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Abba Hassan A, Ibrahim AM, Nadkarni A. A systematic review of task-sharing interventions for substance use and substance use disorder in low- and middle-income countries. Drug Alcohol Depend 2024; 256:111093. [PMID: 38309090 DOI: 10.1016/j.drugalcdep.2024.111093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 12/14/2023] [Accepted: 01/10/2024] [Indexed: 02/05/2024]
Abstract
INTRODUCTION Substance use (SU) and substance use disorders (SUDs) are associated with adverse health and socio-economic consequences. Due to the shortage of specialist healthcare providers, people with SUDs in low- and middle-income countries (LMICs) have limited access to adequate treatment. Task-sharing with non-specialist health workers (NSHWs) has the potential to improve treatment accessibility for these individuals. This review synthesizes the evidence on the effectiveness of task-sharing interventions for SU and SUDs outcomes in LMICs. METHODS PsycINFO, MEDLINE, EMBASE, Global Health and CENTRAL databases were searched to identify eligible studies. Quality assessment was conducted using the Cochrane risk of bias (RoB2) and Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool. A narrative synthesis was undertaken to analyze the data. RESULTS Nineteen RCTs and two quasi-experimental studies met the eligibility criteria, and the majority had a low risk of bias rating. NSHW-delivered interventions significantly impact SU and SUDs outcomes, particularly in reducing alcohol and other substance use, cessation of smoking, and use of opioids. Multiple sessions delivered via face-to-face interactions was the most utilized method for intervention delivery. There were variations in terms of components of the intervention across studies; however, the most common intervention strategies used were a) personalized feedback, b) psychoeducation, c) motivational enhancement, d) problem-solving, and e) coping skills. CONCLUSION Our review highlights the growing interests in leveraging NSHWs to provide interventions to people with SU and SUDs in LMICs where access to treatment is limited. However, additional research is necessary to explore the effectiveness of these interventions and identify the specific active components linked to enhancing treatment outcomes on a broader scale.
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Affiliation(s)
- Asma'u Abba Hassan
- Department of Psychiatry, Karu General Hospital, Federal Capital Territory, Abuja, Nigeria.
| | - Abba M Ibrahim
- Department of Mental Health, University of Maiduguri Teaching Hospital, Maiduguri, Borno State, Nigeria
| | - Abhijit Nadkarni
- Center for Global Mental Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.
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Oladeji BD, Ayinde OO, Bello T, Kola L, Faregh N, Abdulmalik J, Zelkowitz P, Seedat S, Gureje O. Addressing the challenges of integrating care for perinatal depression in primary care in Nigeria. Soc Psychiatry Psychiatr Epidemiol 2024:10.1007/s00127-024-02611-7. [PMID: 38329495 DOI: 10.1007/s00127-024-02611-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 01/01/2024] [Indexed: 02/09/2024]
Abstract
PURPOSE This report provides the results of a task-shared approach for integrating care for perinatal depression (PND) within primary maternal and child healthcare (PMCH), including the factors that may facilitate or impede the process. METHODS This hybrid implementation-effectiveness study guided by the Replicating Effective Programmes framework was conducted in 27 PMCH clinics in Ibadan, Nigeria. The primary implementation outcome was change in the identification rates of PND by primary health care workers (PHCW) while the primary effectiveness outcome was the difference in symptom remission (EPDS score ≤ 5) 6 months postpartum. Outcome measures were compared between two cohorts of pregnant women, one recruited before and the other after training PHCW to identify and treat PND. Barriers and facilitators were explored in qualitative interviews. RESULTS Identification of PND improved from 1.4% before to 17.4% after training; post-training rate was significantly higher in clinics where PHCW routinely screened using the 2-item patient health questionnaire (24.8%) compared to non-screening clinics (5.6%). At 6-months postpartum, 60% of cohort one experienced remission from depression, compared to 56.5% cohort two [OR-0.9 (95%CI-0.6, 1.3) p = 0.58]. Identified facilitators for successful integration included existence of policy specifying mental health as a component of PHC, use of screening to aid identification and supportive supervision, while barriers included language and cultural attitudes towards mental health and human resource constraints. PHCW were able to make adaptations to address these barriers. CONCLUSIONS Successful implementation of task-shared care for perinatal depression requires addressing staff shortages and adopting strategies that can improve identification by non-specialist providers. TRIAL REGISTRATION This study was retrospectively registered 03 Dec 2019. https://doi.org/10.1186/ISRCTN94230307 .
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Affiliation(s)
- Bibilola D Oladeji
- Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria.
- WHO Collaborating Centre for Mental Health, Neurosciences and Drug and Alcohol Abuse, Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria.
| | - Olatunde O Ayinde
- Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria
- WHO Collaborating Centre for Mental Health, Neurosciences and Drug and Alcohol Abuse, Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Toyin Bello
- WHO Collaborating Centre for Mental Health, Neurosciences and Drug and Alcohol Abuse, Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Lola Kola
- WHO Collaborating Centre for Mental Health, Neurosciences and Drug and Alcohol Abuse, Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Neda Faregh
- Department of Psychology, Carleton University, Ottawa, ON, Canada
| | - Jibril Abdulmalik
- Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | | | - Soraya Seedat
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Oye Gureje
- Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria
- WHO Collaborating Centre for Mental Health, Neurosciences and Drug and Alcohol Abuse, Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria
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Yang LH, Bass JK, Le PD, Singh R, Gurung D, Velasco PR, Grivel MM, Susser E, Cleland CM, Muñoz RA, Kohrt BA, Bhana A. 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. Res Sq 2024:rs.3.rs-3877031. [PMID: 38343864 PMCID: PMC10854285 DOI: 10.21203/rs.3.rs-3877031/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
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.
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Affiliation(s)
- Lawrence H Yang
- New York University School of Global Public Health, Department of Social and Behavioral Sciences
| | - Judy K Bass
- Johns Hopkins Bloomberg School of Public Health, Department of Mental Health
| | - PhuongThao Dinh Le
- New York University School of Global Public Health, Department of Social and Behavioral Sciences
| | - Ritika Singh
- George Washington University, Division of Global Mental Health, Department of Psychiatry and Behavioral Sciences
| | - Dristy Gurung
- Transcultural Psychosocial Organization (TPO) Nepal; King's College London, Denmark Hill Campus
| | - Paola R Velasco
- Universidad O'Higgins; Universidad Católica de Chile; Universidad de Chile
| | - Margaux M Grivel
- 1 New York University School of Global Public Health, Department of Social and Behavioral Sciences
| | - Ezra Susser
- Columbia University Mailman School of Public Health; New York State Psychiatric Institute
| | - Charles M Cleland
- New York University Grossman School of Medicine, Department of Population Health
| | | | - Brandon A Kohrt
- George Washington University, Division of Global Mental Health, Department of Psychiatry and Behavioral Sciences
| | - Arvin Bhana
- University of KwaZulu-Natal, Centre for Rural Health; South African Medical Research Council, Health Systems Research Unit
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Mudiyanselage KWW, De Santis KK, Jörg F, Saleem M, Stewart R, Zeeb H, Busse H. The effectiveness of mental health interventions involving non-specialists and digital technology in low-and middle-income countries - a systematic review. BMC Public Health 2024; 24:77. [PMID: 38172713 PMCID: PMC10763181 DOI: 10.1186/s12889-023-17417-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 12/05/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Combining non-specialists and digital technologies in mental health interventions could decrease the mental healthcare gap in resource scarce countries. This systematic review examined different combinations of non-specialists and digital technologies in mental health interventions and their effectiveness in reducing the mental healthcare gap in low-and middle-income countries. METHODS Literature searches were conducted in four databases (September 2023), three trial registries (January-February 2022), and using forward and backward citation searches (May-June 2022). The review included primary studies on mental health interventions combining non-specialists and digital technologies in low-and middle-income countries. The outcomes were: (1) the mental health of intervention receivers and (2) the competencies of non-specialists to deliver mental health interventions. Data were expressed as standardised effect sizes (Cohen's d) and narratively synthesised. Risk of bias assessment was conducted using the Cochrane risk-of-bias tools for individual and cluster randomised and non-randomised controlled trials. RESULTS Of the 28 included studies (n = 32 interventions), digital technology was mainly used in non-specialist primary-delivery treatment models for common mental disorders or subthreshold symptoms. The competencies of non-specialists were improved with digital training (d ≤ 0.8 in 4/7 outcomes, n = 4 studies, 398 participants). The mental health of receivers improved through non-specialist-delivered interventions, in which digital technologies were used to support the delivery of the intervention (d > 0.8 in 24/40 outcomes, n = 11, 2469) or to supervise the non-specialists' work (d = 0.2-0.8 in 10/17 outcomes, n = 3, 3096). Additionally, the mental health of service receivers improved through digitally delivered mental health services with non-specialist involvement (d = 0.2-0.8 in 12/27 outcomes, n = 8, 2335). However, the overall certainty of the evidence was poor. CONCLUSION Incorporating digital technologies into non-specialist mental health interventions tended to enhance non-specialists' competencies and knowledge in intervention delivery, and had a positive influence on the severity of mental health problems, mental healthcare utilization, and psychosocial functioning outcomes of service recipients, primarily within primary-deliverer care models. More robust evidence is needed to compare the magnitude of effectiveness and identify the clinical relevance of specific digital functions. Future studies should also explore long-term and potential adverse effects and interventions targeting men and marginalised communities.
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Affiliation(s)
- Kalpani Wijekoon Wijekoon Mudiyanselage
- Faculty 11 Human and Health Sciences, University of Bremen, Bremen, Germany.
- Department of Prevention and Evaluation, Leibniz Institute for Prevention Research and Epidemiology- BIPS, Bremen, Germany.
| | - Karina Karolina De Santis
- Department of Prevention and Evaluation, Leibniz Institute for Prevention Research and Epidemiology- BIPS, Bremen, Germany
| | - Frederike Jörg
- Department of Psychiatry, Interdisciplinary Center Psychopathology and Emotion regulation, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Department of Education and Research, Friesland Mental Health Care Services, Leeuwarden, the Netherlands
| | - Maham Saleem
- Department of Prevention and Evaluation, Leibniz Institute for Prevention Research and Epidemiology- BIPS, Bremen, Germany
| | - Roy Stewart
- Department of Health Sciences, Community & Occupational Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Hajo Zeeb
- Faculty 11 Human and Health Sciences, University of Bremen, Bremen, Germany
- Department of Prevention and Evaluation, Leibniz Institute for Prevention Research and Epidemiology- BIPS, Bremen, Germany
- Leibniz ScienceCampus Digital Public Health Bremen, Bremen, Germany
| | - Heide Busse
- Department of Prevention and Evaluation, Leibniz Institute for Prevention Research and Epidemiology- BIPS, Bremen, Germany
- Leibniz ScienceCampus Digital Public Health Bremen, Bremen, Germany
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Myers B, Regenauer KS, Rose A, Johnson K, Ndamase S, Ciya N, Brown I, Joska J, Bassett IV, Belus JM, Ma TC, Sibeko G, Magidson JF. Community health worker training to reduce mental health and substance use stigma towards patients who have disengaged from HIV/TB care in South Africa: protocol for a stepped wedge hybrid type II pilot implementation trial. Implement Sci Commun 2024; 5:1. [PMID: 38167261 PMCID: PMC10759561 DOI: 10.1186/s43058-023-00537-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 12/10/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND South Africa has deployed community health workers (CHWs) to support individuals to enter and stay in HIV/TB care. Although CHWs routinely encounter patients with mental health (particularly depression) and substance use (SU) conditions that impact their engagement in HIV/TB care, CHWs are rarely trained in how to work with these patients. This contributes to mental health and SU stigma among CHWs, a known barrier to patient engagement in care. Mental health and SU training interventions could reduce CHW stigma and potentially improve patient engagement in care, but evidence of the feasibility, acceptability, and preliminary effectiveness of these interventions is scarce. Therefore, we designed a hybrid type 2 effectiveness-implementation pilot trial to evaluate the implementation and preliminary effectiveness of a CHW training intervention for reducing depression and SU stigma in the Western Cape, South Africa. METHODS This stepped wedge pilot trial will engage CHWs from six primary care clinics offering HIV/TB care. Clinics will be block randomized into three-step cohorts that receive the intervention at varying time points. The Siyakhana intervention involves 3 days of training in depression and SU focused on psychoeducation, evidence-based skills for working with patients, and self-care strategies for promoting CHW wellness. The implementation strategy involves social contact with people with lived experience of depression/SU during training (via patient videos and a peer trainer) and clinical supervision to support CHWs to practice new skills. Both implementation outcomes (acceptability, feasibility, fidelity) and preliminary effectiveness of the intervention on CHW stigma will be assessed using mixed methods at 3- and 6-month follow-up assessments. DISCUSSION This trial will advance knowledge of the feasibility, acceptability, and preliminary effectiveness of a CHW training for reducing depression and SU stigma towards patients with HIV and/or TB. Study findings will inform a larger implementation trial to evaluate the longer-term implementation and effectiveness of this intervention for reducing CHW stigma towards patients with depression and SU and improving patient engagement in HIV/TB care. TRIAL REGISTRATION ClinicalTrials.gov NCT05282173. Registered on 7 March 2022.
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Affiliation(s)
- Bronwyn Myers
- Curtin enAble Institute, Faculty of Health Sciences, Curtin University, Kent Street, Perth, WA, Australia.
- Mental Health, Alcohol, Substance Use and Tobacco Research Unit, South African Medical Research Council, Parow, Cape Town, South Africa.
- Department of Psychiatry and Mental Health, Division of Addiction Psychiatry, University of Cape Town, Cape Town, South Africa.
| | - Kristen S Regenauer
- Department of Psychology, University of Maryland, College Park, College Park, MD, USA
| | - Alexandra Rose
- Department of Psychology, University of Maryland, College Park, College Park, MD, USA
| | - Kim Johnson
- Mental Health, Alcohol, Substance Use and Tobacco Research Unit, South African Medical Research Council, Parow, Cape Town, South Africa
| | - Sibabalwe Ndamase
- Mental Health, Alcohol, Substance Use and Tobacco Research Unit, South African Medical Research Council, Parow, Cape Town, South Africa
| | - Nonceba Ciya
- Mental Health, Alcohol, Substance Use and Tobacco Research Unit, South African Medical Research Council, Parow, Cape Town, South Africa
| | - Imani Brown
- Department of Psychology, University of Maryland, College Park, College Park, MD, USA
| | - John Joska
- Department of Psychiatry and Mental Health, Division of Neuropsychiatry, University of Cape Town, HIV Mental Health Research Unit, Cape Town, South Africa
| | - Ingrid V Bassett
- Division of Infectious Diseases, Medical Practice Evaluation Center, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - Jennifer M Belus
- Department of Clinical Research, Division of Clinical Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Medicine, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
| | - Tianzhou Charles Ma
- Department of Epidemiology and Biostatistics, University of Maryland, College Park, MD, USA
| | - Goodman Sibeko
- Department of Psychiatry and Mental Health, Division of Addiction Psychiatry, University of Cape Town, Cape Town, South Africa
| | - Jessica F Magidson
- Department of Psychology, University of Maryland, College Park, College Park, MD, USA
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Joska JA, Lee JS, Andersen LS, Stanton AM, O' Clereigh C, Safren S. "Trajectories of treatment response in a cognitive-behavioral therapy intervention for depression and adherence in persons with HIV in South Africa". J Affect Disord 2023; 343:136-143. [PMID: 37797752 DOI: 10.1016/j.jad.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 09/08/2023] [Accepted: 10/02/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND People with HIV (PHW) are at greater risk of depression than the general population. Insight into the time-to-treatment-response and predictors of response to psychotherapy may improve implementation in primary care. METHODS We assessed depression treatment response among 80 participants in a trial of cognitive-behavioral therapy for adherence and depression (CBT-AD) for PWH with MDD and suboptimal antiretroviral therapy (ART) adherence. Participants self-reported depressive symptoms (CESD) at each therapy session. Clinicians assessed participants' depression (HAMD), along with potential predictors of response, every four months for one year. Latent class analyses examined classes of responders for the active and the post-treatment phases. Regression analyses identified predictors of class membership for each phase. RESULTS During the active treatment phase (CESD) we identified an early response (at session 2 and with continued trajectory of improvement) and a non-response group. There were also two classes during post-treatment (HAM-D): early responders (4-month) and late responders (12-month). Distress aversion was associated with lower likelihood of early response to CBT-AD (aOR = 0.74, 95%CI[0.56-0.90], p = .009), and social support was associated with increased likelihood of early response (aOR = 2.24, 95%CI[1.07-5.46], p = .045). LIMITATIONS Self-reported depression during the treatment phase may have resulted from social desirability bias. CONCLUSIONS Most participants responded to CBT-AD early during treatment (89 %) and had sustained improvements in depression by 4 months (80 %). Distress aversion was a risk factor for late response, and social support was protective. Future research is needed to assess the optimal dose of CBT-AD in resource limited settings.
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Affiliation(s)
- John A Joska
- HIV Mental Health Research Unit, Neuroscience Institute, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa.
| | - Jasper S Lee
- Behavioral Medicine Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Lena S Andersen
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Amelia M Stanton
- Department of Psychological and Brain Sciences, Boston University, Boston, MA, USA
| | - Conall O' Clereigh
- Behavioral Medicine Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Steven Safren
- Department of Psychology, University of Miami, Miami, FL, USA
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Edeh NC, Eseadi C. Mental health implications of suicide rates in South Africa. World J Clin Cases 2023; 11:8099-8105. [PMID: 38130796 PMCID: PMC10731174 DOI: 10.12998/wjcc.v11.i34.8099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 11/02/2023] [Accepted: 11/29/2023] [Indexed: 12/06/2023] Open
Abstract
Mental health challenges are a severe issue that could lead to suicide if not properly addressed. South Africa has a significant burden of mental health issues, which contributes to the soaring rate of suicide. Adequate mental health-care provision could reduce the high suicide rate in South Africa. Since the apartheid regime, the country has made a series of efforts to improve mental health. This study aimed to review and examine available literature on mental health and suicide issues in South Africa and demonstrate the policy implications. This study adopted a narrative review approach. Electronic databases (PubMed, Scilit, Google Scholar and Semantic Scholar) were used to identify published articles in the English language with crucial search terms that included mental health, South African mental health policy, South Africa, suicide and policy. Literature suggests that at the provincial level, there are no adequate mental health policies, and the implementation of the country's mental health policy is faced with many challenges, such as a shortage of professionals and finances. The review also showed that task sharing and counselling have been pilot-tested and shown to be effective methods for the prevention of mental illness and promotion of positive mental health. This study concludes that the mental health treatment gap still exists in South Africa, and this needs to be tackled using effective, multi-level counselling interventions and policy initiatives. Adequate mental health-care provision and effective implementation of mental health policy could reduce the high rate of suicide in South Africa.
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Affiliation(s)
- Nkechinyere C Edeh
- Department of Social Science Education, University of Nigeria, Nsukka 41001, Enugu State, Nigeria
| | - Chiedu Eseadi
- Department of Educational Psychology, University of Johannesburg, Johannesburg 2006, Gauteng, South Africa
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Oladeji BD, Ayinde OO, Bello T, Kola L, Faregh N, Abdulmalik J, Zelkowitz P, Seedat S, Gureje O. Cascade training for scaling up care for perinatal depression in primary care in Nigeria. Int J Ment Health Syst 2023; 17:41. [PMID: 37986025 PMCID: PMC10658820 DOI: 10.1186/s13033-023-00607-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 10/06/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND Task-shared care is a demonstrated approach for integrating mental health into maternal and child healthcare (MCH) services. Training and continued support for frontline providers is key to the success of task sharing initiatives. In most settings this is provided by mental health specialists. However, in resource constrained settings where specialists are in short supply, there is a need to explore alternative models for providing training and supportive supervision to frontline maternal care providers. This paper reports on the impact of a cascade training (train-the-trainers) approach in improving the knowledge and attitudes of primary healthcare workers (PHCW) to perinatal depression. METHODS Senior primary health care providers selected from across participating local government areas were trained to provide training to other PHCWs. The training sessions facilitated by these trainers were observed and rated for fidelity by specialist trainers, while the trainees provided their impression of and satisfaction with the training sessions using predesigned assessment forms. Training outcomes assessed included knowledge of depression (using mhGAP training questions and knowledge of depression questionnaire) and attitude towards providing care for depression (revised depression attitude questionnaire (R-DAQ)) measured pre and post training as well as six months after training. RESULTS Trainees were 198 PHCWs (94.4% female), who routinely provide MCH services in 28 selected primary care clinics and had between 6- and 34-years' experience. Training was provided by 11 trained trainers who were general physicians or senior nurses. Training sessions were rated high in fidelity and on training style. Sessions were rated excellent by 77.8% of the trainees with the trainers described as knowledgeable, effective and engaging. Knowledge of depression mean score improved from a pre-training level of 12.3 ± 3.5 to 15.4 ± 3.7, immediately post-training and 14.7 ± 3.2, six months post-training (both comparisons: p < 0.001). The proportion of PHCW workers endorsing statements indicative of positive attitudes on the professional confidence and the generalist perspective modules of the R-DAQ also increased with training. CONCLUSION Our findings suggest that cascade training can be an effective model for rapidly providing training and upskilling frontline PHCWs to deliver care for women with perinatal depression in resource limited settings. TRIAL REGISTRATION This study was retrospectively registered 03 December 2019. https://doi.org/10.1186/ISRCTN 94,230,307.
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Affiliation(s)
- Bibilola D Oladeji
- Department of Psychiatry of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria.
| | - Olatunde O Ayinde
- Department of Psychiatry of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Toyin Bello
- WHO Collaborating Centre for Research and Training in Mental Health, Neurosciences and Drug and Alcohol Abuse, Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Lola Kola
- WHO Collaborating Centre for Research and Training in Mental Health, Neurosciences and Drug and Alcohol Abuse, Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Neda Faregh
- Department of Psychology, Carleton University, Ottawa, ON, Canada
| | - Jibril Abdulmalik
- Department of Psychiatry of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | | | - Soraya Seedat
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Oye Gureje
- Department of Psychiatry of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria
- WHO Collaborating Centre for Research and Training in Mental Health, Neurosciences and Drug and Alcohol Abuse, Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria
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Aderoba AK, Kabra R, Kiarie JN. Implementation strategies, facilitators, and barriers to scaling up and sustaining task-sharing in family planning: a protocol for a mixed-methods systematic review. Syst Rev 2023; 12:190. [PMID: 37805571 PMCID: PMC10559628 DOI: 10.1186/s13643-023-02356-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 09/21/2023] [Indexed: 10/09/2023] Open
Abstract
BACKGROUND Ensuring access to quality family planning (FP) services is fundamental to achieving the Sustainable Development Goals (SDG) targets 3.1, 3.7, and 5.6, including universal access to reproductive health services. However, barriers such as health workforce shortages and restrictive policies on the role of mid and lower-level health workforce cadres limit access to contraceptives and FP in many settings. Workforce reorganization makes more efficient use of human resources. Consequently, the World Health Organization (WHO) recommends task-sharing for FP by different cadres. Evidence on the implementation strategies, facilitators, and barriers to scaling up and sustaining task-sharing could inform financing, implementation approaches, and technical assistance of national and global FP task-sharing programs. Therefore, this study aims to describe and assess the quality of the evidence on implementation strategies, facilitators, and barriers to scaling up and sustaining task-sharing in FP and the outcome of the scale-up/sustainability interventions. METHODS This systematic review protocol was developed using relevant guidelines, including the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Protocols (PRISMA-P). A search of five databases, namely CINAHL (EBSCOhost), EMBASE (OvidSP), Global Health (OvidSP), MEDLINE (OvidSP), and Scopus ( www.scopus.com ), and gray literature resources will be conducted. Two independent reviewers will screen and select studies, assess their quality using the "Mixed Methods Appraisal Tool," and extract data from eligible studies. Publications or articles are eligible if they report implementation strategies, facilitators, or barriers to scaling up/sustainability of task-sharing in FP/contraception or the outcomes of the scale-up/sustainability interventions. A convergent synthesis that integrates qualitative, quantitative, descriptive, and mixed-methods data into one dataset will be used for analysis based on an a priori framework-the Cochrane Effective Practice and Organization of Care (EPOC) taxonomy of the health system framework. Two independent reviewers will assess the quality of evidence using the GRADE-CERQual guideline. DISCUSSION To our knowledge, this systematic review of implementation strategies, facilitators, and barriers to scaling up and sustaining task-sharing in family planning is the first in this area. Our rigorous methodology based on up-to-date guidelines can help generate relevant recommendations to support interventions to scale up and sustain task-sharing in family planning. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42022339885.
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Affiliation(s)
- Adeniyi Kolade Aderoba
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
- Centre for Population Health and Interdisciplinary Research, HealthMATE360, Box 603, Ondo Town, Ondo State, Nigeria.
| | - Rita Kabra
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization Headquarters, Geneva, Switzerland
| | - James Njogu Kiarie
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization Headquarters, Geneva, Switzerland
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Tyagi V, Khan A, Siddiqui S, Kakra Abhilashi M, Dhurve P, Tugnawat D, Bhan A, Naslund JA. Development of a Digital Program for Training Community Health Workers in the Detection and Referral of Schizophrenia in Rural India. Psychiatr Q 2023; 94:141-163. [PMID: 36988785 PMCID: PMC10052309 DOI: 10.1007/s11126-023-10019-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/12/2023] [Indexed: 03/30/2023]
Abstract
This study aimed to develop and assess the acceptability of a digital program for training community health workers (CHWs) in the detection and referral of patients with schizophrenia in community settings in rural India. An iterative design process was employed. First, evidence-based content from existing community programs for schizophrenia care was incorporated into the curriculum, and reviewed by experts to ensure clinical utility and fidelity of the adapted content. Second, CHWs provided feedback on the appropriateness of language, content, and an initial prototype of the digital training program to ensure relevance for the local context. Focus group discussions were then used to understand the acceptability of the digital training prototype and to inform modifications to the design and layout. Qualitative data was analysed using a rapid thematic analysis approach based on predetermined topics pertaining to acceptability of the training content and digital platform. Development of the initial prototype involved content review by 13 subject matter experts with clinical expertise or experience accessing and receiving mental health services, and engagement of 23 CHWs, of which 11 provided feedback for contextualization of the training content and 12 participated in focus group discussions on the acceptability of the prototype. Additionally, 2 service-users with lived experience of schizophrenia contributed to initial testing of the digital training prototype and offered feedback in a focus group discussion. During contextualization of the training content, key feedback pertained to simplifying the language and presentation of the content by removing technical terms and including interactive content and images to enhance interest and engagement with the digital training. During prototype testing, CHWs shared their familiarity with similar symptoms but were unaware of schizophrenia as a treatable illness. They shared that training can help them identify symptoms of schizophrenia and connect patients with specialized care. They were also able to understand misconceptions and discrimination towards people with schizophrenia, and how to address these challenges by supporting others and spreading awareness in their communities. Participants also appreciated the digital training, as it could save them time and could be incorporated within their routine work. This study shows the acceptability of leveraging digital technology for building capacity of CHWs to support early detection and referral of schizophrenia in community settings in rural India. These findings can inform the subsequent evaluation of this digital training program to determine its impact on enhancing the knowledge and skills of CHWs.
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Affiliation(s)
| | | | | | | | | | | | | | - John A Naslund
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA, USA.
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Rieder AD, Viljoen M, Seris N, Shabalala N, Ndlovu M, Turner EL, Simmons R, de Vries PJ, Franz L. Improving access to early intervention for autism: findings from a proof-of-principle cascaded task-sharing naturalistic developmental behavioural intervention in South Africa. Child Adolesc Psychiatry Ment Health 2023; 17:64. [PMID: 37210513 PMCID: PMC10199438 DOI: 10.1186/s13034-023-00611-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 05/05/2023] [Indexed: 05/22/2023] Open
Abstract
BACKGROUND Despite the high number of children living with neurodevelopmental disabilities in sub-Saharan Africa, access to early intervention is almost non-existent. It is therefore important to develop feasible, scalable early autism intervention that can be integrated into systems of care. While Naturalistic Developmental Behavioural Intervention (NDBI) has emerged as an evidence-based intervention approach, implementation gaps exist globally, and task-sharing approaches may address access gaps. In this South African proof-of-principle pilot study, we set out to answer two questions about a 12-session cascaded task-sharing NDBI-whether the approach could be delivered with fidelity, and whether we could identify signals of change in child and caregiver outcomes. METHODS We utilized a single-arm pre-post design. Fidelity (non-specialists, caregivers), caregiver outcomes (stress, sense of competence), and child outcomes (developmental, adaptive) were measured at baseline (T1) and follow-up (T2). Ten caregiver-child dyads and four non-specialists participated. Pre-to-post summary statistics were presented alongside individual trajectories. Non-parametric Wilcoxon signed rank test for paired samples was used to compare group medians between T1 and T2. RESULTS Caregiver implementation fidelity increased in 10/10 participants. Non-specialists demonstrated a significant increase in coaching fidelity (increases in 7/10 dyads). Significant gains were seen on two Griffiths-III subscales (Language/Communication-9/10 improved, Foundations of Learning-10/10 improved) and on the General Developmental Quotient (9/10 improved). Significant gains were also seen on two Vineland Adaptive Behaviour Scales (Third Edition) subscales (Communication-9/10 improved, Socialization-6/10 improved) and in the Adaptive Behaviour Standard Score (9/10 improved). Caregiver sense of competence improved in 7/10 caregivers and caregiver stress in 6/10 caregivers. CONCLUSIONS This proof-of-principle pilot study of the first cascaded task-sharing NDBI in Sub-Saharan Africa provided fidelity and intervention outcome data which supported the potential of such approaches in low-resource contexts. Larger studies are needed to expand on the evidence-base and answer questions on intervention effectiveness and implementation outcomes.
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Affiliation(s)
- Amber D Rieder
- Division of Child and Family Mental Health & Community Psychiatry, Department of Psychiatry and Behavioral Sciences, Duke University, Durham, North Carolina, USA
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Duke Center for Autism and Brain Development, Department of Psychiatry and Behavioral Sciences, Duke University, Durham, USA
| | - Marisa Viljoen
- Centre for Autism Research in Africa (CARA), Division of Child & Adolescent Psychiatry, University of Cape Town, 46 Sawkins Road, Rondebosch, 7700, South Africa.
| | - Noleen Seris
- Centre for Autism Research in Africa (CARA), Division of Child & Adolescent Psychiatry, University of Cape Town, 46 Sawkins Road, Rondebosch, 7700, South Africa
| | - Nokuthula Shabalala
- Centre for Autism Research in Africa (CARA), Division of Child & Adolescent Psychiatry, University of Cape Town, 46 Sawkins Road, Rondebosch, 7700, South Africa
| | - Minkateko Ndlovu
- Centre for Autism Research in Africa (CARA), Division of Child & Adolescent Psychiatry, University of Cape Town, 46 Sawkins Road, Rondebosch, 7700, South Africa
- Department of Psychology, University of Cape Town, Cape Town, South Africa
| | - Elizabeth L Turner
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Ryan Simmons
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Petrus J de Vries
- Centre for Autism Research in Africa (CARA), Division of Child & Adolescent Psychiatry, University of Cape Town, 46 Sawkins Road, Rondebosch, 7700, South Africa
| | - Lauren Franz
- Centre for Autism Research in Africa (CARA), Division of Child & Adolescent Psychiatry, University of Cape Town, 46 Sawkins Road, Rondebosch, 7700, South Africa
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Duke Center for Autism and Brain Development, Department of Psychiatry and Behavioral Sciences, Duke University, Durham, USA
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Selohilwe O, Fairall L, Bhana A, Kathree T, Zani B, Folb N, Lund C, Thornicroft G, Petersen I. Challenges and opportunities for implementation and dissemination of a task- sharing counselling intervention for depression at primary health care level in South Africa. Int J Ment Health Syst 2023; 17:7. [PMID: 36998053 PMCID: PMC10064738 DOI: 10.1186/s13033-023-00575-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 03/08/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND The treatment gap for mental health services is a growing public health concern. A lay-counselling service located at primary health care (PHC) level could potentially help to close the large treatment gap for common mental disorders in South Africa. The aim of this study was to understand multilevel factors contributing to implementation and potential dissemination of such a service for depression at PHC level. METHODS Process qualitative data of the lay-counselling service for patients with depressive symptoms was collected alongside a pragmatic randomized controlled trial evaluating a collaborative care model that included a lay-counselling service for patients with depressive symptoms. Semi-structured key informant interviews (SSI) were conducted with a purposive sample of PHC providers (lay-counsellors, nurse practitioners, operational managers), lay-counsellor supervisors, district and provincial managers, and patients in receipt of services. A total of 86 interviews were conducted. The Consolidated Framework for Implementation Research (CFIR) was used to guide data collection as well as Framework Analysis to determine barriers and facilitators for implementation and dissemination of the lay-counselling service. RESULTS Facilitators identified include supervision and support available for counsellors; person focused counselling approach; organizational integration of the counsellor within facilities. Barriers included lack of organizational support of the counselling service, including lack of counselling dedicated space; high counsellor turnover, resulting in a counsellor not available all the time; lack of an identified cadre to deliver the intervention in the system; and treatment of mental health conditions including counselling not included within mental health indicators. CONCLUSIONS Several system level issues need to be addressed to promote integration and dissemination of lay-counselling services within PHC facilities in South Africa. Key system requirements are facility organizational readiness for improvement of integration of lay-counselling services; formal recognition of counselling services provided by lay counsellors as well as inclusion of lay counselling as a treatment modality within mental health treatment data element definitions and the need for diversification of the roles of psychologists to include training and supervision of lay counsellors was also emphasized.
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Affiliation(s)
- One Selohilwe
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, 4001, South Africa.
| | - Lara Fairall
- Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa
- School of Life Course & Population Sciences, King's College London, London, UK
| | - Arvin Bhana
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, 4001, South Africa
- Health Systems Research Unit, South African Medical Research Centre, Durban, 4091, South Africa
| | - Tasneem Kathree
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, 4001, South Africa
| | - Babalwa Zani
- Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa
| | - Naomi Folb
- Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa
| | - Crick Lund
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Graham Thornicroft
- Centre for Global Mental Health and Centre for Implementation Science, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Inge Petersen
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, 4001, South Africa
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Marklund M, Cherukupalli R, Pathak P, Neupane D, Krishna A, Wu JH, Neal B, Kaur P, Moran AE, Appel LJ, Matsushita K. Hypertension treatment capacity in India by increased workforce, greater task-sharing, and extended prescription period: a modelling study. Lancet Reg Health Southeast Asia 2023; 10:100124. [PMID: 37383361 PMCID: PMC10306017 DOI: 10.1016/j.lansea.2022.100124] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 11/11/2022] [Accepted: 11/22/2022] [Indexed: 06/30/2023]
Abstract
Background The worldwide control rate for hypertension is dismal. An inadequate number of physicians to treat patients with hypertension is one key obstacle. Innovative health system approaches such as delegation of basic tasks to non-physician health workers (task-sharing) might alleviate this problem. Massive scale up of population-wide hypertension management is especially important for low- and middle-income countries such as India. Methods Using constrained optimization models, we estimated the hypertension treatment capacity and salary costs of staff involved in hypertension care within the public health system of India and simulated the potential effects of (1) an increased workforce, (2) greater task-sharing among health workers, and (3) extended average prescription periods that reduce treatment visit frequency (e.g., quarterly instead of monthly). Findings Currently, only an estimated 8% (95% uncertainty interval 7%-10%) of ∼245 million adults with hypertension can be treated by physician-led services in the Indian public health system (assuming the current number of health workers, no greater task-sharing, and monthly visits for prescriptions). Without task-sharing and with continued monthly visits for prescriptions, the least costly workforce expansion to treat 70% of adults with hypertension would require ∼1.6 (1.0-2.5) million additional staff (all non-physicians), with ∼INR 200 billion (≈USD 2.7 billion) in additional annual salary costs. Implementing task-sharing among health workers (without increasing the overall time on hypertension care) or allowing a 3-month prescription period was estimated to allow the current workforce to treat ∼25% of patients. Joint implementation of task-sharing and a longer prescription period could treat ∼70% of patients with hypertension in India. Interpretation The combination of greater task-sharing and extended prescription periods could substantially increase the hypertension treatment capacity in India without any expansion of the current workforce in the public health system. By contrast, workforce expansion alone would require considerable, additional human and financial resources. Funding Resolve to Save Lives, an initiative of Vital Strategies, was funded by grants from Bloomberg Philanthropies; the Bill and Melinda Gates Foundation; and Gates Philanthropy Partners (funded with support from the Chan Zuckerberg Foundation).
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Affiliation(s)
- Matti Marklund
- The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | | | - Priya Pathak
- The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Dinesh Neupane
- The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Jason H.Y. Wu
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Bruce Neal
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
- Imperial College London, London, UK
| | - Prabhdeep Kaur
- National Institute of Epidemiology, The Indian Council of Medical Research, Chennai, Tamil Nadu, India
| | - Andrew E. Moran
- Resolve to Save Lives, New York, NY, USA
- Columbia University Irving Medical Center, New York, NY, USA
| | - Lawrence J. Appel
- The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Gouveia L, Lovero KL, Fumo W, Fumo AMT, Dos Santos P, Mocumbi AO, Oquendo MA, Mari JJ, Wainberg ML, Duarte CS. A Multi-Site Study of Mental Disorders in the Mozambican Health Care System. Adm Policy Ment Health 2023; 50:33-42. [PMID: 36229748 PMCID: PMC10099511 DOI: 10.1007/s10488-022-01221-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2022] [Indexed: 02/04/2023]
Abstract
In Mozambique, human and financial resources for public mental health services are extremely limited. Understanding the mental health needs of those seeking healthcare can inform efficient targeting of mental health services. We examined if the frequency of mental disorders in a health facility varied based on the level of specialization of such facility, from primary care without mental health specialists (PrCMH -), to those with mental health specialists (PrCMH +) and tertiary care (TerC), where both inpatient and outpatient mental health services are available. Participants were adults (convenience sample) seeking health or mental health services at six facilities (2 PrCMH + , 3 PrCMH -, and 1 TerC) in the cities of Maputo and Nampula in Mozambique. Mental disorders were assessed by the MINI International Neuropsychiatric Interview (MINI) 4.0.0. We compared the sociodemographic characteristics and MINI diagnoses across the three types of health facilities. Multiple logistic regression models determined the likelihood that a person seeking services at each type of facility would have any mental disorder, common mental disorders (CMD), severe mental disorders (SMD), substance use disorders (SUD), and moderate-to-high suicide risk, adjusting for sociodemographic factors. Of the 612 total participants, 52.6% (n = 322) were positive for at least one mental disorder: 37.1% were positive for CMD, 28.9% for SMD, 13.2% for SUD, and 10.5% had suicide risk. Presence of any mental disorder was highest in TerC (62.5%) and lowest in PrCMH - (48.4%). Adjusting for sociodemographic covariates, participants in PrCMH + were significantly more likely to have SMD (OR 1.85, 95%CI 1.10-3.11) and SUD (OR 2.79, 95%CI 1.31-5.94) than participants in PrCMH -; participants in TerC were more likely to have CMD (OR 1.70, 95%CI 1.01-2.87) and SUD (OR 2.57, 95%CI 1.14-5.79) than in PrCMH -. Suicide risk was the only condition that did not differ across facility types. As anticipated, people with mental disorders were more likely to be cared for at facilities with mental health specialists. However, our study detected in this convenience sample a remarkably high frequency of mental disorders across different types of facilities within the Mozambican healthcare system. These results, if confirmed in representative samples, suggest a need to increase mental health services at the primary care level.
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Affiliation(s)
- Lidia Gouveia
- Department of Mental Health, Ministry of Health, Av. Eduardo Mondlane/Av. Salvador Allende, P.O. Box 1613, Maputo, Mozambique.
- Department of Psychiatry, Universidade Federal de São Paulo, Rua Major Maragliano, 241, São Paulo, São Paulo, Brasil.
| | - Kathryn L Lovero
- Department of Psychiatry, Vagelos College of Physicians and Surgeons, New York State Psychiatric Institute and Columbia University, 1051 Riverside Dr. Unit #24, New York, NY, USA
| | - Wilza Fumo
- Department of Mental Health, Ministry of Health, Av. Eduardo Mondlane/Av. Salvador Allende, P.O. Box 1613, Maputo, Mozambique
- Department of Psychiatry, Universidade Federal de São Paulo, Rua Major Maragliano, 241, São Paulo, São Paulo, Brasil
| | - Afonso Mazine Tiago Fumo
- Department of Mental Health, Ministry of Health, Av. Eduardo Mondlane/Av. Salvador Allende, P.O. Box 1613, Maputo, Mozambique
| | - Palmira Dos Santos
- Department of Mental Health, Ministry of Health, Av. Eduardo Mondlane/Av. Salvador Allende, P.O. Box 1613, Maputo, Mozambique
| | - Ana Olga Mocumbi
- National Institute of Health, ENI, Bairro da Vila-Parcela nº, 3943, Marracuene, Maputo Province, Mozambique
| | - Maria A Oquendo
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, 3535 Market Street Suite 200, Philadelphia, PA, USA
| | - Jair J Mari
- Department of Psychiatry, Universidade Federal de São Paulo, Rua Major Maragliano, 241, São Paulo, São Paulo, Brasil
| | - Milton L Wainberg
- Department of Psychiatry, Vagelos College of Physicians and Surgeons, New York State Psychiatric Institute and Columbia University, 1051 Riverside Dr. Unit #24, New York, NY, USA
| | - Cristiane S Duarte
- Department of Psychiatry, Vagelos College of Physicians and Surgeons, New York State Psychiatric Institute and Columbia University, 1051 Riverside Dr. Unit #24, New York, NY, USA
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Petersen I, Selohilwe O, Georgeu-Pepper D, Ras CJ, Zani B, Petrus R, Anderson L, Mntambo N, Kathree T, Bhana A, Thornicroft G, Fairall L. A collaborative care package for depression comorbid with chronic physical conditions in South Africa. BMC Health Serv Res 2022; 22:1465. [PMID: 36457094 PMCID: PMC9717432 DOI: 10.1186/s12913-022-08874-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 11/23/2022] [Indexed: 12/05/2022] Open
Abstract
INTRODUCTION A task-sharing collaborative care model for integrated depression care for South Africa's burgeoning primary health care population with chronic conditions was developed and tested through two pragmatic cluster randomized controlled trials. One trial focused on patients with hypertension and was located in one district where a collaborative care model was co-designed with district stakeholders. The other trial, focused on patients on antiretroviral treatment, was located in the same district site, with the addition of a second neighbouring district, without adaptation of the original model. This paper describes the package used to implement this model, and implementation outcomes across the two sites, and summarises lessons and challenges. METHODS The Template for Intervention Description and Replication (TIDieR) framework, adapted for complex health systems interventions, was used to describe components of the package. Additional elements of 'modifications made' and 'actual implementation' introduced in the 'Getting messier with TIDieR' framework, were used to describe implementation outcomes in terms of reach, adoption and implementation across the two trial districts. RESULTS In the absence of a co-design process to adapt the model to the context of the second site, there was less system level support for the model. Consequently, more project employed human resources were deployed to support training of primary care nurses in identification and referral of patients with depression; and supervise co-located lay counsellors. Referrals to co-located lay counselling services were more than double in the second site. However, uptake of counselling sessions was greater in the first site. This was attributed to greater in-vivo supervision and support from existing mental health specialists in the system. There was greater reliance on online supervision and support in the second site where geographical distances between clinics were larger. CONCLUSION The need for in-country co-designed collaborative care models, and 'implementation heavy' implementation research to understand adaptations required to accommodate varying in-country health system contexts is highlighted.
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Affiliation(s)
- Inge Petersen
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Howard College, Mazisi Kunene Road, Durban, 4001 South Africa
- Institute for Global Health, University College London, London, UK
| | - One Selohilwe
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Howard College, Mazisi Kunene Road, Durban, 4001 South Africa
| | | | - Christy-Joy Ras
- Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa
| | - Babalwa Zani
- Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa
| | - Ruwayda Petrus
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Howard College, Mazisi Kunene Road, Durban, 4001 South Africa
- School of Applied Human Sciences, University of KwaZulu-Natal, Howard College, Mazisi Kunene Road, Durban, 4001 South Africa
| | - Lauren Anderson
- Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa
| | - Ntokozo Mntambo
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Howard College, Mazisi Kunene Road, Durban, 4001 South Africa
- School of Applied Human Sciences, University of KwaZulu-Natal, Howard College, Mazisi Kunene Road, Durban, 4001 South Africa
| | - Tasneem Kathree
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Howard College, Mazisi Kunene Road, Durban, 4001 South Africa
| | - Arvin Bhana
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Howard College, Mazisi Kunene Road, Durban, 4001 South Africa
- Health Systems Research Unit, South African Medical Research Council, 491 Peter Mokaba Ridge, Overport, Durban, South Africa
| | - Graham Thornicroft
- Centre for Global Mental Health and Centre for Implementation Science, Institute of Psychiatry, Psychology and Neuroscience, King’s College, London, UK
| | - Lara Fairall
- Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa
- Global Health Institute, King’s College London, London, UK
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17
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Moodley SV, Wolvaardt J, Grobler C. Enabling mental health task-sharing: a collective case study of undergraduate clinical associate training programmes in South Africa. BMC Med Educ 2022; 22:745. [PMID: 36307798 PMCID: PMC9615622 DOI: 10.1186/s12909-022-03806-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 09/21/2022] [Accepted: 10/14/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND There is a shortage of the human resources needed to deliver mental health services which is likely to be exacerbated by COVID-19. Due to mental health workforce shortages, task-shifting and task-sharing approaches have been implemented in a number of countries. Clinical associates, a mid-level cadre working under the supervision of medical practitioners, could play a role in delivering mental health services but it is not clear if they are adequately prepared. This study explored the mental health curriculum content of the undergraduate clinical associate training programmes in South Africa and the views of key informants of the adequacy of training in mental health. METHODS A qualitative collective case study approach was utilised for this multisite study at the three universities in South Africa offering clinical associate degrees. The study consisted of in-depth interviews utilising videoconferencing of individuals involved in each programme and a document review. Thematic analysis of the data was conducted. RESULTS Nineteen interviews were conducted. Mental health formed part of the curriculum in all three programmes with the bulk of the training taking place in the final year of the three-year degree. Facility-based training ranged from two weeks to four weeks with one university only using hospitals with mental health units while two universities used hospitals at which the students were based for the year regardless of potential mental health exposure they would receive. The list of curricula inclusions extended to seldom-seen conditions. The quality of training and supervision appeared site-dependant and only one university set minimum experiential targets. CONCLUSION There is a basis on which to build the competencies and skills regarding mental health in this cadre. A training model that integrates mental health early in the undergraduate curriculum, focuses on common conditions and those with high disease burden, includes time in a mental health unit, provides facility-based trainers with detailed guidance to improve standardisation, and includes specific experiential targets that are monitored will enhance the potential utility of this cadre.
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Affiliation(s)
| | - Jacqueline Wolvaardt
- School of Health Systems and Public Health, University of Pretoria, Pretoria, South Africa
| | - Christoffel Grobler
- School of Health Systems and Public Health, University of Pretoria, Pretoria, South Africa
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18
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Moodley SV, Wolvaardt J, Grobler C. Mental health task-sharing in South Africa - a role for clinical associates? BMC Health Serv Res 2022; 22:1242. [PMID: 36209219 PMCID: PMC9547675 DOI: 10.1186/s12913-022-08638-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 10/05/2022] [Indexed: 11/25/2022] Open
Abstract
Background South Africa (SA) lacks the specialised workforce needed to provide mental health services particularly in the public sector and in rural areas. Mid-level medical workers offer a potential option for mental health task-sharing in countries where they exist, including SA. The objectives of the study were to explore the roles that SA’s mid-level medical worker cadre (clinical associates) could play in mental health service delivery, and to explore views on advanced training in mental health for this cadre. Methods This was an explorative, qualitative study involving key informants linked to the three clinical associate training programmes in SA. A total of 19 in-depth interviews were conducted with university-based academic staff, facility-based trainers, and student representatives. The interviews were audio-recorded and professionally transcribed. Thematic analysis was conducted with the aid of Atlas.ti software. Themes and subthemes were identified. Results The first theme identified was ‘there is a place for them at the table’. Participants felt that there was a definite role for clinical associates in mental health service provision. The levels of care thought most appropriate were primary health care facilities and district hospitals. The most frequently identified role for clinical associates was in providing immediate care and stabilising mental health patients presenting in emergency settings. Other potential settings included inpatient wards, outpatients’ departments, and in communities (e.g. home visits). The second theme identified was ‘earning a seat at the table’. There was virtually unanimous support for additional training and in particular a postgraduate clinical specialisation in mental health. Participants felt a clinical specialisation in mental health would strengthen the health system by addressing workforce shortages as well as access and equity issues. They also held the view it would strengthen the profession by creating a career path and providing more employment opportunities for clinical associates. Conclusions There was broad support for a role for clinical associates in mental health service delivery in SA as well as for the establishing a clinical specialisation in mental health for clinical associates. Clinical associates with advanced training in mental health could potentially play an important role in rural settings to alleviate the shortage of specialist mental health practitioners. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08638-3.
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Affiliation(s)
- Saiendhra Vasudevan Moodley
- School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, 0084, South Africa.
| | - Jacqueline Wolvaardt
- School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, 0084, South Africa
| | - Christoffel Grobler
- School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, 0084, South Africa
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19
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Atif N, Nazir H, Sultan ZH, Rauf R, Waqas A, Malik A, Sikander S, Rahman A. Technology-assisted peer therapy: a new way of delivering evidence-based psychological interventions. BMC Health Serv Res 2022; 22:842. [PMID: 35773677 PMCID: PMC9245257 DOI: 10.1186/s12913-022-08233-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 06/16/2022] [Indexed: 11/20/2022] Open
Abstract
In low-income settings, ninety percent of individuals with clinical depression have no access to evidence-based psychological interventions. Reasons include lack of funds for specialist services, scarcity of trained mental health professionals, and the stigma attached to mental illness. In recent years there have been many studies demonstrating effective delivery of psychological interventions through a variety of non-specialists. While these interventions are cost-effective and less stigmatising, efforts to scale-up are hampered by issues of quality-control, and what has been described by implementation scientists as ‘voltage-drop’ and ‘programme-drift.’ Using principles of Human Centred Design in a rural setting in Pakistan, we worked with potential users to co-design a Tablet or Smartphone-based App that can assist a lay-person deliver the Thinking Healthy Programme, a World Health Organization-endorsed evidence-based intervention for perinatal depression. The active ingredients of this cognitive-therapy based intervention are delivered by a virtual ‘avatar’ therapist incorporated into the App which is operated by a ‘peer’ (a woman from the neighbourhood with no prior experience of healthcare delivery). Using automated cues from the App, the peer reinforces key therapeutic messages, helps with problem-solving and provides the non-specific but essential therapeutic elements of empathy and support. The peer and App therefore act as co-therapists in delivery of the intervention. The peer can deliver the intervention with good fidelity after brief automated in-built training. This approach has the potential to be applied to other areas of mental health and help bridge the treatment gap, especially in resource-poor settings. This paper describes the process of co-development with end-users and key features of the App.
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Affiliation(s)
- Najia Atif
- Human Development Research Foundation, Rawalpindi, Pakistan
| | - Huma Nazir
- Human Development Research Foundation, Rawalpindi, Pakistan
| | | | - Rabia Rauf
- Human Development Research Foundation, Rawalpindi, Pakistan
| | - Ahmed Waqas
- Department of Primary Care and Mental Health, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Abid Malik
- Human Development Research Foundation, Rawalpindi, Pakistan.,Health Services Academy, Chak Shahzad, Islamabad, Pakistan
| | - Siham Sikander
- Department of Primary Care and Mental Health, Institute of Population Health, University of Liverpool, Liverpool, UK.,Global Institute of Human Development, Shifa Tameer-E-Millat University, Islamabad, Pakistan
| | - Atif Rahman
- Department of Primary Care and Mental Health, Institute of Population Health, University of Liverpool, Liverpool, UK.
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20
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Cumbe VFJ, Muanido AG, Turner M, Ramiro I, Sherr K, Weiner BJ, Flaherty BP, Sharma M, Faduque F, Xerinda ER, Wagenaar BH. Systems analysis and improvement approach to optimize outpatient mental health treatment cascades in Mozambique (SAIA-MH): study protocol for a cluster randomized trial. Implement Sci 2022; 17:37. [PMID: 35668423 PMCID: PMC9169330 DOI: 10.1186/s13012-022-01213-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 05/15/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Significant investments are being made to close the mental health (MH) treatment gap, which often exceeds 90% in many low- and middle-income countries (LMICs). However, limited attention has been paid to patient quality of care in nascent and evolving LMIC MH systems. In system assessments across sub-Saharan Africa, MH loss-to-follow-up often exceeds 50% and sub-optimal medication adherence often exceeds 60%. This study aims to fill a gap of evidence-based implementation strategies targeting the optimization of MH treatment cascades in LMICs by testing a low-cost multicomponent implementation strategy integrated into routine government MH care in Mozambique. METHODS Using a cluster-randomized trial design, 16 clinics (8 intervention and 8 control) providing primary MH care will be randomized to the Systems Analysis and Improvement Approach for Mental Health (SAIA-MH) or an attentional placebo control. SAIA-MH is a multicomponent implementation strategy blending external facilitation, clinical consultation, and provider team meetings with system-engineering tools in an overall continuous quality improvement framework. Following a 6-month baseline period, intervention facilities will implement the SAIA-MH strategy for a 2-year intensive implementation period, followed by a 1-year sustainment phase. Primary outcomes will be the proportion of all patients diagnosed with a MH condition and receiving pharmaceutical-based treatment who achieve functional improvement, adherence to medication, and retention in MH care. The Consolidated Framework for Implementation Research (CFIR) will be used to assess determinants of implementation success. Specific Aim 1b will include the evaluation of mechanisms of the SAIA-MH strategy using longitudinal structural equation modeling as well as specific aim 2 estimating cost and cost-effectiveness of scaling-up SAIA-MH in Mozambique to provincial and national levels. DISCUSSION This study is innovative in being the first, to our knowledge, to test a multicomponent implementation strategy for MH care cascade optimization in LMICs. By design, SAIA-MH is a low-cost strategy to generate contextually relevant solutions to barriers to effective primary MH care, and thus focuses on system improvements that can be sustained over the long term. Since SAIA-MH is integrated into routine government MH service delivery, this pragmatic trial has the potential to inform potential SAIA-MH scale-up in Mozambique and other similar LMICs. TRIAL REGISTRATION ClinicalTrials.gov; NCT05103033 ; 11/2/2021.
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Affiliation(s)
- Vasco F J Cumbe
- Provincial Health Directorate, Sofala Province, Ministry of Health, Beira, Mozambique.
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique.
- Department of Psychiatry, Beira Central Hospital, Beira, Mozambique.
| | | | - Morgan Turner
- Department of Global Health, University of Washington, Seattle, WA, USA
| | | | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Industrial & Systems Engineering, University of Washington, Seattle, WA, USA
| | - Bryan J Weiner
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Brian P Flaherty
- Department of Psychology, University of Washington, Seattle, WA, USA
| | - Monisha Sharma
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Flávia Faduque
- Provincial Health Directorate, Manica Province, Ministry of Health, Chimoio, Mozambique
| | | | - Bradley H Wagenaar
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
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21
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Le PD, Eschliman EL, Grivel MM, Tang J, Cho YG, Yang X, Tay C, Li T, Bass J, Yang LH. Barriers and facilitators to implementation of evidence-based task-sharing mental health interventions in low- and middle-income countries: a systematic review using implementation science frameworks. Implement Sci 2022; 17:4. [PMID: 35022081 PMCID: PMC8756725 DOI: 10.1186/s13012-021-01179-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 12/05/2021] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Task-sharing is a promising strategy to expand mental healthcare in low-resource settings, especially in low- and middle-income countries (LMICs). Research on how to best implement task-sharing mental health interventions, however, is hampered by an incomplete understanding of the barriers and facilitators to their implementation. This review aims to systematically identify implementation barriers and facilitators in evidence-based task-sharing mental health interventions using an implementation science lens, organizing factors across a novel, integrated implementation science framework. METHODS PubMed, PsychINFO, CINAHL, and Embase were used to identify English-language, peer-reviewed studies using search terms for three categories: "mental health," "task-sharing," and "LMIC." Articles were included if they: focused on mental disorders as the main outcome(s); included a task-sharing intervention using or based on an evidence-based practice; were implemented in an LMIC setting; and included assessment or data-supported analysis of barriers and facilitators. An initial conceptual model and coding framework derived from the Consolidated Framework for Implementation Research and the Theoretical Domains Framework was developed and iteratively refined to create an integrated conceptual framework, the Barriers and Facilitators in Implementation of Task-Sharing Mental Health Interventions (BeFITS-MH), which specifies 37 constructs across eight domains: (I) client characteristics, (II) provider characteristics, (III) family and community factors, (IV) organizational characteristics, (V) societal factors, (VI) mental health system factors, (VII) intervention characteristics, and (VIII) stigma. RESULTS Of the 26,935 articles screened (title and abstract), 192 articles underwent full-text review, yielding 37 articles representing 28 unique intervention studies that met the inclusion criteria. The most prevalent facilitators occur in domains that are more amenable to adaptation (i.e., the intervention and provider characteristics domains), while salient barriers occur in domains that are more challenging to modulate or intervene on-these include constructs in the client characteristics as well as the broader societal and structural levels of influence (i.e., the organizational, mental health system domains). Other notable trends include constructs in the family and community domains occurring as barriers and as facilitators roughly equally, and stigma constructs acting exclusively as barriers. CONCLUSIONS Using the BeFITS-MH model we developed based on implementation science frameworks, this systematic review provides a comprehensive identification and organization of barriers and facilitators to evidence-based task-sharing mental health interventions in LMICs. These findings have important implications for ongoing and future implementation of this critically needed intervention strategy, including the promise of leveraging task-sharing intervention characteristics as sites of continued innovation, the importance of but relative lack of engagement with constructs in macro-level domains (e.g., organizational characteristics, stigma), and the need for more delineation of strategies for task-sharing mental health interventions that researchers and implementers can employ to enhance implementation in and across levels. TRIAL REGISTRATION PROSPERO CRD42020161357.
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Affiliation(s)
- PhuongThao D. Le
- grid.137628.90000 0004 1936 8753Department of Social and Behavioral Sciences, New York University School of Global Public Health, 708 Broadway, NY 10012 New York, USA
| | - Evan L. Eschliman
- grid.21107.350000 0001 2171 9311Department of Health, Behavior and Society, Johns Hopkins University Bloomberg School of Public Health, 615 North Wolfe St., Baltimore, MD 21205 USA
| | - Margaux M. Grivel
- grid.137628.90000 0004 1936 8753Department of Social and Behavioral Sciences, New York University School of Global Public Health, 708 Broadway, NY 10012 New York, USA
| | - Jeffrey Tang
- grid.137628.90000 0004 1936 8753Department of Psychology, New York University Graduate School of Arts and Science, One-Half Fifth Avenue, New York, NY 10003 USA
| | - Young G. Cho
- grid.21729.3f0000000419368729New York State Psychiatric Institute, Columbia University, 1051 Riverside Dr., New York, NY 10032 USA
| | - Xinyu Yang
- grid.21729.3f0000000419368729Department of Epidemiology, Columbia University Mailman School of Public Health, 722 West 168th St., New York, NY 10032 USA
| | - Charisse Tay
- grid.21729.3f0000000419368729Columbia University Teachers College, 525 West 120th Street, New York, NY 10027 USA
| | - Tingyu Li
- grid.21729.3f0000000419368729Columbia University Teachers College, 525 West 120th Street, New York, NY 10027 USA
| | - Judith Bass
- grid.21107.350000 0001 2171 9311Department of Mental Health, Johns Hopkins University Bloomberg School of Public Health, Hampton House, 8th Floor, 624 N. Broadway, Baltimore, MD 21205 USA
| | - Lawrence H. Yang
- grid.137628.90000 0004 1936 8753Department of Social and Behavioral Sciences, New York University School of Global Public Health, 708 Broadway, NY 10012 New York, USA ,grid.21729.3f0000000419368729Department of Epidemiology, Columbia University Mailman School of Public Health, 722 West 168th St., New York, NY 10032 USA
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22
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Dev S, Lincoln AK, Shidhaye R. Evidence to Practice for Mental Health Task-Sharing: Understanding Readiness for Change among Accredited Social Health Activists in Sehore District, Madhya Pradesh, India. Adm Policy Ment Health 2021. [PMID: 34800181 DOI: 10.1007/s10488-021-01176-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2021] [Indexed: 10/19/2022]
Abstract
Involvement of community health workers (CHWs) within task-sharing to bridge the mental health treatment gap has been proven to be efficacious in randomized controlled trials. The impact of mental health programs based on task-sharing paradigm greatly depends on the performance of CHWs which, in-turn, is influenced by their readiness for change. However, there is dearth of literature assessing the role of readiness for change as an important predicator of CHW performance. The aim of this study is to examine the applicability of the readiness for change model and investigate its cultural and contextual nuances among Accredited Social Health Activists (ASHAs), a cadre of CHWs in India, to understand their engagement in mental health task-sharing. We conducted in-depth, semi-structured interviews with a purposive sample of n = 12 key informants including ASHAs and other healthcare professionals in Sehore district, India. The interview guide consisted of open-ended questions based on the readiness for change factors including ASHAs' attitudes towards their role in mental health care, perception of capability to implement mental health task-sharing, of support from the public health system, etc. Framework analysis with a combined inductive-deductive approach was employed to code the data and generate themes. Participants endorsed three readiness for change themes relevant to task-sharing among ASHAs including change valence or value ascribed to task-sharing, change-efficacy or the perceived ability to implement task-sharing, and job valence or value ascribed to their regular job role. In addition, they provided insights into the culturally and contextually salient aspects of these factors. Themes of personal empowerment, gaining respect and trust from community, professional duty, relationship with supervisors, and lack of resources availability were majorly highlighted. This is the first study to qualitatively investigate the applicability of the readiness for change model and its culture- and context-specific nuances among a cadre of non-specialist health workers in India. Our findings posit that implementation science models should strongly consider the culture and context within which they are being applied to enhance fit and relevance. Further, our results should be taken into consideration to adapt and validate measurement tools and build readiness for change in this population.
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23
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Kormendi NM, Brown AD. Asian American mental health during COVID-19: A call for task-sharing interventions. SSM Ment Health 2021; 1:100006. [PMID: 34494013 PMCID: PMC8413682 DOI: 10.1016/j.ssmmh.2021.100006] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 06/12/2021] [Accepted: 06/12/2021] [Indexed: 12/05/2022] Open
Abstract
In the age of COVID-19, the Asian American community is facing a number of unique risks and barriers to mental health care. Mounting challenges—including language barriers, unemployment, racialized trauma, and anti-Asian violence—threaten the health and wellness of these communities. Yet, structural obstacles prevent Asian Americans from accessing care within the professionalized behavioral health workforce. Leveraging the resources of Asian American peer networks, collectives, and community-based organizations through a task-sharing program presents an attractive alternative for mental health care provision. Investing in task-sharing approaches to care would both address access barriers and build capacity within the Asian American community.
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Affiliation(s)
- Nicole Misun Kormendi
- Apicha Community Health Center, 400 Broadway, New York, NY, USA, 10013.,Vassar College, 124 Raymond Ave, Poughkeepsie, NY, USA, 12604
| | - Adam D Brown
- Department of Psychology, New School for Social Research, 80 5th Avenue, 601, New York, NY, USA, 10011.,Department of Psychiatry, New York University School of Medicine, 1 Park Avenue, New York, NY, USA, 10016
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24
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Zhao Y, Hagel C, Tweheyo R, Sirili N, Gathara D, English M. Task-sharing to support paediatric and child health service delivery in low- and middle-income countries: current practice and a scoping review of emerging opportunities. Hum Resour Health 2021; 19:95. [PMID: 34348709 PMCID: PMC8336272 DOI: 10.1186/s12960-021-00637-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 07/23/2021] [Indexed: 05/13/2023]
Abstract
BACKGROUND Demographic and epidemiological changes have prompted thinking on the need to broaden the child health agenda to include care for complex and chronic conditions in the 0-19 years (paediatric) age range. Providing such services will be undermined by general and skilled paediatric workforce shortages especially in low- and middle-income countries (LMICs). In this paper, we aim to understand existing, sanctioned forms of task-sharing to support the delivery of care for more complex and chronic paediatric and child health conditions in LMICs and emerging opportunities for task-sharing. We specifically focus on conditions other than acute infectious diseases and malnutrition that are historically shifted. METHODS We (1) reviewed the Global Burden of Diseases study to understand which conditions may need to be prioritized; (2) investigated training opportunities and national policies related to task-sharing (current practice) in five purposefully selected African countries (Kenya, Uganda, Tanzania, Malawi and South Africa); and (3) summarized reported experience of task-sharing and paediatric and child health service delivery through a scoping review of research literature in LMICs published between 1990 and 2019 using MEDLINE, Embase, Global Health, PsycINFO, CINAHL and the Cochrane Library. RESULTS We found that while some training opportunities nominally support emerging roles for non-physician clinicians and nurses, formal scopes of practices often remain rather restricted and neither training nor policy seems well aligned with probable needs from high-burden complex and chronic conditions. From 83 studies in 24 LMICs, and aside from the historically shifted conditions, we found some evidence examining task-sharing for a small set of specific conditions (circumcision, some complex surgery, rheumatic heart diseases, epilepsy, mental health). CONCLUSION As child health strategies are further redesigned to address the previously unmet needs careful strategic thinking on the development of an appropriate paediatric workforce is needed. To achieve coverage at scale countries may need to transform their paediatric workforce including possible new roles for non-physician cadres to support safe, accessible and high-quality care.
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Affiliation(s)
- Yingxi Zhao
- Oxford Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, S Parks Rd, Oxford, OX1 3SY, UK.
| | - Christiane Hagel
- Oxford Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, S Parks Rd, Oxford, OX1 3SY, UK
| | - Raymond Tweheyo
- Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda
- Department of Public Health, Lira University, Lira, Uganda
| | - Nathanael Sirili
- Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - David Gathara
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- MARCH Centre, London School of Hygiene and Tropical Medicine, London, UK
| | - Mike English
- Oxford Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, S Parks Rd, Oxford, OX1 3SY, UK
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
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25
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Jacobs Y, Myers B, van der Westhuizen C, Brooke-Sumner C, Sorsdahl K. Task Sharing or Task Dumping: Counsellors Experiences of Delivering a Psychosocial Intervention for Mental Health Problems in South Africa. Community Ment Health J 2021; 57:1082-1093. [PMID: 33161458 PMCID: PMC8217044 DOI: 10.1007/s10597-020-00734-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 10/22/2020] [Indexed: 12/12/2022]
Abstract
Given task-sharing mental health counselling to non-specialist providers is a recognised strategy to increase service capacity, ensuring that their training, supervision, and support needs are met is necessary to facilitate the sustainable delivery of a high-quality service. Using in-depth interviews, we qualitatively explored the experiences of 18 facility-based counsellors (FBCs) tasked with delivering a counselling intervention within chronic disease services offered within primary care facilities participating in the project MIND cluster randomised controlled trial. Findings show that project MIND training with a strong emphasis on role playing and skills rehearsal improved FBCs' confidence and competence, complemented by highly structured supervision and debriefing provided by a registered counsellor, were key strategies for supporting the implementation of task-shared mental health counselling. FBCs perceived many benefits to providing mental health counselling in primary healthcare but systemic interventions are needed for sustained implementation.
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Affiliation(s)
- Y Jacobs
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa.,Alan J. Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - B Myers
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa.,Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - C van der Westhuizen
- Alan J. Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - C Brooke-Sumner
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa.,Alan J. Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - K Sorsdahl
- Alan J. Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa.
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26
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Ng LC, Serba EG, Dubale BW, Fekadu A, Hanlon C. Posttraumatic stress disorder intervention for people with severe mental illness in a low-income country primary care setting: a randomized feasibility trial protocol. Pilot Feasibility Stud 2021; 7:149. [PMID: 34330334 PMCID: PMC8323310 DOI: 10.1186/s40814-021-00883-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 07/09/2021] [Indexed: 11/25/2022] Open
Abstract
Background In this protocol, we outline a mixed-methods randomized feasibility trial of Brief Relaxation, Education and Trauma Healing (BREATHE) Ethiopia. BREATHE Ethiopia is a culturally and contextually adapted intervention for PTSD in participants with severe mental illness. BREATHE Ethiopia maps onto the World Health Organization’s guidelines for posttraumatic stress disorder (PTSD) treatment in low- and middle-income country primary care settings. Methods Specifically, this study includes a non-randomized pre-pilot (n = 5) and a randomized feasibility trial comparing BREATHE Ethiopia to Treatment as Usual (n = 40) to assess trial procedures, acceptability, and feasibility of intervention delivery, and investigate potential effectiveness and implementation. In a process evaluation, we will collect data that will be critical for a future fully randomized controlled trial, including the numbers of participants who are eligible, who consent, who engage in treatment, and who complete the assessments, as well as the feasibility and acceptability of assessments and the intervention. Qualitative data on facilitators and barriers to intervention delivery and quantitative data on provider fidelity to the intervention and participant and provider satisfaction will also be collected. Quantitative assessments at baseline, post-treatment, 1-month follow-up, and 3-month follow-up will assess change in mental health symptoms and functional impairment and hypothesized intervention mechanisms, including knowledge about PTSD, stigma, trauma-related cognitions, and physiological arousal. Discussion Findings from this study will inform a future fully-powered randomized controlled trial, and if found to be effective, the intervention has the potential to be integrated into mental healthcare scale-up efforts in other low-resource settings. Trial registration Registered with ClinicalTrials.gov (NCT04385498) first posted May 13th, 2020; https://www.clinicaltrials.gov/ct2/show/NCT04385498?term=ethiopia&cond=PTSD&draw=2&rank=1. Supplementary Information The online version contains supplementary material available at 10.1186/s40814-021-00883-3.
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Affiliation(s)
- Lauren C Ng
- Department of Psychology, University of California Los Angeles, Los Angeles, CA, USA.
| | - Eyerusalem Getachew Serba
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Benyam W Dubale
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Abebaw Fekadu
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,Department of Global Health & Infection, Brighton and Sussex Medical School, Brighton, UK
| | - Charlotte Hanlon
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.,Department of Psychiatry, WHO Collaborating Centre for Mental Health Research and Capacity-Building, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Sevene E, Boene H, Vidler M, Valá A, Macuacua S, Augusto O, Fernandes Q, Bique C, Macete E, Sidat M, von Dadelszen P, Munguambe K. Feasibility of task-sharing with community health workers for the identification, emergency management and referral of women with pre-eclampsia, in Mozambique. Reprod Health 2021; 18:145. [PMID: 34229709 PMCID: PMC8259411 DOI: 10.1186/s12978-021-01192-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 06/24/2021] [Indexed: 11/21/2022] Open
Abstract
Background Maternal mortality is an important public health problem in low-income countries. Delays in reaching health facilities and insufficient health care professionals call for innovative community-level solutions. There is limited evidence on the role of community health workers in the management of pregnancy complications. This study aimed to describe the feasibility of task-sharing the initial screening and initiation of obstetric emergency care for pre-eclampsia/eclampsia from the primary healthcare providers to community health workers in Mozambique and document healthcare facility preparedness to respond to referrals. Method The study took place in Maputo and Gaza Provinces in southern Mozambique and aimed to inform the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomized controlled trial. This was a mixed-methods study. The quantitative data was collected through self-administered questionnaires completed by community health workers and a health facility survey; this data was analysed using Stata v13. The qualitative data was collected through focus group discussions and in-depth interviews with various community groups, health care providers, and policymakers. All discussions were audio-recorded and transcribed verbatim prior to thematic analysis using QSR NVivo 10. Data collection was complemented by reviewing existing documents regarding maternal health and community health worker policies, guidelines, reports and manuals. Results Community health workers in Mozambique were trained to identify the basic danger signs of pregnancy; however, they have not been trained to manage obstetric emergencies. Furthermore, barriers at health facilities were identified, including lack of equipment, shortage of supervisors, and irregular drug availability. All primary and the majority of secondary-level facilities (57%) do not provide blood transfusions or have surgical capacity, and thus such cases must be referred to the tertiary-level. Although most healthcare facilities (96%) had access to an ambulance for referrals, no transport was available from the community to the healthcare facility. Conclusions This study showed that task-sharing for screening and pre-referral management of pre-eclampsia and eclampsia were deemed feasible and acceptable at the community-level, but an effort should be in place to address challenges at the health system level. Maternal mortality is an important public health problem in Mozambique. Delays in reaching health facilities and insufficient health care professionals call for innovative community-level solutions. We conducted a study to describe the feasibility of task-sharing the screening and initiation of management for pre-eclampsia/eclampsia from the primary healthcare providers to community health workers in Mozambique and to document healthcare facility preparedness to respond to referrals. The study was done to inform a future intervention trial known as the Community-Level Interventions for Pre-eclampsia (CLIP) study. We interviewed community health workers, women, various community groups, health care providers, and policymakers and assessed health facilities in Maputo and Gaza provinces, Mozambique. Our results showed that community health workers in Mozambique were trained to identify the basic danger signs of pregnancy; however, they were not trained or equipped to provide obstetric emergencies care prior to referral. Nurses at primary health facilities were supportive of task-sharing with community health workers; however, some barriers mentioned include a lack of equipment, shortage of supervisors, and irregular drug availability. Local stakeholders emphasized the need for comprehensive training and supervision of community health workers to take on new tasks. Task-sharing for screening and pre-referral management of pre-eclampsia and eclampsia was deemed feasible at the community level in southern Mozambique, but still, to be addressed some health system level barriers to the management of pregnancies complications.
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Affiliation(s)
- Esperança Sevene
- Maternal Health Unit, Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique. .,Department of Physiologic Science, Clinical Pharmacology, Faculty of Medicine, Universidade Eduardo Mondlane, Maputo, Mozambique.
| | - Helena Boene
- Maternal Health Unit, Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, and The Child and Family Research Unit, University of British Columbia, Vancouver, BC, Canada
| | - Anifa Valá
- Maternal Health Unit, Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique
| | - Salésio Macuacua
- Maternal Health Unit, Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique
| | - Orvalho Augusto
- Maternal Health Unit, Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique.,Department of Community Health, Faculty of Medicine,, Universidade Eduardo Mondlane, Maputo, Mozambique
| | | | - Cassimo Bique
- Ministério da Saúde, Maputo, Mozambique.,Hospital Central de Maputo, Maputo, Mozambique
| | - Eusébio Macete
- Maternal Health Unit, Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique.,Ministério da Saúde, Maputo, Mozambique
| | - Mohsin Sidat
- Department of Community Health, Faculty of Medicine,, Universidade Eduardo Mondlane, Maputo, Mozambique
| | | | - Khátia Munguambe
- Maternal Health Unit, Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique.,Department of Community Health, Faculty of Medicine,, Universidade Eduardo Mondlane, Maputo, Mozambique
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Chau LW, Murphy J, Nguyen VC, Lou H, Khanh H, Thu T, Minas H, O'Neil J. Lay social workers implementing a task-sharing approach to managing depression in Vietnam. Int J Ment Health Syst 2021; 15:52. [PMID: 34051848 PMCID: PMC8164490 DOI: 10.1186/s13033-021-00478-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 05/22/2021] [Indexed: 11/05/2022] Open
Abstract
Background While depression is a leading contributor to burden of disease in Vietnam, there is a critical gap in depression care due to the shortage of mental health specialists and extremely limited mental health services in general health care settings. We have previously reported the effectiveness of a supported self-management (SSM) task-sharing intervention for depression, delivered by social collaborators (lay social workers). The purpose of this study was to identify factors influencing the effectiveness of delivery of SSM by social collaborators and delineate areas for further attention that are relevant for scale-up. Methods A hundred and ten (110) key informant interviews were conducted with three stakeholder groups (patients, social collaborators, experts) from eight provinces in Vietnam. Participants were identified through records from a recently completed randomized trial that showed the effectiveness of SSM in community-based settings in Vietnam. Qualitative descriptive methods and thematic analysis were used to examine the interviews. A coding framework and corresponding themes were developed deductively, based on the findings from the randomized trial and the literature, and through inductive analysis, to describe the contextual factors that impacted the social collaborators’ role in successfully implementing the SSM intervention. Results Our analysis identified the following benefits of working with social collaborators: (1) increased awareness of mental health in the family and community; (2) reduced stigma; (3) a better understanding that depression is treatable; (4) increased help-seeking; and (5) improved access to care. There were also significant challenges, including social collaborator characteristics (age, education, pre-existing training and skills) and contextual factors influencing their work (roles and responsibilities, training, compensation, support from government). Conclusions Engaging social collaborators in the delivery of SSM in the community can help fill a critical gap in depression care in Vietnam. However, several contextual challenges that are an impediment to increased engagement and sustainable integration into health and social systems need to be resolved through policy change to regulate their practice, define their scope of work, and provide adequate remuneration.
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Affiliation(s)
- Leena W Chau
- Faculty of Health Sciences, Centre for Applied Research in Mental Health and Addiction, Simon Fraser University, 515 West Hastings Street, Vancouver, BC, V6B 5K3, Canada
| | - Jill Murphy
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Mood Disorders Centre, 2255 Wesbrook Mall, Vancouver, BC, V6T 2A1, Canada
| | - Vu Cong Nguyen
- Institute of Population, Health and Development, 14th level, ICON4 Tower, 3 Cau Giay Street, Hanoi, Vietnam
| | - Hayami Lou
- Faculty of Health Sciences, Centre for Applied Research in Mental Health and Addiction, Simon Fraser University, 515 West Hastings Street, Vancouver, BC, V6B 5K3, Canada
| | - Huyen Khanh
- Institute of Population, Health and Development, 14th level, ICON4 Tower, 3 Cau Giay Street, Hanoi, Vietnam
| | - Trang Thu
- Institute of Population, Health and Development, 14th level, ICON4 Tower, 3 Cau Giay Street, Hanoi, Vietnam
| | - Harry Minas
- Global and Cultural Mental Health Unit, Centre for Mental Health, Melbourne School of Population and Global Health, 207 Bouverie Street, Carlton, VIC, 3053, Australia
| | - John O'Neil
- Faculty of Health Sciences, Centre for Applied Research in Mental Health and Addiction, Simon Fraser University, 515 West Hastings Street, Vancouver, BC, V6B 5K3, Canada.
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van der Westhuizen C, Malan M, Naledi T, Roelofse M, Myers B, Stein DJ, Lahri S, Sorsdahl K. Patient outcomes and experience of a task-shared screening and brief intervention service for problem substance use in South African emergency centres: a mixed methods study. Addict Sci Clin Pract 2021; 16:31. [PMID: 33980314 PMCID: PMC8117325 DOI: 10.1186/s13722-021-00239-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 04/27/2021] [Indexed: 11/17/2022] Open
Abstract
Background Screening, brief intervention and referral to treatment (SBIRT) programmes have resulted in generally positive outcomes in healthcare settings, particularly for problem alcohol use, yet implementation is hampered by barriers such as concerns regarding the burden on healthcare professionals. In low-resourced settings, task-sharing approaches can reduce this burden by using non-professional healthcare workers, yet data are scarce regarding the outcomes and acceptability to patients within a SBIRT service. This study aims to evaluate patient-reported outcomes, patient acceptability, perceived benefits and recommendations for improving a task-shared SBIRT service in South African emergency centres (ECs). Methods This mixed methods study incorporates quantitative substance use screening and patient satisfaction data collected routinely within the service at three hospitals, and qualitative semi-structured interviews with 18 EC patient beneficiaries of the programme exploring acceptability and perceived benefits of the programme, as well as recommendations to improve the service. Approximately three months after the acute EC visit, a sub-sample of patients were followed up telephonically to assess patient-reported satisfaction and substance use outcomes. Results Of the 4847 patients eligible for the brief intervention, 3707 patients (76%) used alcohol as their primary substance and 794 (16%) used cannabis. At follow-up (n = 273), significant reductions in substance use frequency and severity were noted and over 95% of patients were satisfied with the service. In the semi-structured interviews, participants identified the non-judgemental caring approach of the counsellors, and the screening and psychoeducation components of the intervention as being the most valuable, motivating them to decrease substance use and make other positive lifestyle changes. Study participants made recommendations to include group sessions, market the programme in communities and extend the programme’s reach to include a broader age group and a variety of settings. Conclusions This task-shared SBIRT service was found to be acceptable to patients, who reported several benefits of a single SBIRT contact session delivered during an acute EC visit. These findings add to the SBIRT literature by highlighting the role of non-professional healthcare workers in delivering a low-intensity SBIRT service feasible to implement in low-resourced settings.
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Affiliation(s)
- Claire van der Westhuizen
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, 46 Sawkins Road, Rondebosch, Cape Town, 7700, South Africa.
| | - Megan Malan
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, 46 Sawkins Road, Rondebosch, Cape Town, 7700, South Africa
| | - Tracey Naledi
- Public Health Medicine Division, University of Cape Town, Cape Town, South Africa
| | | | - Bronwyn Myers
- Alcohol Tobacco and Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa.,Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Dan J Stein
- Department of Psychiatry and Neuroscience Institute, SA MRC Unit on Risk and Resilience in Mental Disorders, University of Cape Town, Cape Town, South Africa
| | - Sa'ad Lahri
- Department of Emergency Medicine, University of Cape Town, Cape Town, South Africa.,Khayelitsha Hospital Emergency Services, Cape Town, South Africa
| | - Katherine Sorsdahl
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, 46 Sawkins Road, Rondebosch, Cape Town, 7700, South Africa
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Boisits S, Abrahams Z, Schneider M, Honikman S, Kaminer D, Lund C. Developing a task-sharing psychological intervention to treat mild to moderate symptoms of perinatal depression and anxiety in South Africa: a mixed-method formative study. Int J Ment Health Syst 2021; 15:23. [PMID: 33722252 PMCID: PMC7958439 DOI: 10.1186/s13033-021-00443-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 02/16/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Symptoms of depression and anxiety are highly prevalent amongst perinatal women in low-resource settings of South Africa, but there is no access to standardised counselling support for these conditions in public health facilities. The aim of this study is to develop a task-sharing psychological counselling intervention for routine treatment of mild to moderate symptoms of perinatal depression and anxiety in South Africa, as part of the Health Systems Strengthening in sub-Saharan Africa (ASSET) study. METHODS We conducted a review of manuals from seven counselling interventions for depression and anxiety in low- and middle-income countries and two local health system training programmes to gather information on delivery format and common counselling components used across task-sharing interventions. Semi-structured interviews were conducted with 20 health workers and 37 pregnant women from four Midwife Obstetric Units in Cape Town to explore perceptions and needs relating to mental health. Stakeholder engagements further informed the intervention design and appropriate service provider. A four-day pilot training with community-based health workers refined the counselling content and training material. RESULTS The manual review identified problem-solving, psychoeducation, basic counselling skills and behavioural activation as common counselling components across interventions using a variety of delivery formats. The interviews found that participants mostly identified symptoms of depression and anxiety in behavioural terms, and lay health workers and pregnant women demonstrated their understanding through a range of local idioms. Perceived causes of symptoms related to interpersonal conflict and challenging social circumstances. Stakeholder engagements identified a three-session counselling model as most feasible for delivery as part of existing health care practices and community health workers in ward-based outreach teams as the best placed delivery agents. Pilot training of a three-session intervention with community-based health workers resulted in minor adaptations of the counselling assessment method. CONCLUSION Input from health workers and pregnant women is a critical component of adapting existing maternal mental health protocols to the context of routine care in South Africa, providing valuable data to align therapeutic content with contextual needs. Multisector stakeholder engagements is vital to align the intervention design to health system requirements and guidelines.
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Affiliation(s)
- Sonet Boisits
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, 46 Sawkins Road, Rondebosch, Cape Town, 7700, South Africa.
| | - Zulfa Abrahams
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, 46 Sawkins Road, Rondebosch, Cape Town, 7700, South Africa
| | - Marguerite Schneider
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, 46 Sawkins Road, Rondebosch, Cape Town, 7700, South Africa
| | - Simone Honikman
- Perinatal Mental Health Project, Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, 46 Sawkins Road, Rondebosch, Cape Town, 7700, South Africa
| | - Debra Kaminer
- Department of Psychology, University of Cape Town, Rondebosch, Cape Town, 7701, South Africa
| | - Crick Lund
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, 46 Sawkins Road, Rondebosch, Cape Town, 7700, South Africa
- 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, De Crisping Park, London, SE5 8AF, UK
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Petersen I, Fairall L, Zani B, Bhana A, Lombard C, Folb N, Selohilwe O, Georgeu-Pepper D, Petrus R, Mntambo N, Kathree T, Bachmann M, Levitt N, Thornicroft G, Lund C. Effectiveness of a task-sharing collaborative care model for identification and management of depressive symptoms in patients with hypertension attending public sector primary care clinics in South Africa: pragmatic parallel cluster randomised controlled trial. J Affect Disord 2021; 282:112-21. [PMID: 33412490 DOI: 10.1016/j.jad.2020.12.123] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 10/21/2020] [Accepted: 12/24/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND We tested the real-world effectiveness of a collaborative task-sharing model on depressive symptom reduction in hypertensive Primary Health Care (PHC) patients in South Africa. METHOD A pragmatic parallel cluster randomised trial in 20 clinics in the Dr Kenneth Kaunda district, North West province. PHC clinics were stratified by sub-district and randomised in a 1:1 ratio. Control clinics received care as usual (CAU), involving referral to PHC doctors and/or mental health specialists. Intervention clinics received CAU plus enhanced mental health training and a lay counselling referral service. Participant inclusion criteria were ≥ 18 years old, Patient Health Questionnaire-9 (PHQ-9) score ≥ 9 and receiving hypertension medication. Primary superiority outcome was ≥ 50% reduction in PHQ-9 score at 6 months. Statistical analyses comprised mixed effects regression models and a non-inferiority analysis. TRIAL REGISTRATION NUMBER NCT02425124. RESULTS Between April 2015 and October 2015, 1043 participants were enrolled (504 intervention and 539 control); 82% were women; half were ≥ 55 years. At 6 and 12 months follow-up, 91% and 89% of participants were interviewed respectively. One control group participant committed suicide. There was no significant difference in the primary outcome between intervention (N=256/456) and control (N=232/492) groups (55.9% versus 50.9%; adjusted risk difference = -0.04 ([95% CI = -0.19; 0.11], p = 0.6). The difference in PHQ-9 scores was within the defined equivalence limits at 6 and 12 months for the non-inferiority analysis. LIMITATIONS The trial was limited by low exposure to depression treatment by trial participants and by observed co-intervention in control clinics CONCLUSIONS: Incorporating lay counselling services within collaborative care models does not produce superior nor inferior outcomes to models with specialist only counselling services. FUNDING This work was supported by the UK Department for International Development [201446] as well as the National Institute of Mental Health, United States of America, grant number 1R01MH100470-01. Graham Thornicroft is supported by the National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South London at King's College London and King's College Hospital NHS Foundation Trust.
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Gbagbo FY, Morhe ES. Increasing access to intrauterine contraceptive device uptake in Ghana: stakeholders views on task sharing service delivery with community health nurses. Ghana Med J 2021; 54:114-120. [PMID: 33536682 PMCID: PMC7829047 DOI: 10.4314/gmj.v54i2.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Introduction Evidence supporting successful task sharing to increase Intrauterine Contraceptive Device (IUD) uptake exist in some developing countries that have challenges with availability of trained health professionals. Although Community Health Nurses (CHNs) in Ghana are trained to provide primary health care including emergency deliveries in rural communities, they are not professionally mandated to provide IUD services. Objectives To explore stakeholders' views on task sharing IUD services with CHNs in Ghana. Methods This qualitative case study was conducted in Accra, Ghana between June and September 2018. Focus group discussions and in-depth interviews were used to collect data from purposively selected participants. Included in the study were policy makers, policy implementing institutions, service regulators, Non-Governmental Organisations, field providers and service end users. Interviews were recorded and transcribed verbatim. We manually performed thematic analysis of data and findings were appropriately described by paraphrasing and/or quoting relevant responses verbatim. Results There is a general mixed feeling towards task sharing IUD services with community health nurses in Ghana. Policy makers, programmers, gynaecologists and IUD users interviewed believed that CHNs are capable of providing safe IUD services when well trained, adequately resourced and supervised. Based on some field experiences of complications associated with IUD insertions, participants who were midwives clearly indicated the need for effective training and careful implementation strategies. Conclusions Despite concerns about user safety, respondents endorsed task-sharing IUD services with trained CHNs in Ghana. Implementation study focusing on competency-based IUD training for selected CHNs is recommended to provide empirical evidence to back policy decisions. Funding Marie Stopes Ghana funded the field work.
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Affiliation(s)
- Fred Y Gbagbo
- Department of Health Administration, University of Education Winneba, P. O. Box 25. Winneba, Ghana
| | - Emmanuel Sk Morhe
- Depart of Obstetrics and Gynaecology, University of Health and Allied Sciences, PMB 31, Ho, Ghana
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Abstract
Objective To analyze the extent to which task‐sharing to midlevel providers has been implemented as a strategy to increase access to abortion provision in Colombia, and examine the factors that have affected decentralization of services. Methods We conducted a case study based on the World Health Organization's 2015 guideline: Health Worker Roles in Providing Safe Abortion Care and Post‐abortion Contraception. Documentation was collected on the standard and epidemiological landscape of abortion in Colombia, followed by semistructured discussions with groups and individual stakeholders. Results Task‐sharing as a distinct policy to increase access to abortion services has not been implemented in Colombia. However, role distribution toward nonspecialist physicians has been used as a strategy to ensure access. Other professionals, such as nurses, have limited tasks in abortion care despite evidence to support a more expanded role. Conclusion The implementation of task‐sharing as a strategy to increase access to safe abortion services in Colombia is influenced by a wide range of factors and, although it is not policy, nonspecialist and diverse healthcare professionals supervise abortion care. Knowing the evidence‐based guidelines to safely and successfully include other healthcare professionals in abortion provision is a fundamental step in implementing this strategy. Task‐sharing for abortion provision does not exist as policy in Colombia. However, the C‐355 ruling that decriminalized abortion in 2006 paved the way for distribution of tasks to nonspecialist physicians and other healthcare professionals, and the decentralization and simplification of services.
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Schiavon R, Troncoso E. Inequalities in access to and quality of abortion services in Mexico: Can task-sharing be an opportunity to increase legal and safe abortion care? Int J Gynaecol Obstet 2021; 150 Suppl 1:25-33. [PMID: 33219993 DOI: 10.1002/ijgo.13002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
First-trimester abortion became legal in Mexico City in April 2007. Since then, 216 755 abortions have been provided, initially in hospitals, by specialized physicians using surgical techniques. With time and experience, services were provided increasingly in health centers, by general physicians using medical therapies. Meanwhile, abortion remains legally restricted in the remaining 31/32 Mexican states. Demand and need for abortion care have increased throughout the country, while overall abortion-specific mortality rates have declined. In an effort to ensure universal access to and improved quality of reproductive and maternal health services, including abortion, Mexico recently expanded its cadres of health professionals. While initial advances are evident in pregnancy and delivery care, many obstacles and barriers impair the task-sharing/shifting process in abortion care. Efforts to expand the provider base for legal abortion and postabortion care to include midlevel professionals should be pursued by authorities in the new Mexican administration to further reduce abortion mortality and complications.
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Endler M, Cleeve A, Sääv I, Gemzell-Danielsson K. How task-sharing in abortion care became the norm in Sweden: A case study of historic and current determinants and events. Int J Gynaecol Obstet 2021; 150 Suppl 1:34-42. [PMID: 33219992 PMCID: PMC7539959 DOI: 10.1002/ijgo.13003] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We performed a country case study using thematic analysis of interviews and existing grey and published literature to identify facilitators and barriers to the implementation of midwife-provided abortion care in Sweden. Identified facilitating factors were: (1) the historical role and high status of Swedish midwives; (2) Swedish research and development of medical abortion that enabled an enlarged clinical role for midwives; (3) collaborations between individual clinicians and researchers within the professional associations, and the autonomy of clinical units to implement changes in clinical practice; (4) a historic precedent of changes in abortion policy occurring without prior official or legal sanction; (5) a context of liberal abortion laws, secularity, gender equality, public support for abortion, trust in public institutions; and (6) an increasing global interest in task-shifting to increase access and reduce costs. Identified barriers/risks were: (1) the lack of systems for monitoring and evaluation; and (2) a loss of physician competence in abortion care.
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Affiliation(s)
- Margit Endler
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Women's Health Research Unit, University of Cape Town, Cape Town, South Africa
| | - Amanda Cleeve
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Ingrid Sääv
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
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Aborigo RA, Moyer CA, Sekwo E, Kuwolamo I, Kumaga E, Oduro AR, Awoonor-Williams JK. Optimizing task-sharing in abortion care in Ghana: Stakeholder perspectives. Int J Gynaecol Obstet 2021; 150 Suppl 1:17-24. [PMID: 33219998 PMCID: PMC7540373 DOI: 10.1002/ijgo.13000] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Ghana has made progress in expanding providers in abortion care but access to the service is still a challenge. We explored stakeholder perspectives on task‐sharing in abortion care and the opportunities that exist to optimize this strategy in Ghana. We purposively sampled 12 representatives of agencies that played a key role in expanding abortion care to include midwives for key informant interviews. All interviews were audio recorded, transcribed verbatim, and then coded for thematic analysis. Stakeholders indicated that Ghana was motivated to practice task‐sharing in abortion care because unsafe abortion was contributing significantly to maternal mortality. They noted that the Ghana Health Service utilized the high maternal mortality in the country at the time, advancements in medicine, and the lack of clarity in the definition of the term “health practitioner” to work with partner nongovernmental organizations to successfully task‐share abortion care to include midwives. Access, however, is still poor and provider stigma continues to contribute significantly to conscientious objection. This calls for further task‐sharing in abortion care to include medical or physician assistants, community health officers, and pharmacists to ensure that more women have access to abortion care. Midwives are providing abortion care in Ghana through task‐sharing; access is still limited, therefore further expansion to include physician assistants and community health nurses is needed.
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Affiliation(s)
- Raymond A Aborigo
- Navrongo Health Research Centre, Navrongo, Ghana.,The Ghana Health Service, Accra, Ghana
| | | | - Enos Sekwo
- Navrongo Health Research Centre, Navrongo, Ghana
| | - Irene Kuwolamo
- Navrongo Health Research Centre, Navrongo, Ghana.,The Ghana Health Service, Accra, Ghana
| | | | - Abraham R Oduro
- Navrongo Health Research Centre, Navrongo, Ghana.,The Ghana Health Service, Accra, Ghana
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Abstract
Objective To explore the strategies undertaken to decentralize menstrual regulation services and implement task‐sharing, including barriers and facilitators, with nonphysician providers in Bangladesh. Methods We conducted a desk review of relevant policies and health service information from grey and published literature on task‐sharing in menstrual regulation services, plus stakeholder interviews with 19 representatives of relevant health organizations to investigate facilitators for and barriers to the implementation of task‐sharing of these services. Results Task‐sharing in menstrual regulation began in 1979 as part of the national family planning program. The Ministry of Health and Family Welfare has guidelines for menstrual regulation services provided by a wide range of healthcare workers using manual vacuum aspiration and the medications misoprostol and mifepristone. Despite government approval, implementation of task‐sharing is challenging owing to lack of skilled providers, lack of facility readiness, and unmet need for family planning. Conclusion The government needs to implement effective planning for skills building of nonphysician providers and ensuring facility readiness for provision of menstrual regulation services to reduce unsafe abortion in Bangladesh. Task‐sharing in menstrual regulation services is supported by the government in Bangladesh and associated policies and guidelines are available; however, shortage of skilled providers is a barrier.
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Manning V, Ganatra B, Gandhi M, Patil A. Adapting the WHO recommendations on health worker roles for safe abortion to a country setting: A case study from India. Int J Gynaecol Obstet 2021; 150 Suppl 1:55-64. [PMID: 33219994 PMCID: PMC7540050 DOI: 10.1002/ijgo.13001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
In 2015, the World Health Organization (WHO) published a guideline on the role of health workers in providing safe abortion and postabortion contraception, with evidence‐based recommendations on the range of providers who can perform interventions to provide safe abortion, postabortion care, and postabortion contraception. The WHO guideline is global in nature and must be contextualized to individual country settings. The present paper compares the scenario in India, including the legal and policy frameworks, with the WHO guidelines. It provides legal and policy recommendations that are needed to improve access to comprehensive abortion care in India, with a focus on expanding the provider base. The process used to develop these recommendations was a combination of empirical evidence gathering and multistakeholder consultations. An outcome of this exercise was a policy brief entitled “Improving access to comprehensive abortion care in India with focus on expanding provider base,” which is used as an advocacy tool. The process followed by multistakeholders to develop evidence‐based country‐specific recommendations focusing on expanding the provider base using WHO guidelines on the role of health workers to provide comprehensive abortion care.
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Affiliation(s)
| | - Bela Ganatra
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Geneva, Switzerland
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Sorhaindo AM. Creativity, serendipity, and collaboration: Cross-cutting features of successful task-sharing in comprehensive safe abortion care. Int J Gynaecol Obstet 2021; 150 Suppl 1:49-54. [PMID: 33219999 PMCID: PMC7539976 DOI: 10.1002/ijgo.13011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Limited capacity to deliver comprehensive safe abortion care and shortages in trained healthcare providers contribute to a lack of access to safe services. The World Health Organization published guidelines and recommendations on expanding health worker roles through task-sharing as one way to address disparities. A multicountry case study was conducted in six diverse contexts (Bangladesh, Colombia, Ghana, Mexico City in Mexico, Sweden, and Tunisia) to determine the cross-cutting strategies that enabled inclusion of a broader range of healthcare workers in comprehensive safe abortion care. Five strategies emerged: leveraging of favorable contexts, policies, and guidelines; use of evidence for advocacy; building upon existing task-sharing; mitigation of negative responses to abortion and task-sharing; and collaboration across sectors. The findings suggest that there are potential opportunities for stakeholders to employ these strategies in many contexts to broaden health worker roles in comprehensive safe abortion care.
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Affiliation(s)
- Annik M Sorhaindo
- Independent Consultant in Reproductive and Sexual Health, Mexico City, Mexico
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Abstract
Objective To review the relevant literature on abortion and summarize interviews with key stakeholders to assess the role of midwives in the evolution of abortion‐related care in Tunisia. Methods Interviews with eight stakeholders from different organizations based on a guide developed for the study, focusing on policies, strategies used for implementation, capacities used for expansion, user opinions and experience, obstacles and facilitators, and control and evaluation. Results Task‐sharing for midwifes was encouraged in the family planning program from the beginning and when medical abortion was introduced. It allows midwifes to contribute widely, develop good skills and performance for several tasks, and helps reduce regional disparities in human resource allocation. Success and safety of home use of medical abortion confirms the ability of women to manage their own abortion. Yet, obstacles to accessing abortion still exist for several reasons. Conclusion This study, based on interviews with personnel with significant experience and solid knowledge of sexual and reproductive health services, allowed us to consider proposals for a future strategy to integrate task‐sharing into abortion care and address the barriers to legal and safe abortion access for all women in Tunisia. Task‐sharing of abortion care with midwives has a positive impact on quality of services and addresses barriers to accessing abortion in Tunisia.
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Lund C, Schneider M, Garman EC, Davies T, Munodawafa M, Honikman S, Bhana A, Bass J, Bolton P, Dewey M, Joska J, Kagee A, Myer L, Petersen I, Prince M, Stein DJ, Tabana H, Thornicroft G, Tomlinson M, Hanlon C, Alem A, Susser E. Task-sharing of psychological treatment for antenatal depression in Khayelitsha, South Africa: Effects on antenatal and postnatal outcomes in an individual randomised controlled trial. Behav Res Ther 2020; 130:103466. [PMID: 31733813 PMCID: PMC7190434 DOI: 10.1016/j.brat.2019.103466] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 08/16/2019] [Accepted: 09/02/2019] [Indexed: 11/29/2022]
Abstract
The study's objective was to determine the effectiveness of a task-sharing psychological treatment for perinatal depression using non-specialist community health workers. A double-blind individual randomised controlled trial was conducted in two antenatal clinics in the peri-urban settlement of Khayelitsha, Cape Town. Adult pregnant women who scored 13 or above on the Edinburgh Postnatal Depression rating Scale (EPDS) were randomised into the intervention arm (structured six-session psychological treatment) or the control arm (routine antenatal health care and three monthly phone calls). The primary outcome was response on the Hamilton Depression Rating Scale (HDRS) at three months postpartum (minimum 40% score reduction from baseline) among participants who did not experience pregnancy or infant loss (modified intention-to-treat population) (registered on Clinical Trials: NCT01977326). Of 2187 eligible women approached, 425 (19.4%) screened positive on the EPDS and were randomised; 384 were included in the modified intention-to-treat analysis (control: n = 200; intervention: n = 184). There were no significant differences in response on the HDRS at three months postpartum between the intervention and control arm. A task-sharing psychological treatment was not effective in treating depression among women living in Khayelitsha, South Africa. The findings give cause for reflection on the strategy of task-sharing in low-resource settings.
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Affiliation(s)
- Crick Lund
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, South Africa; King's College London, Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, London, UK.
| | - Marguerite Schneider
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, South Africa
| | - Emily C Garman
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, South Africa
| | - Thandi Davies
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, South Africa
| | - Memory Munodawafa
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, South Africa
| | - Simone Honikman
- Perinatal Mental Health Project, Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Arvin Bhana
- Medical Research Council, Durban, South Africa; Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Judith Bass
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA; Center for Humanitarian Health, Departments of International Health and Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Paul Bolton
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA; Center for Humanitarian Health, Departments of International Health and Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Michael Dewey
- King's College London, Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - John Joska
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Ashraf Kagee
- Alan J Flisher Centre for Public Mental Health, Department of Psychology, Stellenbosch University, Stellenbosch, South Africa
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Inge Petersen
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Martin Prince
- King's College London, Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Dan J Stein
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa; MRC Unit on Risk & Resilience in Mental Disorders, Medical Research Council, Cape Town, South Africa
| | - Hanani Tabana
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Graham Thornicroft
- King's College London, Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Mark Tomlinson
- Institute for Life Course Health Research, Department of Global Health, Stellenbosch University, Cape Town, South Africa, And School of Nursing and Midwifery, Queens University, Belfast, UK
| | - Charlotte Hanlon
- King's College London, Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, London, UK; Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia; Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Atalay Alem
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ezra Susser
- Mailman School of Public Health, Columbia University, New York, USA; New York State Psychiatric Institute, New York, USA
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Aifah A, Onakomaiya D, Iwelunmor J, Oladele D, Gbajabiamila T, Obiezu-Umeh C, Nwaozuru U, Musa AZ, Ezechi O, Ogedegbe G. Nurses' perceptions on implementing a task-shifting/sharing strategy for hypertension management in patients with HIV in Nigeria: a group concept mapping study. Implement Sci Commun 2020; 1:58. [PMID: 32885213 DOI: 10.1186/s43058-020-00048-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 06/10/2020] [Indexed: 02/07/2023] Open
Abstract
Background People living with HIV (PWH) in Africa have higher burden of cardiovascular diseases (CVD) compared to the general population, probably due to increased burden of hypertension (HTN). In this study, we explored nurses’ perceptions of factors that may influence the integration of an evidence-based task-shifting/sharing strategy for hypertension control (TASSH) into routine HIV care in Lagos, Nigeria. Methods Using group concept mapping, we examined the perceptions of 22 nurses from HIV clinics in Lagos. Participants responded to a focused prompt on the barriers and facilitators of integrating TASSH into HIV care; next, separate focus groups generated relevant statements on these factors; and statements were then sorted and rated on their importance and feasibility of adoption to create cluster maps of related themes. The statements and cluster maps were categorized according to the Consolidated Framework for Implementation Research (CFIR) domains. Results All study participants were women and with 2 to 16 years’ experience in the provision of HIV care. From the GCM activities, 81 statements were generated and grouped into 12 themes. The most salient statements reflected the need for ongoing training of HIV nurses in HTN management and challenges in adapting TASSH in HIV clinics. A synthesis of the cluster themes using CFIR showed that most clusters reflected intervention characteristics and inner setting domains. The potential challenges to implementing TASSH included limited hypertension knowledge among HIV nurses and the need for on-going supervision on implementing task-shifting/sharing. Conclusions Findings from this study illustrate a variety of opinions regarding the integration of HTN management into HIV care in Nigeria. More importantly, it provides critical, evidence-based support in response to the call to action raised by the 2018 International AIDS Society Conference regarding the need to implement more NCD-HIV integration interventions in low-and middle-income countries through strategies, which enhance human resources. This study provides insight into factors that can facilitate stakeholder engagement in utilizing study results and prioritizing next steps for TASSH integration within HIV care in Nigeria.
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Anger HA, Dabash R, Hassanein N, Darwish E, Ramadan MC, Nawar M, Charles D, Breebaart M, Winikoff B. A cluster-randomized, non-inferiority trial comparing use of misoprostol for universal prophylaxis vs. secondary prevention of postpartum hemorrhage among community level births in Egypt. BMC Pregnancy Childbirth 2020; 20:317. [PMID: 32448257 PMCID: PMC7245883 DOI: 10.1186/s12884-020-03008-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 05/11/2020] [Indexed: 11/10/2022] Open
Abstract
Background Previous community-based research shows that secondary prevention of postpartum hemorrhage (PPH) with misoprostol only given to women with above-average measured blood loss produces similar clinical outcomes compared to routine administration of misoprostol for prevention of PPH. Given the difficulty of routinely measuring blood loss for all deliveries, more operational models of secondary prevention are needed. Methods This cluster-randomized, non-inferiority trial included women giving birth with nurse-midwives at home or in Primary Health Units (PHUs) in rural Egypt. Two PPH management approaches were compared: 1) 600mcg oral misoprostol given to all women after delivery (i.e. primary prevention, current standard of care); 2) 800mcg sublingual misoprostol given only to women with 350-500 ml postpartum blood loss estimated using an underpad (i.e. secondary prevention). The primary outcome was mean change in pre- and post-delivery hemoglobin. Secondary outcomes included hemoglobin ≥2 g/dL and other PPH interventions. Results Misoprostol was administered after delivery to 100% (1555/1555) and 10.7% (117/1099) of women in primary and secondary prevention clusters, respectively. The mean drop in pre- to post-delivery hemoglobin was 0.37 (SD: 0.91) and 0.45 (SD: 0.76) among women in primary and secondary prevention clusters, respectively (difference adjusted for clustering = 0.01, one-sided 95% CI: < 0.27, p = 0.535). There were no statistically significant differences in secondary outcomes, including hemoglobin drop ≥2 g/dL, PPH diagnosis, transfer to higher level, or other interventions. Conclusions Misoprostol for secondary prevention of PPH is comparable to universal prophylaxis and can be implemented using local materials, such as underpads. Trial registration Clinicaltrials.gov NCT02226588, date of registration 27 August 2014.
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Affiliation(s)
- Holly A Anger
- Gynuity Health Projects, 220 E 42nd St, Suite 710, New York, NY, USA.
| | - Rasha Dabash
- Gynuity Health Projects, 220 E 42nd St, Suite 710, New York, NY, USA
| | | | - Emad Darwish
- Faculty of Medicine, Alexandria University, 17 Champollion St, El Messalah, Alexandria, Egypt
| | | | - Medhat Nawar
- El Beheira Governorate, Ministry of Health and Population, Damanhour, Egypt
| | - Dyanna Charles
- Gynuity Health Projects, 220 E 42nd St, Suite 710, New York, NY, USA
| | | | - Beverly Winikoff
- Gynuity Health Projects, 220 E 42nd St, Suite 710, New York, NY, USA
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Robertson FC, Esene IN, Kolias AG, Kamalo P, Fieggen G, Gormley WB, Broekman ML, Park KB. Task-Shifting and Task-Sharing in Neurosurgery: An International Survey of Current Practices in Low- and Middle-Income Countries. World Neurosurg X 2020; 6:100059. [PMID: 32309800 PMCID: PMC7154228 DOI: 10.1016/j.wnsx.2019.100059] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 08/28/2019] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Because nearly 23,000 more neurosurgeons are needed globally to address 5 million essential neurosurgical cases that go untreated each year, there is an increasing interest in task-shifting and task-sharing (TS/S), delegating neurosurgical tasks to nonspecialists, particularly in low- and middle-income countries (LMICs). This global survey aimed to provide a cross-sectional understanding of the prevalence and structure of current neurosurgical TS/S practices in LMICs. METHODS The survey was distributed to a convenience sample of individuals providing neurosurgical care in LMICs with a Web-based survey link via electronic mailing lists of continental societies and various neurosurgical groups, conference announcements, e-mailing lists, and social media platforms. Country-level data were analyzed by descriptive statistics. RESULTS The survey yielded 127 responses from 47 LMICs; 20 countries (42.6%) reported ongoing TS/S. Most TS/S procedures involved emergency interventions, the top 3 being burr holes, craniotomy for hematoma evacuation, and external ventricular drain. Most (65.0%) believed that their Ministry of Health does not endorse TS/S (24.0% unsure), and only 11% believed that TS/S training was structured. There were few opportunities for TS/S providers to continue medical education (11.6%) or maintenance of certification (9.4%, or receive remuneration (4.2%). CONCLUSIONS TS/S is ongoing in many LMICs without substantial structure or oversight, which is concerning for patient safety. These data invite future clinical outcomes studies to assess effectiveness and discussions on policy recommendations such as standardized curricula, certification protocols, specialist oversight, and referral networks to increase the level of TS/S care and to continue to increase the specialist workforce.
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Affiliation(s)
- Faith C. Robertson
- Harvard Medical School, Boston, Massachusetts, USA
- Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ignatius N. Esene
- Neurosurgery Division, Department of Surgery, University of Bamenda, Cameroon
| | - Angelos G. Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Patrick Kamalo
- University of Malawi, College of Medicine, Department of Surgery, Blantyre, Malawi
- Stellenbosch University, Centre for Medical Ethics and Law, Cape Town, South Africa
| | - Graham Fieggen
- Division of Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - William B. Gormley
- Harvard Medical School, Boston, Massachusetts, USA
- Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Neurological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marike L.D. Broekman
- Leiden University Medical Center, Neurosurgery, Leiden, Netherlands
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, Netherlands
| | - Kee B. Park
- Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Murphy JK, Xie H, Nguyen VC, Chau LW, Oanh PT, Nhu TK, O'Neil J, Goldsmith CH, Van Hoi N, Ma Y, Lou H, Jones W, Minas H. Is supported self-management for depression effective for adults in community-based settings in Vietnam?: a modified stepped-wedge cluster randomized controlled trial. Int J Ment Health Syst 2020; 14:8. [PMID: 32071614 PMCID: PMC7014690 DOI: 10.1186/s13033-020-00342-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 02/03/2020] [Indexed: 11/30/2022] Open
Abstract
Background This study tested the effectiveness of a supported self-management (SSM) intervention to reduce symptoms of depression among adults compared with enhanced treatment as usual in community-based and primary care settings in Vietnam. Methods The cluster randomized trial included 376 adults in 32 communes in eight provinces. Eligible participants scored > 7 on the SRQ-20 depression scale. Patients with severe symptoms were excluded and referred to tertiary care. Randomization took place at the commune level. The immediate intervention group included 16 communes with 190 participants and the delayed group included 16 communes with 186 participants. Participants in communes randomized to the immediate intervention group received a two-month course of SSM, consisting of a workbook and supportive coaching. Those in communes randomized to the delayed group received enhanced treatment as usual and, for ethical purposes, received the SSM intervention after 4 months. The primary outcome is the effect of SSM on reduction in depression scores as indicated by a reduced proportion of participants with SRQ-20 scores > 7 at 2 months after commencement of SSM intervention. Blinding was not possible during intervention delivery but outcome assessors were blinded. Analysis was intention-to-treat. Results At 2 months, 26.4% of the intervention group and 42.3% of the delayed group had SRQ-20 scores > 7. The adjusted odds ratio of having depression between the intervention and control was 0.42 (p < 0.0001), 95% CI (0.28, 0.63). Receiving the intervention thus reduces the odds of having depression by 58%, compared with receiving the control after 2 months of treatment. No adverse events were reported. Conclusions Results suggest that SSM is effective for decreasing depression symptoms among adults in community-based settings in Vietnam. Trial Registration This trial is registered at ClinicalTrials.gov, number NCT03001063.
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Affiliation(s)
- Jill K Murphy
- 1Department of Psychiatry, Faculty of Medicine, University of British Columbia, Mood Disorders Centre, 2255 Westbrook Mall, Vancouver, BC V6T 2A1 Canada
| | - Hui Xie
- 2Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, BC V5A 1S6 Canada
| | - Vu Cong Nguyen
- 3Institute of Population, Health and Development, 132/18 Hoa Bang Street, Cau Giay, Hanoi, 122667 Vietnam
| | - Leena W Chau
- 4Centre for Applied Research in Mental Health & Addiction, Faculty of Health Sciences, Simon Fraser University, 515 West Hastings Street, Vancouver, BC V6B 5K3 Canada
| | - Pham Thi Oanh
- 3Institute of Population, Health and Development, 132/18 Hoa Bang Street, Cau Giay, Hanoi, 122667 Vietnam
| | - Tran Kieu Nhu
- 3Institute of Population, Health and Development, 132/18 Hoa Bang Street, Cau Giay, Hanoi, 122667 Vietnam
| | - John O'Neil
- 4Centre for Applied Research in Mental Health & Addiction, Faculty of Health Sciences, Simon Fraser University, 515 West Hastings Street, Vancouver, BC V6B 5K3 Canada
| | - Charles H Goldsmith
- 2Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, BC V5A 1S6 Canada
| | - Nguyen Van Hoi
- 5Ministry of Labour, Invalids and Social Affairs, 12 Ngo Quyen Street, Hoan Kiem District, Ha Noi, 159999 Vietnam
| | - Yue Ma
- 6BC Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6 Canada
| | - Hayami Lou
- 4Centre for Applied Research in Mental Health & Addiction, Faculty of Health Sciences, Simon Fraser University, 515 West Hastings Street, Vancouver, BC V6B 5K3 Canada
| | - Wayne Jones
- 4Centre for Applied Research in Mental Health & Addiction, Faculty of Health Sciences, Simon Fraser University, 515 West Hastings Street, Vancouver, BC V6B 5K3 Canada
| | - Harry Minas
- 7Melbourne School of Population and Global Health, University of Melbourne, 207 Bouverie Street, Carlton, VIC 3053 Australia
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Dorsey S, Gray CL, Wasonga AI, Amanya C, Weiner BJ, Belden CM, Martin P, Meza RD, Weinhold AK, Soi C, Murray LK, Lucid L, Turner EL, Mildon R, Whetten K. Advancing successful implementation of task-shifted mental health care in low-resource settings (BASIC): protocol for a stepped wedge cluster randomized trial. BMC Psychiatry 2020; 20:10. [PMID: 31914959 PMCID: PMC6947833 DOI: 10.1186/s12888-019-2364-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 11/15/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The mental health treatment gap-the difference between those with mental health need and those who receive treatment-is high in low- and middle-income countries. Task-shifting has been used to address the shortage of mental health professionals, with a growing body of research demonstrating the effectiveness of mental health interventions delivered through task-shifting. However, very little research has focused on how to embed, support, and sustain task-shifting in government-funded systems with potential for scale up. The goal of the Building and Sustaining Interventions for Children (BASIC) study is to examine implementation policies and practices that predict adoption, fidelity, and sustainment of a mental health intervention in the education sector via teacher delivery and the health sector via community health volunteer delivery. METHODS BASIC is a Hybrid Type II Implementation-Effectiveness trial. The study design is a stepped wedge, cluster randomized trial involving 7 sequences of 40 schools and 40 communities surrounding the schools. Enrollment consists of 120 teachers, 120 community health volunteers, up to 80 site leaders, and up to 1280 youth and one of their primary guardians. The evidence-based mental health intervention is a locally adapted version of Trauma-focused Cognitive Behavioral Therapy, called Pamoja Tunaweza. Lay counselors are trained and supervised in Pamoja Tunaweza by local trainers who are experienced in delivering the intervention and who participated in a Train-the-Trainer model of skills transfer. After the first sequence completes implementation, in-depth interviews are conducted with initial implementing sites' counselors and leaders. Findings are used to inform delivery of implementation facilitation for subsequent sequences' sites. We use a mixed methods approach including qualitative comparative analysis to identify necessary and sufficient implementation policies and practices that predict 3 implementation outcomes of interest: adoption, fidelity, and sustainment. We also examine child mental health outcomes and cost of the intervention in both the education and health sectors. DISCUSSION The BASIC study will provide knowledge about how implementation of task-shifted mental health care can be supported in government systems that already serve children and adolescents. Knowledge about implementation policies and practices from BASIC can advance the science of implementation in low-resource contexts. TRIAL REGISTRATION Trial Registration: ClinicalTrials.gov Identifier: NCT03243396. Registered 9th August 2017, https://clinicaltrials.gov/ct2/show/NCT03243396.
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Affiliation(s)
- Shannon Dorsey
- Department of Psychology, University of Washington Guthrie Hall 119A, Box 351525, Seattle, WA, 98195, USA.
| | - Christine L Gray
- Center for Health Policy and Inequalities Research, Duke Global Health Institute, Duke University, Campus Box 90392, Durham, NC, 27710, USA
| | | | - Cyrilla Amanya
- Research Department, Ace Africa Kenya, P.O. Box 1185, Bungoma, 50200, Kenya
| | - Bryan J Weiner
- Department of Global Health, University of Washington, Harris Hydraulics Laboratory, 1510 San Juan Road, Seattle, WA, 98195, USA
- Department of Health Services, School of Public Health, University of Washington, Box 357965, Seattle, WA, 98195, USA
| | - C Micha Belden
- Center for Health Policy and Inequalities Research, Duke Global Health Institute, Duke University, Campus Box 90392, Durham, NC, 27710, USA
| | - Prerna Martin
- Department of Psychology, University of Washington Guthrie Hall 119A, Box 351525, Seattle, WA, 98195, USA
| | - Rosemary D Meza
- Department of Psychology, University of Washington Guthrie Hall 119A, Box 351525, Seattle, WA, 98195, USA
| | - Andrew K Weinhold
- Center for Health Policy and Inequalities Research, Duke Global Health Institute, Duke University, Campus Box 90392, Durham, NC, 27710, USA
| | - Caroline Soi
- Department of Global Health, University of Washington, Harris Hydraulics Laboratory, 1510 San Juan Road, Seattle, WA, 98195, USA
| | - Laura K Murray
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, 8th floor, Baltimore, MD, 21205, USA
| | - Leah Lucid
- Department of Psychology, University of Washington Guthrie Hall 119A, Box 351525, Seattle, WA, 98195, USA
| | - Elizabeth L Turner
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Duke University, Durham, NC, 27710, USA
- Duke Global Health Institute, Duke University, Campus Box 90519, Durham, NC, 27708, USA
| | - Robyn Mildon
- Centre for Evidence and Implementation, 33 Lincoln Square South, Carlton, Victoria, 3053, Australia
| | - Kathryn Whetten
- Center for Health Policy and Inequalities Research, Duke Global Health Institute, Duke University, Campus Box 90392, Durham, NC, 27710, USA
- Terry Sanford Institute of Public Policy, Duke University, Box 90239, Durham, NC, 27708, USA
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Robertson FC, Esene IN, Kolias AG, Kamalo P, Fieggen G, Gormley WB, Broekman ML, Park KB. Task-Shifting and Task-Sharing in Neurosurgery: An International Survey of Current Practices in Low- and Middle-Income Countries. World Neurosurg X 2019. [PMID: 32309800 PMCID: PMC7154228 DOI: 10.1016/j.wnsx.2019.100059;] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Because nearly 23,000 more neurosurgeons are needed globally to address 5 million essential neurosurgical cases that go untreated each year, there is an increasing interest in task-shifting and task-sharing (TS/S), delegating neurosurgical tasks to nonspecialists, particularly in low- and middle-income countries (LMICs). This global survey aimed to provide a cross-sectional understanding of the prevalence and structure of current neurosurgical TS/S practices in LMICs. METHODS The survey was distributed to a convenience sample of individuals providing neurosurgical care in LMICs with a Web-based survey link via electronic mailing lists of continental societies and various neurosurgical groups, conference announcements, e-mailing lists, and social media platforms. Country-level data were analyzed by descriptive statistics. RESULTS The survey yielded 127 responses from 47 LMICs; 20 countries (42.6%) reported ongoing TS/S. Most TS/S procedures involved emergency interventions, the top 3 being burr holes, craniotomy for hematoma evacuation, and external ventricular drain. Most (65.0%) believed that their Ministry of Health does not endorse TS/S (24.0% unsure), and only 11% believed that TS/S training was structured. There were few opportunities for TS/S providers to continue medical education (11.6%) or maintenance of certification (9.4%, or receive remuneration (4.2%). CONCLUSIONS TS/S is ongoing in many LMICs without substantial structure or oversight, which is concerning for patient safety. These data invite future clinical outcomes studies to assess effectiveness and discussions on policy recommendations such as standardized curricula, certification protocols, specialist oversight, and referral networks to increase the level of TS/S care and to continue to increase the specialist workforce.
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Affiliation(s)
- Faith C. Robertson
- Harvard Medical School, Boston, Massachusetts, USA,Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts, USA,To whom correspondence should be addressed: Faith C. Robertson, M.D., M.Sc.
| | - Ignatius N. Esene
- Neurosurgery Division, Department of Surgery, University of Bamenda, Cameroon
| | - Angelos G. Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom,NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Patrick Kamalo
- University of Malawi, College of Medicine, Department of Surgery, Blantyre, Malawi,Stellenbosch University, Centre for Medical Ethics and Law, Cape Town, South Africa
| | - Graham Fieggen
- Division of Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - William B. Gormley
- Harvard Medical School, Boston, Massachusetts, USA,Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts, USA,Department of Neurological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marike L.D. Broekman
- Leiden University Medical Center, Neurosurgery, Leiden, Netherlands,Department of Neurosurgery, Haaglanden Medical Center, The Hague, Netherlands
| | - Kee B. Park
- Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Robertson FC, Briones R, Mekary RA, Baticulon RE, Jimenez MA, Leather AJM, Broekman MLD, Park KB, Gormley WB, Lucena LL. Task-Sharing for Emergency Neurosurgery: A Retrospective Cohort Study in the Philippines. World Neurosurg X 2019; 6:100058. [PMID: 32309799 PMCID: PMC7154225 DOI: 10.1016/j.wnsx.2019.100058] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 08/28/2019] [Indexed: 12/18/2022] Open
Abstract
Objective The safety and effectiveness of task-sharing (TS) in neurosurgery, delegating clinical roles to non-neurosurgeons, is not well understood. This study evaluated an ongoing TS model in the Philippines, where neurosurgical workforce deficits are compounded with a large neurotrauma burden. Methods Medical records from emergency neurosurgical admissions to 2 hospitals were reviewed (January 2015-June 2018): Bicol Medical Center (BMC), a government hospital in which emergency neurosurgery is chiefly performed by general surgery residents (TS providers), and Mother Seton Hospital, an adjacent private hospital where neurosurgery consultants are the primary surgeons. Univariable and multivariable linear and logistic regression compared provider-associated outcomes. Results Of 214 emergency neurosurgery operations, TS providers performed 95 and neurosurgeons, 119. TS patients were more often male (88.4% vs. 73.1%; P = 0.007), younger (mean age, 27.6 vs. 50.5 years; P < 0.001), and had experienced road traffic accidents (69.1% vs. 31.4%; P < 0.001). There were no significant differences between Glasgow Coma Scale (GCS) scores on admission. Provider type was not associated with mortality (neurosurgeons, 20.2%; TS, 17.9%; P = 0.68), reoperation, or pneumonia. No significant differences were observed for GCS improvement between admission and discharge or in-hospital GCS improvement, including or excluding inpatient deaths. TS patients had shorter lengths of stay (17.3 days vs. 24.4 days; coefficient, -6.67; 95% confidence interval, -13.01 to -0.34; P < 0.05) and were more likely to undergo tracheostomy (odds ratio, 3.1; 95% confidence interval, 1.30-7.40; P = 0.01). Conclusions This study, one of the first to examine outcomes of neurosurgical TS, shows that a strategic TS model for emergency neurosurgery produces comparable outcomes to the local neurosurgeons.
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Key Words
- BMC, Bicol Medical Center
- CI, Confidence interval
- CT, Computed tomography
- GCS, Glasgow Coma Scale
- Global health
- Global neurosurgery
- HIC, High-income country
- ICU, Intensive care unit
- LMIC
- LMIC, Low- and middle-income country
- MS, Mother Seton Hospital
- Neurotrauma
- OR, Odds ratio
- TBI, Traumatic brain injury
- TS, Task-sharing
- TS/S, Task-shifting and task-sharing
- Task-sharing
- Task-shifting
- Workforce
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Affiliation(s)
- Faith C Robertson
- Harvard Medical School, Boston, Massachusetts, USA.,Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Richard Briones
- Department of Surgery, Bicol Medical Center, Naga City, Philippines
| | - Rania A Mekary
- Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts, USA.,MCPHS University, Department of Pharmaceutical Business and Administrative Sciences, School of Pharmacy, Boston, Massachusetts, USA
| | - Ronnie E Baticulon
- Departments of Anatomy and Neurosciences, University of the Philippines-Philippines General Hospital, Manila, Philippines
| | - Miguel A Jimenez
- Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Andrew J M Leather
- King's Centre for Global Health & Health Partnerships, School of Population Health and Environmental Sciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
| | - Marike L D Broekman
- Leiden University Medical Center, Neurosurgery, Leiden, the Netherlands.,Department of Neurosurgery, Haaglanden Medical Center, The Hague, Netherlands
| | - Kee B Park
- Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - William B Gormley
- Harvard Medical School, Boston, Massachusetts, USA.,Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Neurological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lynne L Lucena
- Department of Surgery, Bicol Medical Center, Naga City, Philippines.,Bicol Regional Teaching and Training Hospital, Legazpi, Bicol, Philippines
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Blum J, Karki C, Tamang A, Shochet T, Shrestha A, Tuladhar H, Karki A, Sharma J, Abbas DF, Dragoman M, Winikoff B. Feasibility of a hospital outpatient day procedure for medication abortion at 13-18 weeks gestation: Findings from Nepal .. Contraception 2019; 100:451-6. [PMID: 31491379 DOI: 10.1016/j.contraception.2019.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 08/21/2019] [Accepted: 08/26/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To evaluate the safety, acceptability and feasibility of a one-day outpatient medication abortion service at gestations 13-18 weeks. STUDY DESIGN Open-label prospective study in which participants received mifepristone 200 mg orally to swallow at home or at the clinic followed 24 h later by misoprostol 400 mcg buccally. They presented to the outpatient clinic 24-48 h after mifepristone for misoprostol 400 mcg buccally every three hours (no maximum dose). The primary outcome was successful abortion without transfer to overnight inpatient care. Secondary outcomes included time to abortion from initial misoprostol dose, safety, additional interventions and side effects. RESULTS We enrolled 230 women from December 2017 to November 2018. Approximately nine of ten (n = 206, 89.6%) achieved a successful abortion without transfer to overnight care. Twenty-four were transferred to overnight inpatient care; of these 18 were to manage a complication, five for incomplete abortion and two by choice. Among these 24, three women experienced an SAE. The median time to successful abortion from time of the first misoprostol dose was 7.2 h (range: 0.75-92.3), with an average of three misoprostol doses. Most participants expelled the fetus and the placenta at or around the same time; median time between fetal and placental expulsion was 15 minutes (range: 0-4.5 h). Fifteen participants (6.6%) received more than five misoprostol doses and were transferred to inpatient care. Administration of more than five doses of misoprostol was associated with nulliparity. Provision of antibiotics (27.9%, n = 64), manual removal of placenta (15.3%, n = 35), uterotonics (4.4%, n = 10) and surgical interventions (4.4%, n = 10) were also reported. About one in four participants experienced nausea, vomiting and chills; fever was infrequent (2.5%, n = 5). CONCLUSIONS For gestations 13-18 weeks, an outpatient day process for medication abortion is safe, effective and feasible. IMPLICATIONS Medication abortion in 13 - 18 weeks need not be limited to inpatient care; nine of ten cases can be managed as an outpatient day service.
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Nandagiri R. "Like a mother-daughter relationship": Community health intermediaries' knowledge of and attitudes to abortion in Karnataka, India. Soc Sci Med 2019; 239:112525. [PMID: 31499333 DOI: 10.1016/j.socscimed.2019.112525] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 08/24/2019] [Accepted: 08/27/2019] [Indexed: 10/26/2022]
Abstract
Community Health Intermediaries (CHIs)- ANMs, ASHAs, and pharmacists- are key to realising task-sharing efforts to increase abortion access in LMICs, but their knowledge of and attitudes to abortion remains underexplored. Evidence on abortion task-sharing has focused primarily on CHIs' technical and clinical abilities, overlooking social contexts and norms that influence attitudes and behaviours. This mixed-methods study describes the abortion knowledge, attitudes, and roles of three cadres of CHIs in rural districts of Karnataka, India. Quantitative data on CHIs' abortion attitudes (n = 118) were collected using the Stigmatising Attitudes, Behaviours, and Actions Scale (SABAS), followed by in-depth interviews (n = 21) with a subset of the population over eight months in 2017. Findings show that CHIs, present at multiple points in women's abortion trajectories, serve as barriers or facilitate access to abortion care. Their abortion attitudes reflect social contexts and environments, drawing on social norms surrounding fertility, woman- and mother-hood. They demonstrate poor knowledge of abortion laws, conflating them with sex-selection laws. CHIs also reflect poor knowledge of abortion methods. They report little to no training on abortion. CHIs contend with entrenched social and structural inequalities in carrying out their tasks, affecting the kind and quality of care they are able to provide. Understanding CHIs' experiences, knowledge and attitudes can advance abortion care-provision, support task-sharing efforts, and potentially improve the quality of women's abortion-seeking experiences.
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Affiliation(s)
- Rishita Nandagiri
- Department of Social Policy, London School of Economics and Political Science, Houghton Street, London, WC2A 2AE, United Kingdom.
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