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

Testing the Shamiri Intervention and Its Components With Kenyan Adolescents During the COVID-19 Pandemic: Outcomes of a Universal, Five-Arm Randomized Controlled Trial

OBJECTIVE

Mental health problems are prevalent among African adolescents, but professional treatment capacity is limited. Shamiri, an efficient lay-provider-delivered intervention, has significantly reduced depression and anxiety symptoms in previous RCTs. We investigated effects of the full Shamiri intervention and its components (growth-only, gratitude-only, and values-only), against a study-skills control.

METHOD

In a five-group RCT with adolescents from Kenyan high-schools, anxiety, depression, and wellbeing were self-reported through eight-month follow-up. The RCT occurred immediately after an unanticipated government-mandated COVID shutdown forced three years of schoolwork into two, escalating academic pressures.

RESULTS

Participants (N=1,252; 48.72% female) were allocated to: growth (n=249), gratitude (n=237), values (n=265), Shamiri (n=250), and study-skills (n=251). Longitudinal multilevel models showed that, across all conditions, anxiety scores significantly improved at midpoint (B=-0.847), endpoint (B=-2.948), one-month (B=-1.587), three-month (B=-2.374), and eight-month (B=-1.917) follow-ups. Depression scores also improved significantly at midpoint (B=-0.796), endpoint (B=-3.126), one-month (B=-2.382), three-month (B=-2.521), and eight-month (B=-2.237) follow-ups. Wellbeing scores improved significantly at midpoint (B=1.73), endpoint (B=3.44), one-month (B=2.21), three-month (B=1.78), and eight-month (B=1.59) follow-ups. Symptom-reduction with Shamiri matched that of pre-COVID trials, but symptom-reduction with study-skills far outpaced that of trials before the COVID-related school shutdown (31% greater anxiety reduction and 60% greater depression reduction). Thus, in contrast to previous RCTs, this COVID-era trial showed no significant differences between outcomes in any intervention and active control groups.

CONCLUSION

Our RCT conducted during a post-COVID period of heightened academic pressure produced unexpected results. Improvements in youth-reported anxiety and depression were consistent with previous trials for Shamiri, but markedly larger than in previous trials for study-skills. "Control interventions" teaching life-skills may produce mental health benefits when they convey skills of particular contextual relevance.

A Case Study of the Development of a Valid and Pragmatic Implementation Science Measure: The Barriers and Facilitators in Implementation of Task-Sharing Mental Health Interventions (BeFITS-MH) Measure

Background

Few implementation science (IS) measures have been evaluated for validity, reliability and utility - the latter referring to whether a measure captures meaningful aspects of implementation contexts. In this case study, we describe the process of developing an IS measure that aims to assess Barriers and Facilitators in Implementation of Task-Sharing in Mental Health services (BeFITS-MH), and the procedures we implemented to enhance its utility.

Methods

We summarize conceptual and empirical work that informed the development of the BeFITS-MH measure, including a description of the Delphi process, detailed translation and local adaptation procedures, and concurrent pilot testing. As validity and reliability are key aspects of measure development, we also report on our process of assessing the measure's construct validity and utility for the implementation outcomes of acceptability, appropriateness, and feasibility.

Results

Continuous stakeholder involvement and concurrent pilot testing resulted in several adaptations of the BeFITS-MH measure's structure, scaling, and format to enhance contextual relevance and utility. Adaptations of broad terms such as "program," "provider type," and "type of service" were necessary due to the heterogeneous nature of interventions, type of task-sharing providers employed, and clients served across the three global sites. Item selection benefited from the iterative process, enabling identification of relevance of key aspects of identified barriers and facilitators, and what aspects were common across sites. Program implementers' conceptions of utility regarding the measure's acceptability, appropriateness, and feasibility were seen to cluster across several common categories.

Conclusions

This case study provides a rigorous, multi-step process for developing a pragmatic IS measure. The process and lessons learned will aid in the teaching, practice and research of IS measurement development. The importance of including experiences and knowledge from different types of stakeholders in different global settings was reinforced and resulted in a more globally useful measure while allowing for locally-relevant adaptation. To increase the relevance of the measure it is important to target actionable domains that predict markers of utility (e.g., successful uptake) per program implementers' preferences. With this case study, we provide a detailed roadmap for others seeking to develop and validate IS measures that maximize local utility and impact.

Using wearable activity trackers for research in the global south: Lessons learned from adolescent psychotherapy research in Kenya

Wearable activity trackers have emerged as valuable tools for health research, providing high-resolution data on measures such as physical activity. While most research on these devices has been conducted in high-income countries, there is growing interest in their use in the global south. This perspective discusses the challenges faced and strategies employed when using wearable activity trackers to test the effects of a school-based intervention for depression and anxiety among Kenyan youth. Lessons learned include the importance of validating data output, establishing an internal procedure for international procurement, providing on-site support for participants, designating a full-time team member for wearable activity tracker operation, and issuing a paper-based information sheet to participants. The insights shared in this perspective serve as guidance for researchers undertaking studies with wearables in similar settings, contributing to the evidence base for mental health interventions targeting youth in the global south. Despite the challenges to set up, deploy and extract data from wearable activity trackers, we believe that wearables are a relatively economical approach to provide insight into the daily lives of research participants, and recommend their use to other researchers.

Primary-level and community worker interventions for the prevention of mental disorders and the promotion of well-being in low- and middle-income countries

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.

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

TRIAL REGISTRATION

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

Mental health literacy: Perspectives from Northern Kenya Turkana adolescents

Mental illness accounts for high levels of morbidity, mortality and poor quality of life among young people. Depression, anxiety, conduct issues and hyperactive disorder account for 13% of the global burden of disease that affects one in seven adolescents. In Kenya, not much is documented about the mental health of non-school-going adolescents, and yet they make up about 1.8 million of the country's population. An ethnographic study by Focus Group Discussions with 32 rural northern Kenya Turkana-based adolescents divided into school and nonschool groups was conducted. We read out vignettes in which the main character exhibited symptoms of depression, schizophrenia or anxiety and explored their knowledge of causes and management options for the same, and then analyzed the data thematically. Participants described the conditions without referring to the local names we had collected earlier: depression (Akiyalolong), schizophrenia (waarit/Ngikerep) and anxiety (Ngatameta naaronok). They assigned curses, guilt, hunger pangs, and evil spells as causes, and believed friends and age-mates, parents, teachers, and the local chief, among others, could help, but rarely medical intervention. Interventions to improve the adolescent's knowledge of mental illness are a much-needed support for the health of young people.

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

TRIAL REGISTRATION

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

Centering decriminalization of suicide in low - and middle - income countries on effective suicide prevention strategies

Globally, over 800,000 people die by suicide every year. For every one completed suicide, 20 more attempts have been made. As previous attempts are one of the strongest predictors of future suicide, help-seeking in moments of crisis, particularly after an attempt, may have important implications for suicide prevention. Unfortunately, the criminalization of suicide in several countries hinders help-seeking, increases the stigmatization of those who attempt suicide and obstructs the accurate tracking of suicides. Here, we highlight the negative effects of suicide criminalization and discuss evidence-based strategies for suicide prevention such as means restriction, improved mental health literacy and access to psychosocial support, and responsible media coverage of suicides.