Meshesha HS, Johnson V. A Systematic Review of Culturally Responsive Approaches to Child and Adolescent Mental Health Care in Ethiopia. FRONTIERS IN SOCIOLOGY 2021; 5:583864. [PMID: 33869510 PMCID: PMC8022520 DOI: 10.3389/fsoc.2020.583864] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 12/21/2020] [Indexed: 06/12/2023]
Abstract
In 2012/2013, the prevalence of child mental illness was estimated to be between 12 and 25% in Ethiopia. The Federal Ministry of Health is currently considering the implementation of the second national mental health strategy guided by the World Health Organization's pyramid model for an optimal mix of services. This model states self-care as the fundamental concept and practice that can be facilitated by the formal and informal sectors surrounding an individual. Despite this remarkable move toward endorsing contemporary approaches to mental health services, Ethiopia struggles with a limited number of knowledgeable and skilled mental health professionals. This systematic review aims at identifying the main challenges Ethiopia might face while implementing the pyramid model. We will suggest ways to bridge the gap between the need for child/adolescent trained mental health professionals and training mental health professionals informed with the value of integrating the concepts of the pyramid model into the system of mental health care for Ethiopians. The paper also discusses the importance of integrating the Wellness based mental health approach into mental health professionals' training as a means of developing a culturally responsive approach to child and adolescent services. This review provides implications for further studies and mental health policy, systems and services in Ethiopia.
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Scaling up public mental health care in Sub-Saharan Africa: insights from infectious disease. Glob Ment Health (Camb) 2021; 8:e41. [PMID: 34868611 PMCID: PMC8607303 DOI: 10.1017/gmh.2021.41] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 09/09/2021] [Accepted: 09/30/2021] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Models estimate that the disability burden from mental disorders in Sub-Saharan Africa (SSA) will more than double in the next 40 years. Similar to HIV, mental disorders are stigmatized in many SSA settings and addressing them requires community engagement and long-term treatment. Yet, in contrast to HIV, the public mental healthcare cascade has not been sustained, despite robust data on scalable strategies. We draw on findings from our International AIDS Society (IAS) 2020 virtual workshop and make recommendations for next steps in the scale up of the SSA public mental healthcare continuum. DISCUSSION Early HIV surveillance and care cascade targets are discussed as important strategies for HIV response in SSA that should be adopted for mental health. Advocacy, including engagement with civil society, and targeted economic arguments to policymakers, are reviewed in the context of HIV success in SSA. Parallel opportunities for mental disorders are identified. Learning from HIV, communication of strategies that advance mental health care needs in SSA must be prioritized for broad global audiences. CONCLUSIONS The COVID-19 pandemic is setting off a colossal escalation of global mental health care needs, well-publicized across scientific, media, policymaker, and civil society domains. The pandemic highlights disparities in healthcare access and reinvigorates the push for universal coverage. Learning from HIV strategies, we must seize this historical moment to improve the public mental health care cascade in SSA and capitalize on the powerful alliances ready to be forged. As noted by Ambassador Goosby in our AIDS 2020 workshop, 'The time is now'.
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Stewart HLN, Jackman M, Agarwal S, Abanga MA, Kyalo C, Mkorongo A, Hagianu RM, Athié K, Jammalamadugu SB, Misganaw E, Mudzamba P, McIntosh K. Perspectives of lived experience across continents: our reality and call for universal health coverage. Lancet Psychiatry 2021; 8:6-8. [PMID: 33341171 DOI: 10.1016/s2215-0366(20)30526-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 11/19/2020] [Accepted: 11/23/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Hannah L N Stewart
- Department of Health Promotion and Behavioral Science, The University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA
| | - Matthew Jackman
- Victoria University College of Health and Biomedicine, Melbourne, VIC, Australia
| | - Sanjay Agarwal
- Psychiatric Department, New Civil Hospital, Surat, India
| | | | | | | | | | - Karen Athié
- Rio de Janeiro State Department of Health, Rio de Janeiro, Rio de Janeiro State, Brazil
| | | | - Eleni Misganaw
- Mental Health Service Users Association Ethiopia, Addis Ababa, Ethiopia
| | - Paida Mudzamba
- Anxiety Support Awareness Centre Trust, Harare, Zimbabwe
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30
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Horn R, Sesay SS, Jalloh M, Bayoh A, Lavally JB, Ager A. Expressions of psychological distress in Sierra Leone: implications for community-based prevention and response. Glob Ment Health (Camb) 2020; 7:e19. [PMID: 32913658 PMCID: PMC7443608 DOI: 10.1017/gmh.2020.12] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/01/2020] [Accepted: 07/05/2020] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Over recent decades there has been considerable mental health research in Sierra Leone but little on local conceptualisations of mental health conditions. Understanding these is crucial both for identifying the experienced needs of the population and utilising relevant community-based resources to address them. This study took a grounded approach to identify the ways in which adults in Sierra Leone express psychological distress. METHODS Rapid ethnographic methods deployed included 75 case study interviews with community members, 12 key informant (KI) pile sorts and 55 KI interviews. Thematic analysis of data was supported by frequency analysis and multi-dimensional scaling. RESULTS Thirty signs of distress were identified. The only consistent 'syndrome' identified with respect to these was a general concept of crase, which referred to psychosis-related presentation but also a wide range of other signs of distress. We did not find consensus on locally defined concepts for mild-moderate forms of mental disorder: people use multiple overlapping signs and terms indicating psychological distress. CONCLUSIONS Analysis supports calls to view mental health problems as a 'continuum of distress' rather than as discrete categories. This framing is coherent with opportunities for prevention and response in Sierra Leone which do not focus primarily on formal healthcare service providers but rather involve a range of community-based actors. It also enables attention to be paid to the identification of milder signs of distress with a view to early response and prevention of more severe mental health problems.
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Affiliation(s)
- Rebecca Horn
- NIHR Global Health Research Unit on Health in Situations of Fragility, Institute for Global Health & Development, Queen Margaret University, Musselburgh, Edinburgh, Scotland
| | | | | | | | | | - Alastair Ager
- NIHR Global Health Research Unit on Health in Situations of Fragility, Institute for Global Health & Development, Queen Margaret University, Musselburgh, Edinburgh, Scotland
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Sit HF, Ling R, Lam AIF, Chen W, Latkin CA, Hall BJ. The Cultural Adaptation of Step-by-Step: An Intervention to Address Depression Among Chinese Young Adults. Front Psychiatry 2020; 11:650. [PMID: 32733296 PMCID: PMC7359726 DOI: 10.3389/fpsyt.2020.00650] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 06/23/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Digital mental health interventions leverage digital communication technology to address the mental health needs of populations. Culturally adapting interventions can lead to a successful, scalable mental health intervention implementation, and cultural adaptation of digital mental health interventions is a critical component to implementing interventions at scale within contexts where mental health services are not well supported. OBJECTIVE The study aims to describe the cultural adaptation of a digital mental health intervention Step-by-Step in order to address depression among Chinese young adults. METHODS Cultural adaptation was carried out in four phases following Ecological Validity Model: (1) stage setting and expert consultation; (2) preliminary content adaptation; (3) iterative content adaptation with community members; (4) finalized adaptation with community feedback meetings. Cognitive interviewing was applied to probe for relevance, acceptability, comprehensibility, and completeness of illustrations and text. Six mental health experts and 34 Chinese young adults were recruited for key informant interviews and focus group discussions. RESULTS We adapted the text and illustrations to fit the culture among Chinese young adults. Eight elements of the intervention were chosen as the targets of cultural adaptation (e.g., language, metaphors, content). Samples of major adaptations included: adding scenarios related to university life (relevance), changing leading characters from a physician to a peer and a cartoon (acceptability), incorporating two language versions (traditional Chinese and simplified Chinese) in the intervention (comprehensibility), and maintaining fundamental therapeutic components (completeness). CONCLUSION This study showed the utility of using Ecological Validity Model and a four-point procedure framework for cultural adaptation and achieved a culturally appropriate version of the Step-by-Step program for Chinese young adults.
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Affiliation(s)
- Hao Fong Sit
- Global and Community Mental Health Research Group, Department of Psychology, University of Macau, Macau, China
| | - Rui Ling
- Global and Community Mental Health Research Group, Department of Psychology, University of Macau, Macau, China
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States
| | - Agnes Iok Fong Lam
- Global and Community Mental Health Research Group, Department of Psychology, University of Macau, Macau, China
- Department of Communication, Faculty of Social Science, University of Macau, Macau, China
- Centre for Macau Studies, University of Macau, Macau, China
| | - Wen Chen
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Carl A. Latkin
- Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Brian J. Hall
- Global and Community Mental Health Research Group, Department of Psychology, University of Macau, Macau, China
- Centre for Macau Studies, University of Macau, Macau, China
- Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
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Abstract
Adolescents living in low-resource settings lack access to adequate psychological care. The barriers to mental health care in low- and middle-income countries (LMIC) include high disease burden, low allocation of resources, lack of national mental health policy and child and adolescent mental health (CAMH) professionals and services, poverty, illiteracy and poor availability of adolescent friendly health services. WHO has recommended a stepped task shifting approach to mental health care in LMIC. Training of non-mental health specialists like peers, teachers, community health workers, paediatricians and primary care physicians by CAMH and framing country-specific evidence-based national mental health policies are vital in overcoming barriers to psychological care in LMIC. Digital technology and telemedicine can be used in providing economical and accessible mental health care services to adolescents.
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Affiliation(s)
| | - Merrian J Brooks
- Craig Dalsimer Division of Adolescent Medicine, Children's Hospital of Philadelphia, USA
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Secor A, Macauley R, Stan L, Kagone M, Sidikiba S, Sow S, Aronovich D, Litvin K, Davis N, Alva S, Sanderson J. Mental health among Ebola survivors in Liberia, Sierra Leone and Guinea: results from a cross-sectional study. BMJ Open 2020; 10:e035217. [PMID: 32461296 PMCID: PMC7259862 DOI: 10.1136/bmjopen-2019-035217] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES To describe the prevalence and correlates of depression and anxiety among adult Ebola virus disease (EVD) survivors in Liberia, Sierra Leone and Guinea. DESIGN Cross-sectional. SETTING One-on-one surveys were conducted in EVD-affected communities in Liberia, Sierra Leone and Guinea in early 2018. PARTICIPANTS 1495 adult EVD survivors (726 male, 769 female). PRIMARY AND SECONDARY OUTCOME MEASURES Patient Health Questionnaire-9 (PHQ-9) depression scores and Generalised Anxiety Disorder-7 (GAD-7) scores. RESULTS Prevalence and severity of depression and anxiety varied across the three countries. Sierra Leone had the highest prevalence of depression, with 22.0% of participants meeting the criteria for a tentative diagnosis of depression, compared with 20.2% in Liberia and 13.0% in Guinea. Sierra Leone also showed the highest prevalence of anxiety, with 10.7% of participants meeting criteria for generalized anxiety disorder (GAD-7 score ≥10), compared with 9.9% in Liberia and 4.2% in Guinea. Between one-third and one-half of respondents reported little interest or pleasure in doing things in the previous 2 weeks (range: 47.0% in Liberia to 37.6% in Sierra Leone), and more than 1 in 10 respondents reported ideation of self-harm or suicide (range: 19.4% in Sierra Leone to 10.4% in Guinea). Higher depression and anxiety scores were statistically significantly associated with each other and with experiences of health facility-based stigma in all three countries. Other associations between mental health scores and respondent characteristics varied across countries. CONCLUSIONS Our results indicate that both depression and anxiety are common among EVD survivors in Liberia, Sierra Leone and Guinea, but that there is country-level heterogeneity in prevalence, severity and correlates of these conditions. All three countries should work to make mental health services available for survivors, and governments and organisations should consider the intersection between EVD-related stigma and mental health when designing programmes and training healthcare providers.
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Affiliation(s)
- Andrew Secor
- JSI Research and Training Institute Inc, Monrovia, Liberia
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Rose Macauley
- JSI Research and Training Institute Inc, Monrovia, Liberia
| | - Laurentiu Stan
- JSI Research and Training Institute Inc, Freetown, Sierra Leone
| | - Meba Kagone
- JSI Research and Training Institute Inc, Conakry, Guinea
| | | | - Sadou Sow
- JSI Research and Training Institute Inc, Conakry, Guinea
| | - Dana Aronovich
- JSI Research and Training Institute Inc, Arlington, Virginia, USA
| | - Kate Litvin
- JSI Research and Training Institute Inc, Arlington, Virginia, USA
| | - Nikki Davis
- JSI Research and Training Institute Inc, Arlington, Virginia, USA
| | - Soumya Alva
- JSI Research and Training Institute Inc, Arlington, Virginia, USA
| | - Jeff Sanderson
- JSI Research and Training Institute Inc, Arlington, Virginia, USA
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Ahrens J, Kokota D, Mafuta C, Konyani M, Chasweka D, Mwale O, Stewart RC, Osborn M, Chikasema B, Mcheka M, Blackwood D, Gilfillan S. Implementing an mhGAP-based training and supervision package to improve healthcare workers' competencies and access to mental health care in Malawi. Int J Ment Health Syst 2020; 14:11. [PMID: 32127914 PMCID: PMC7045435 DOI: 10.1186/s13033-020-00345-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 02/20/2020] [Indexed: 01/19/2023] Open
Abstract
Background It is now well established that the integration of mental health care into primary care is one of the most effective ways of reducing the substantial treatment gap for mental disorders which exists in most low- and middle-income countries. This study set out to determine whether a Mental Health Gap Action Programme (mhGAP) training and supervision package could be contextualised and implemented within the existing health care system in five districts in Southern Malawi. In addition, the study assessed the feasibility of holding community awareness events and establishing peer support groups in each district to further improve the access of the population to evidence-based mental health care. Methods A lead training team of experienced Malawian mental health professionals was appointed and mhGAP training materials were contextualised for use in Malawi. The lead team delivered a 4-day training package to district mental health teams in five districts covering three core conditions: psychosis, moderate-severe depression, and alcohol and substance use disorders. District mental health teams then delivered a 2-day training package and provided monthly supervision for 3 months to 500 non-specialist healthcare workers. Paired sample t-tests were used to compare knowledge, confidence and attitude scores before and immediately after training, and after 6 months in two districts. Case detection rates measured pre- and post-training in the pilot district were compared using Wilcoxon Rank Sum Test. Community awareness events were held and peer support groups were established in each of the five districts. The acceptability of the package was assessed through focus group discussions involving specialist and non-specialist healthcare workers, users and carers. Results Non-specialist healthcare workers’ knowledge and confidence scores significantly increased immediately after training in comparison to pre-training. These scores were maintained at 6 months. However, no statistically significant change in attitude scores was detected. Case detection rates increased immediately after the training in comparison to pre-training. Responses from focus group discussion participants illustrated the programme’s acceptability. Conclusions This study demonstrated that, with minimal additional funding and working within existing structures, an mhGAP based training at primary and secondary health care levels is feasible in Southern Malawi.
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Affiliation(s)
- Jen Ahrens
- 1Mile End Hospital, Bancroft Road, London, E1 4DG UK.,2Department of Mental Health, University of Malawi, College of Medicine, P/Bag 360, Chichiri, Blantyre 3, Malawi
| | - Demoubly Kokota
- 2Department of Mental Health, University of Malawi, College of Medicine, P/Bag 360, Chichiri, Blantyre 3, Malawi
| | | | - Mary Konyani
- Malawi College of Health Sciences, Zomba Campus, Zomba, Malawi
| | - Dennis Chasweka
- 5Department of Paediatrics, University of Malawi, College of Medicine, P/Bag 360, Chichiri, Blantyre 3, Malawi
| | - Owen Mwale
- 2Department of Mental Health, University of Malawi, College of Medicine, P/Bag 360, Chichiri, Blantyre 3, Malawi
| | - Robert C Stewart
- 2Department of Mental Health, University of Malawi, College of Medicine, P/Bag 360, Chichiri, Blantyre 3, Malawi.,6Division of Psychiatry, University of Edinburgh, Royal Edinburgh Hospital, Morningside Park, Edinburgh, EH10 5HF UK
| | - Madeline Osborn
- 7Scotland Malawi Mental Health Education Project, Royal Edinburgh Hospital, Morningside Park, Edinburgh, EH10 5HF UK
| | | | | | - Douglas Blackwood
- 6Division of Psychiatry, University of Edinburgh, Royal Edinburgh Hospital, Morningside Park, Edinburgh, EH10 5HF UK
| | - Sheila Gilfillan
- 2Department of Mental Health, University of Malawi, College of Medicine, P/Bag 360, Chichiri, Blantyre 3, Malawi.,8Royal Edinburgh Hospital, Morningside Park, Edinburgh, EH10 5HF UK
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Cosgrove L, Morrill Z, Yusif M, Vaswani A, Cathcart S, Troeger R, Karter JM. Drivers of and Solutions for the Overuse of Antidepressant Medication in Pediatric Populations. Front Psychiatry 2020; 11:17. [PMID: 32116838 PMCID: PMC7034322 DOI: 10.3389/fpsyt.2020.00017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 01/09/2020] [Indexed: 11/13/2022] Open
Abstract
Children in the United States and internationally are increasingly being diagnosed with depression and related psychiatric conditions and a recent study found that antidepressant (ADM) use in children and adolescents rose substantially in youth cohorts in five Western countries from 2005 to 2012. However, there has been ongoing controversy over the effectiveness and safety of ADM use in children, including concerns about ADM increasing suicidality and self-harm. In addition to the increase in the diagnosis of depression, commercially driven off-label prescriptions have been cited as a significant reason for high rates of pediatric ADM prescribing. In this commentary, we discuss two drivers of the overuse of ADM, both of which are products of an increasingly medicalized approach to mental health: 1) the demand for mental health and depression screening in youth, despite the lack of evidence to support it, and 2) the renewed momentum of the Global Mental Health Movement and concomitant calls to "scale up" the diagnosis and treatment of mental illness. Using the lens of institutional corruption, we identify the ways in which both guild and financial conflicts of interest create obstacles to rational prescribing practices in pediatric populations and offer suggestions for reform.
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Affiliation(s)
| | | | | | | | | | | | - Justin M. Karter
- Department of Counseling and School Psychology, University of Massachusetts Boston, Boston, MA, United States
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Abstract
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.
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Affiliation(s)
- Dörte Bemme
- University of North Carolina at Chapel Hill, USA.,Division of Social & Transcultural Psychiatry, McGill University, Montreal, Quebec, Canada
| | - Laurence J Kirmayer
- Division of Social & Transcultural Psychiatry, McGill University, Montreal, Quebec, Canada
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The treatment of mental illness in faith-based and traditional healing centres in Ghana: perspectives of service users and healers. Glob Ment Health (Camb) 2020; 7:e28. [PMID: 33123375 PMCID: PMC7576926 DOI: 10.1017/gmh.2020.21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 09/07/2020] [Accepted: 09/17/2020] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND The maltreatment of people with mental illness in Ghana's traditional and faith-based healing centres, including shackling, flogging, and forced fasting, has been documented by numerous sources. Such treatment is potentially traumatising and may exacerbate mental health problems. Despite widespread use, few studies have focused on experiences and characteristics of people who seek traditional healing for mental illness or healers' perspectives treatment of these conditions. METHOD Purposeful sampling was used to recruit 82 individuals who were treated in healing centres and 40 traditional healers; all took part in semi-structured interviews. Those treated were asked about experiences in centres and assessed for prior trauma exposure, posttraumatic stress, and functional impairment. Healers were asked about beliefs and practices related to the treatment of mental illness. RESULTS Individuals treated in centres and healers generally believed that mental illness has a spiritual cause. Approximately 30.5% of those treated in centres were exposed to maltreatment; despite this, half would return. Individuals with a history of trauma were more likely to report maltreatment in the centre and had higher symptoms of posttraumatic stress. Most participants had impaired functioning. Healers who used practices like shackling believed they were necessary. Most healers were willing to collaborate with the official health structure. CONCLUSION Results provide insight into the treatment of mental illness by traditional healers in Ghana and the need for trauma-informed mental health services. Findings also highlight the importance of considering cultural beliefs when attempting to implement mental health interventions in the region.
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Nguyen AJ, Rykiel N, Murray L, Amin A, Haroz E, Lee C, Bolton P. Stakeholder perspectives on integration of mental health services into primary care: a mixed methods study in Northern Iraq. Int J Ment Health Syst 2019; 13:75. [PMID: 31890000 PMCID: PMC6935235 DOI: 10.1186/s13033-019-0330-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 12/14/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Integrating evidence-based mental health services into primary care has been identified as one strategy for overcoming the treatment gap in low and middle-income countries, yet their uptake into standard practice remains poor. The purpose of this study was to understand stakeholder perspectives regarding barriers and facilitators to integration of mental health services into primary care settings in Northern Iraq. METHODS Using a convergent mixed methods study design, quantitative and qualitative questionnaires assessed respondent perceptions of implementation factors under the domains of Autonomy, Acceptability, Appropriateness, Feasibility, Penetration/Accessibility, Sustainability, and Organizational Climate. We interviewed four types of stakeholders: clients, providers of mental health services, non-mental health (MH) staff working at the centers, and center directors. Interviews were conducted with clients at the completion of services, and with all other stakeholder groups in the latter half of the first year of program implementation, by Kurdish-speaking interviewer pairs. Qualitative and quantitative data were analyzed separately and merged using qualitative data transformation to quantify frequency of theme and integrate with quantitative findings through woven narrative. RESULTS 123 clients, 26 providers, 40 non-MH staff, and 12 directors provided data. Positive perceptions of the program's acceptability, appropriateness, feasibility, and positive impacts were reported across all stakeholder levels. Providers reported that the program length (8-12 sessions) was a challenge. Clients described logistical challenges (e.g.: transportation, childcare, home duties); support from family and friends appeared to be critical. Lack of private space, insufficient staffing, and need for greater government support were also important issues. CONCLUSIONS This mixed methods study is unique in its inclusion of non-MH staff and director perspectives on integration of mental health services in primary care clinics. Their inclusion proved vital since they included critical human resource barriers to feasibility. Providers reported generally positive integration experiences but that some colleagues (clinic staff not involved in mental health services) were unsupportive. Most non-MH staff were supportive, but some did report negative impacts on their working environment. Future studies of integration of mental health services into other service platforms should include the perspectives of stakeholders not involved in provision of mental health services.
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Affiliation(s)
- Amanda J. Nguyen
- 0000 0000 9136 933Xgrid.27755.32Youth-Nex and the Department of Human Services, Curry School of Education and Human Development, University of Virginia, Charlottesville, VA 22904 USA
| | - Natalie Rykiel
- 0000 0001 2171 9311grid.21107.35Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD 21205 USA
| | - Laura Murray
- 0000 0001 2171 9311grid.21107.35Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205 USA
| | - Ahmed Amin
- Wchan Organization for Victims of Human Rights Violations & Sulaimani Polytechnic University–Technical College of Health, Sulaymaniyah, Iraq
| | - Emily Haroz
- 0000 0001 2171 9311grid.21107.35Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205 USA
| | - Catherine Lee
- 0000 0001 2171 9311grid.21107.35Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205 USA
| | - Paul Bolton
- 0000 0001 2171 9311grid.21107.35Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205 USA
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Ventevogel P, Tarannum S, Elshazly M, Harlass S. Integrating mental health into primary health care in Rohingya refugee settings in Bangladesh: experiences of UNHCR. INTERVENTION 2019. [DOI: 10.4103/intv.intv_34_19] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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