Text message-based Cessation Intervention for People who Smoked or Used Smokeless Tobacco in India: a Feasibility Randomised Controlled Trial

INTRODUCTION

Despite the high burden of tobacco use in India, users do not have access to adequate help. This pilot trial aimed to evaluate the feasibility and acceptability of a text messaging intervention for tobacco cessation, generate preliminary estimates of its impact, and fine-tune procedures for a definitive trial.

METHODS

Parallel two-arm single blind individually randomised controlled pilot trial with nested qualitative study. Participants included adult current tobacco users (smoked and smokeless). Eligible and consenting participants were randomised to receive either (a) text messaging intervention (ToQuit) which covered specific content areas such as psychoeducation about consequences of tobacco use and benefits of quitting and tobacco avoidance strategies or (b) information about tobacco cessation helplines such as the helpline number and the languages in which tobacco cessation support was available (control). Feasibility data included screening and consent rates, treatment dropouts and outcome ascertainment. The primary abstinence outcome was self-reported abstinence from tobacco in the past seven days at three months post-randomisation. In-depth interviews were conducted with a sub-sample of participants primarily to collect acceptability data. The primary abstinence analysis used a chi-squared test and logistic regression (complete-case), and qualitative data analysed using thematic analysis.

RESULTS

Ninety eight participants were randomised into the two trial arms; 77 (79%) completed outcome evaluation. No between-arm differences in abstinence were found though findings favoured the intervention (7-day abstinence: ToQuit 23%, control 19%; adjusted odds ratio 1.23, 95% confidence interval 0.38, 3.97). Participants appreciated the language, comprehensibility, and relevance of the messages; and reported overall satisfaction with and positive impact from the intervention on their lives.

CONCLUSION

The findings indicate the acceptability and feasibility of ToQuit and if found effective, it could be a potentially scalable first-line response to tobacco use in low resource settings.

IMPLICATIONS

Our pilot RCT provides sufficient findings supporting the acceptability and feasibility of an intervention for tobacco cessation which is suitable for a context which has a shortage of healthcare workers and for individuals who use smoked or smokeless tobacco. This is critical on a background of limited contextually relevant interventions for a problem with a high burden in low- and middle- income countries such as India.

Research, education and capacity building priorities for violence, abuse and mental health in low- and middle-income countries: an international qualitative survey

PURPOSE

Despite the World Health Organization and United Nations recognising violence, abuse and mental health as public health priorities, their intersection is under-studied in low- and middle-income countries (LMICs). International violence, abuse and mental health network (iVAMHN) members recognised the need to identify barriers and priorities to develop this field.

METHODS

Informed by collaborative discussion between iVAMHN members, we conducted a pilot study using an online survey to identify research, education and capacity building priorities for violence, abuse and mental health in LMICs. We analysed free-text responses using thematic analysis.

RESULTS

35 senior (29%) and junior researchers (29%), non-government or voluntary sector staff (18%), health workers (11%), students (11%) and administrators (3%) completed the survey. Respondents worked in 24 LMICs, with 20% working in more than one country. Seventy-four percent of respondents worked in sub-Saharan Africa, 37% in Asia and smaller proportions in Latin America, Eastern Europe and the Middle East. Respondents described training, human resource, funding and sensitivity-related barriers to researching violence, abuse and mental health in LMICs and recommended a range of actions to build capacity, streamline research pathways, increase efficiency and foster collaborations and co-production.

CONCLUSION

The intersection between violence, abuse and mental health in LMICs is a priority for individuals with a range of expertise across health, social care and the voluntary sector. There is interest in and support for building a strong network of parties engaged in research, service evaluation, training and education in this field. Networks like iVAMHN can act as hubs, bringing together diverse stakeholders for collaboration, co-production and mutually beneficial exchange of knowledge and skills.

Alcohol policies in India: A scoping review

Globally, alcohol consumption causes significant societal harm and is a leading risk factor for death and disability in adults. In India, 3.7% of all deaths and 3.1% disability adjusted life years (DALYs) can be attributed to alcohol. In the context of rapid economic development and emphasized by the COVID-19 pandemic, India's lack of a consolidated and comprehensive alcohol policy has posed significant challenges to addressing this harm. In this context, the aim of our review was to undertake a comprehensive mapping of the State and national policy environment surrounding alcohol and its use in India, based on an analysis of policy documents. We did this though a scoping review of academic and grey literature, which helped to iteratively identify the websites of 15 international organizations, 21 Indian non-governmental organizations, and eight Indian Federal governmental organizations as well as State/Union Territory government sites, to search for relevant policy documents. We identified 19 Federal policy documents and 36 State level policy documents within which we have identified the specific policy measures which address the 10 categories of the World Health Organization's Global Action Plan to Reduce the Harmful Use of Alcohol. We found that there are major gaps in regulation of marketing and price controls, with much of this controlled by the States. In addition, regulation of availability of alcohol varies widely throughout the country, which is also a policy area controlled locally by States. Through the clear elucidation of the current policy environment surrounding alcohol in India, policy makers, researchers and advocates can create a clearer roadmap for future reform.

Acceptability and feasibility of assisted telepsychiatry in routine healthcare settings in India: a qualitative study

Technology-enabled interventions are often recommended to overcome geographical barriers to access and inequitable distribution of mental healthcare workers. The aim of this study was to examine the acceptability and feasibility of an assisted telepsychiatry model implemented in primary care settings in India. In-depth interviews were conducted with patients who received telepsychiatry consultations. Data were collected about domains such as experience with communicating with psychiatrists over a video call and feasibility of accessing services. Data were analysed using a thematic analysis approach. Patients recognized that technology enabled them to access treatment and appreciated its contribution to the improvement in their mental health condition. They reported that the telepsychiatry experience was comparable to face-to-face consultations. They had a positive experience of facilitation by counsellors and found treatment delivery in primary care non-stigmatizing. While some adapted easily to the technology platform because of increased access to technology in their daily lives, others struggled to communicate over a screen. For some, availability of care closer to their homes was convenient; for others, even the little travel involved posed a financial burden. In some cases, the internet connectivity was poor and interfered with the video calls. Patients believed that scale could be achieved through adoption of this model by the public sector, collaboration with civil society, enhanced demand generation strategies and leveraging platforms beyond health systems. Assisted telepsychiatry integrated in routine healthcare settings has the potential to make scarce specialist mental health services accessible in low resource settings by overcoming geographical and logistical barriers.

Interventions to increase help-seeking for mental health care in low- and middle-income countries: A systematic review

Mental health problems are a significant and growing cause of morbidity worldwide. Despite the availability of evidence-based interventions, most people experiencing mental health problems remain untreated. This treatment gap is particularly large in low- and middle-income countries (LMIC) and is due to both supply-side and demand-side barriers. The aim of this systematic review is to identify and synthesise the evidence on interventions to improve help-seeking for mental health problems in LMICs. The protocol was registered a priori (Registration number: CRD42021255635). We searched eight databases using terms based on three concepts: 'mental health/illness' AND 'help-seeking' AND 'LMICs'; and included all age groups and mental health problems. Forty-two papers were eligible and included in this review. Intervention components were grouped into three categories following the steps in the help-seeking process: (1) raising mental health awareness among the general population (e.g., distribution of printed or audio-visual materials), (2) identification of individuals experiencing mental health problems (e.g., community-level screening or detection), and (3) promoting help-seeking among people in need of mental health care (e.g., sending reminders). The majority of interventions (80%) included components in a combination of the aforementioned categories. Most studies report positive outcomes, yet results on the effectiveness is mixed, with a clear trend in favour of interventions with components from more than one category. Ten out of 42 studies (24%) yielded a statistically significant effect of the intervention on help-seeking; and all targeted a combination of the aforementioned categories (i.e., raising awareness, identification and help-seeking promotion). Only six studies (14%) focused on children and adolescents. Due to the limited number of robust studies done in LMICs and the heterogeneity of study designs, outcomes and components used, no definite conclusions can be drawn with regards to the effects of individual strategies or content of the interventions.

Experiences of a mobile phone delivered brief intervention for hazardous drinking: A qualitative study nested in the AMBIT trial from Goa, India

Background

This study explores the experiences of participants receiving a mobile-based brief intervention (BI) for hazardous drinking in India, to determine characteristics that influenced engagement and examine perceived reasons for change in alcohol consumption.

Methods

Semi-structured interviews were conducted with 10 adult hazardous drinkers who received a mobile-based BI in the intervention arm of a pilot randomised control trial. Data were coded through an iterative process and analysed using thematic analysis.

Findings

Study participants reported a positive experience, with factors such as customised intervention delivery and personal motivation facilitating their engagement. Participants reported a reduction in quantity and frequency of alcohol use. This was credited to the intervention, particularly, its provision of health-related information, goal-setting content and strategies to manage drinking. Apart from alcohol reduction, participants reported improvements in diet, lifestyle, wellbeing, and familial relations.

Implication

By providing a context to explain the impact of the intervention, the learnings from this study can be used to strengthen the implementation of mobile-based interventions. This study outlines the scope for further research in digital health, such as Internet-based health interventions, and incorporating digital interventions within the ambit of existing health care programmes.

Common strategies in empirically supported psychological interventions for alcohol use disorders: A meta-review

ISSUES

Despite the large number of effective psychological interventions for alcohol use disorders (AUD), there is still a lack of clarity concerning the strategies that make these interventions effective.

APPROACH

The overall goal of this review was to identify, examine and synthesise the information about common strategies from evidence-based psychological interventions for AUDs by conducting a review of systematic reviews, that is, a meta-review. We isolated the relevant primary studies from eligible systematic reviews and extracted information about the interventions from these studies to understand the strategies used. Analysis was restricted to narrative summaries.

KEY FINDINGS

Thirteen reviews were eligible for inclusion in our meta-review. Of these, eight demonstrated the effectiveness of a range of psychological interventions-behavioural couples therapy, cognitive behaviour therapy combined with motivational interviewing, brief interventions, contingency management, psychotherapy plus brief interventions, Alcoholics Anonymous and 12-step treatment programs, family-therapy or family-involved treatment, and community reinforcement approach. The most commonly used component strategies in effective interventions for AUDs included assessment, personalised feedback, motivational interviewing, goal setting, setting and review of homework, problem solving skills and relapse prevention/management.

IMPLICATIONS

Evidence about commonly used strategies in evidence-based psychological interventions for AUDs offer the possibility of creating menu-driven interventions that can be tailored to respond to individual client needs and preferences in different contexts.

Schizophrenia Assessment, Referral and Awareness Training for Health Auxiliaries (SARATHA): Protocol for a Mixed-Methods Pilot Study in Rural India

BACKGROUND

Workforce shortages pose major obstacles to the timely detection and treatment of schizophrenia, particularly in low-income and middle-income countries. The SARATHA (Schizophrenia Assessment, Referral, and Awareness Training for Health Auxiliaries) project involves the systematic development, iterative refinement, and pilot testing of a digital program for training community health workers in the early detection and referral of schizophrenia in primary care settings in rural India.

METHODS

SARATHA is a three-phase study. Phase 1 involves consulting with experts and clinicians, and drawing from existing evidence to inform the development of a curriculum for training community health workers. Phase 2 consists of designing and digitizing the training content for delivery on a smartphone app. Design workshops and focus group discussions will be conducted to seek input from community health workers and service users living with schizophrenia to guide revisions and refinements to the program content. Lastly, Phase 3 entails piloting the training program with a target sample of 20 community health workers to assess feasibility and acceptability. Preliminary effectiveness will be explored, as measured by community health workers' changes in knowledge about schizophrenia and the program content after completing the training.

DISCUSSION

If successful, this digital training program will offer a potentially scalable approach for building capacity of frontline community health workers towards reducing delays in early detection of schizophrenia in primary care settings in rural India. This study can inform efforts to improve treatment outcomes for persons living with schizophrenia in low-resource settings.

Brief interventions for alcohol use disorders in low- and middle-income countries: barriers and potential solutions

Global alcohol consumption and harmful use of alcohol is projected to increase in the coming decades, and most of the increase will occur in low- and middle-income countries (LMICs); which calls for cost-effective measures to reduce alcohol exposure in these countries. One such evidence based measure is screening and brief intervention (BI) for alcohol problems. Some of the characteristics of BI make them a particularly appealing choice of interventions in low-resource settings. However, despite evidence of effectiveness, implementation of BI in LMICs is rare. In this paper we discuss barriers to implementation of BI in LMICs, with examples from Latin America and India. Key barriers to implementation of BI in LMICs are the lack of financial and structural resources. Specialized services for alcohol use disorders are limited or non-existent. Hence primary care is often the only possible alternative to implement BI. However, health professionals in such settings generally lack training to deal with these disorders. In our review of BI research in these countries, we find some promising results, primarily in countries from Latin America, but so far there is limited research on effectiveness. Appropriate evaluation of efficacy and effectiveness of BI is undermined by lack of generalisability and methodological limitations. No systematic and scientific efforts to explore the implementation and evaluation of BI in primary and community platforms of care have been published in India. Innovative strategies need to be deployed to overcome supply side barriers related to specialist manpower shortages in LMICs. There is a growing evidence on the effectiveness of non-specialist health workers, including lay counsellors, in delivering frontline psychological interventions for a range of disorders including alcohol use disorders in LMICs. This paper is intended to stimulate discussion among researchers, practitioners and policy-makers in LMICs because increasing access to evidence based care for alcohol use disorders in LMICs would need a concerted effort from all these stakeholders.

Brief intervention for hazardous drinking delivered using text messaging: a pilot randomised controlled trial from Goa, India

OBJECTIVE

To evaluate the feasibility and acceptability of a mobile-based brief intervention (BI), generate preliminary estimates of the impact of the BI and fine-tune the procedures for a definitive randomised controlled trial.

DESIGN

Parallel three-arm single-blind individually randomised controlled pilot trial. Eligible and consenting participants were randomised to receive mobile-based BI, face-to-face BI and information leaflet.

SETTING

Educational institutions, workplaces and primary care centres.

PARTICIPANTS

Adult hazardous drinkers.

RESULTS

Seventy-four participants were randomised into the three trial arms; forty-eight (64·9 %) completed outcome evaluation. There were no significant differences between the three arms on change in any of the drinking outcomes. There were however in two-way comparisons. Face-to-face BI and mobile BI were superior to active control for percent days heavy drinking at follow-up, and mobile BI was superior to active control for mean grams ethanol consumed per week at follow-up.

CONCLUSION

The encouraging findings about feasibility and preliminary impact warrant a definitive trial of our intervention and if found to be effective, our intervention could be a potentially scalable first-line response to hazardous drinking in low-resource settings.

Video-augmentation of the informed consent process in mental health research: An exploratory study from India

Only around 50-75% of individuals fully understand the various aspects of informed consent in research. The aim of our study was to examine whether supplementing the conventional paper-based informed consent process with an audiovisual aid improves participants' understanding of the informed consent process and the information conveyed to them. Participants from two mental health/substance use intervention development studies were recruited for this study through consecutive sampling. They were then administered the traditional paper information and consenting process by itself or in combination with a video depicting the procedures of the study. Subsequently a bespoke questionnaire was administered to assess the participants' understanding of the information conveyed to them about the parent study. The various domains of the questionnaire were compared between those who were administered the two different consenting processes using the chi square test. 27 (58.7%) participants were administered the traditional consenting process and 19 were administered the video-supplemented consenting process. The video-supplemented consenting process was not superior to the traditional paper-based informed consent process on any of the domains examined. In settings with participants having a limited education, and in research involving people with mental health or substance use problems, further research is necessary to identify contextually relevant best practices for the informed consent process.

"I will not step back": A Qualitative Study of Lay Mental Health Workers' Experiences in India

A significant treatment gap exists for mental illnesses across the world, particularly in low- and middle-income countries (LMICs). Task-sharing, a potentially scalable strategy to bridge the treatment gap, has been shown to be feasible and effective for the treatment of a range of mental illnesses. However, there is a lack of research examining lay mental health workers' experiences in such task-sharing roles. The aim of our study was to understand the barriers and facilitators that lay health workers (LHWs) face in delivering mental healthcare. We conducted in-depth interviews with 32 lay mental health workers recruited through maximum variation sampling and 18 stakeholders leading mental health programs at a variety of non-governmental organisations across India. Interviews were semi-structured and data was analyzed using the thematic analysis approach. Results showed that LHWs perceived barriers and facilitators at three levels: individually (related to personal characteristics and family support, and in their daily work such as in relationship building and supervision), organizationally (for example, related to compensation), and societally (such as encountering gender discrimination and stigma). Each of these areas should be taken into consideration when planning and implementing task-sharing interventions for mental illnesses. As the first qualitative study to explore broad LHW experiences in mental healthcare delivery in a diverse set of programs from a LMIC, this study shows that LHW voices should be central to program design and decision-making for mental health interventions.

Home-detoxification and relapse prevention for alcohol dependence in low resource settings: An exploratory study from Goa, India

Despite the increasing burden of alcohol dependence, treatment resources in low- and middle-income countries such as India are concentrated in poorly accessible tertiary care facilities. The aim of our study was to examine the feasibility and acceptability of lay health worker-delivered home-based packages of care for alcohol dependence. We conducted an uncontrolled treatment cohort with alcohol-dependent adult males recruited in primary and secondary care. Lay health workers delivered home-detoxification and/or relapse prevention counseling. Process data were analyzed using descriptive statistics. Eleven men with alcohol dependence received home detoxification and relapse prevention counseling, and 27 men received only relapse prevention counseling. Of the 11 receiving home detoxification, one participant re-started drinking; all the rest safely completed the home detoxification. During detoxification, the pulse, blood pressure, and temperature remained within the normal range and ataxia, dehydration, disorientation, and sleep normalized over the course of the detoxification. Of the 38 who entered relapse prevention treatment, 15 (39.5%) completed treatment or had a planned discharge. The mean number of sessions was 2.4 (SD = 1.3); those who had a planned discharge received an average of 3.7 (SD 0.5) sessions, and those who dropped out received an average of 1.4 (SD 0.8) sessions. There was no significant change in daily alcohol consumption and percentage days of heavy drinking (PDHD) between baseline and follow-up in the whole cohort. The SIP score reduced significantly in the whole cohort (24.5 vs. 15.0, p = 0.002), and also reduced when segregated by treatment settings, and type of treatment package received. With appropriate adaptations, our intervention warrants further research, as it has the potential to bridge the significant treatment gap for alcohol dependence in low- and middle-income countries.

Auditing the AUDIT: A systematic review of cut-off scores for the Alcohol Use Disorders Identification Test (AUDIT) in low- and middle-income countries

INTRODUCTION

The World Health Organization's (WHO) Alcohol Use Disorders Identification Test (AUDIT) is used extensively across the world, with cut-off scores recommended by the WHO. We reviewed the use and validity of AUDIT cut-off scores in low- and middle-income countries as cultural contexts are expected to influence the detection of alcohol use disorders.

MATERIALS AND METHODS

The systematic review was guided by an a priori defined protocol consistent with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. We searched Cochrane library, Medline, EMBASE, PsycINFO, CINAHL, Indmed, LILACS, and AJOL databases using appropriate search terms. We conducted a narrative synthesis of the data.

RESULTS

We identified 54 distinct studies that used AUDIT cut-off scores which were not in alignment with those recommended by the WHO. India (n = 10), Nigeria (n = 9), and Brazil (n = 9) produced most of these included studies. Most of the studies (n = 42) did not conduct psychometric evaluations of AUDIT cut-off scores. Of the twelve studies which did report psychometric results, a wide range of cut-off scores performed well. In these studies the cut-off scores to detect hazardous drinking ranged from >3 to >5, for harmful drinking from >5 to >16, and for dependent drinking from >7 to >24.

DISCUSSION

AUDIT is being widely used in LMICs and non-recommended cut-off scores are considered to be appropriate in these countries. It is important to systematically evaluate the psychometric properties of those cut-off scores to ensure the internal validity of the studies in which they are used.

The prevalence, patterns, and correlates of gambling behaviours in men: An exploratory study from Goa, India

BACKGROUND

There is a significant evidence gap on gambling in India, where gambling is viewed predominantly through the legal lens. The aim of this study is to determine the prevalence, patterns, and correlates of gambling.

METHODS

Cross-sectional data from the follow-up assessment in a cohort (n = 1514 men) from India. The following data were collected using a structured questionnaire: socio-demographic information, gambling, interpersonal violence, tobacco use, alcohol use disorders (AUD), common mental disorders, and suicidality. Logistic regression models were used to examine the correlates of gambling.

RESULTS

658 participants (45.4%) reported gambling in the past year, and lottery was the most frequent form of gambling (67.8%). Current gambling was correlated with rural residence (OR 1.42, CI 1.05-1.93, p = 0.02), work-related problems (OR 1.42, CI 1.03-1.96, p = 0.03), interpersonal violence (OR 3.45, CI 1.22-9.75, p = 0.02), tobacco use (OR 1.59, CI 1.16-2.19, p = 0.004), and AUD (OR 2.14, CI 1.35-3.41, p = 0.001). 724 (49.9%) participants reported gambling at least once in their lifetime. Lifetime gambling was correlated with work-related problems (OR 1.57, CI 1.14-2.17, p = 0.006), interpersonal violence (OR 4.03, CI 1.32-12.30 p = 0.02), tobacco use (OR 1.60, CI 1.16-2.20, p = 0.004), and AUD (OR 2.12, CI 1.33-3.40, p = 0.002). Age was significantly associated with playing lottery more frequently (OR 3.24, CI 1.34-7.84, p = 0.009) and tobacco use was significantly associated with playing matka more frequently (OR 1.69, CI 1.08-2.64, p = 0.02).

DISCUSSION

The high prevalence of gambling and its association with social problems and risk factors for non-communicable diseases warrants further epidemiological research.

Policy environment impacting the societal harm caused by alcohol in India: protocol for a scoping review

INTRODUCTION

The aim of this review is to provide the first consolidation of the policy environment surrounding alcohol-related societal harm in India giving researchers and policy-makers a clearer base for future reforms. This review is also an important adaptation on the scoping review method for policy reviews in low-resource settings that may serve as an example for other policy reviews in similar settings.

METHODS AND ANALYSIS

We will undertake a scoping review with policy relevant adaptations in order to map the alcohol-related policy environment in India. Following the six-step approach put forward by ArskeyandO'Malley and refined by Levac, we will first undertake an academic scoping search to identify relevant knowledge already existing in the literature about the policy environment in India. We will then use the knowledge that appears in this search iteratively, as is true to the scoping method, to develop a more targeted search of grey literature and Indian government websites for Indian policy documents. These documents will be analysed using qualitative methods to synthesise the current alcohol policy environment in India.

ETHICS AND DISSEMINATION

This study will only use already published information and therefore does not require an ethics review. We will circulate this protocol and the final report to policy researchers in similar settings who could make use of our adaptation of the scoping review method for a low-resource setting. We will also publish our findings in a peer-review journal.

Psychosocial interventions for addiction-affected families in Low and Middle Income Countries: A systematic review

AIM

To review the literature on psychosocial interventions for addiction affected family members in Low and Middle Income Countries (LMIC).

METHODS

A systematic review with a detailed search strategy focussing on psychosocial interventions directed towards people affected by addiction without any gender, year or language specifications was conducted. Identified titles and abstracts were screened; where needed full papers retrieved, and then independently reviewed. Data was extracted based on the aims of the study, to describe the modalities, acceptability, feasibility and effectiveness of the interventions.

RESULTS

Four papers met our selection criteria. They were published between 2003 and 2014; the total sample size was 137 participants, and two studies were from Mexico and one each from Vietnam and Malaysia. The predominantly female participants comprised of parents, spouses and siblings. The common components of all the interventions included providing information regarding addiction, teaching coping skills, and providing support. Though preliminary these small studies suggests a positive effect on affected family members (AFM). There was lowering of psychological and physical distress, along with a better understanding of addictive behaviour. The interventions led to better coping; with improvements in self-esteem and assertive behaviour. The interventions, mostly delivered in group settings, were largely acceptable.

CONCLUSIONS

The limited evidence does suggest positive benefits to AFMs. The scope of research needs to be extended to other addictions, and family members other than spouse and female relatives. Indigenous and locally adapted interventions are needed to address this issue keeping in mind the limited resources of LMIC. This is a field indeed in its infancy and this under recognised and under-served group needs urgent attention of researchers and policy makers.

The onset and progression of alcohol use disorders: A qualitative study from Goa, India

Quantitative evidence about the burden of alcohol use disorders (AUDs) needs to be complemented with a nuanced qualitative understanding of explanatory models to help supplement public health strategies that are too often steeped uncritically in biomedical models. The aim of this study was to identify the role of various factors in the onset and persistence of AUD and recovery from AUD. This was a qualitative study nested in a population cohort from Goa, India. In-depth interviews of men with incident, recovered, and persistent AUD covered topics such as changes in drinking habits over time, perceptions and experiences about starting/stopping drinking, and so on. Data were analyzed using thematic analysis. Reasons to begin drinking included social drinking, functional use of alcohol, stress, and boredom. Progression to problematic drinking patterns was characterized by drinking alone, alternating between abstinent and heavy drinking periods, and drinking based on the availability of finances. Some enablers to reduce/stop drinking included consequences of drinking lifestyle and personal resolve; some barriers included availability of alcohol at social events and stress. Some reasons for persisting heavy use of alcohol included lack of family support, physical withdrawal symptoms, peer pressure, stress, and easy availability. This article offers a strong conceptualization and nuanced understanding of AUD across a spectrum of developmental courses. This adds to the limited literature on explanatory models of AUD in India and identifies potential targets for prevention and treatment strategies for AUD in low- and middle-income country settings.

The management of adult psychiatric emergencies in low-income and middle-income countries: a systematic review

The aim of this Review is to identify effective interventions and treatment guidelines to manage common types of psychiatric emergencies in non-specialist settings in low-income and middle-income countries. Mental health specialist services in low-income and middle-income countries are scarce. We did a systematic review of interventions for psychiatric emergencies and a literature search for low-income and middle-income-specific treatment guidelines for psychiatric emergencies. A dearth of high-quality guidelines and contextualised primary evidence for management of psychiatric emergencies in low-income and middle-income countries exists. Filling these gaps in present guidelines needs to be an urgent research priority in view of the adverse health and social consequences of such presentations and the present drive to scale up mental health care.

"Someone like us": delivering maternal mental health through peers in two South Asian contexts

BACKGROUND

Peer-led psychosocial interventions are one solution to address the great paucity of skilled mental health human resources in South Asia. The aim of this study was to explore peer-delivered care for maternal depression in two diverse contexts in South Asia.

METHODS

The study was carried out in the urban setting of Goa, India and rural setting in Rawalpindi, Pakistan. In total, 61 in-depth interviews (IDIs) and 3 focus group discussions (FGDs), and 38 IDIs and 10 FGDs, were conducted with multiple stakeholders in urban Goa and rural Rawalpindi respectively. We used the framework approach to analyze data.

RESULTS

Peers from the same community were the most preferred delivery agents of a community-based psychosocial intervention in both sites. There were contextual similarities and differences between the two sites. Preferred characteristics among peers included local, middle-aged, educated mothers with similar experiences to participants, good communication skills and a good character. Key differences between the two contexts included a greater emphasis on the peer׳s family social standing in rural Rawalpindi and financial incentives as motivators for individual peers in urban Goa.

LIMITATIONS

Generalizability of our findings is limited to two specific contexts in a vast and diverse region.

DISCUSSION

Our study demonstrates that peers have the potential to deliver maternal psychosocial interventions in low-income settings. There are contextual differences in the preferred characteristics and motivators between the sites, and these should be carefully considered in program implementation.

MAP1D, a novel methionine aminopeptidase family member is overexpressed in colon cancer

N-terminal methionine removal is an important cellular process required for proper biological activity, subcellular localization, and eventual degradation of many proteins. The enzymes that catalyze this reaction are called Methionine Aminopeptidases (MAPs). To date, only two MAP family members, MAP1A and MAP2, have been well characterized and studied in mammals. In our studies, we have cloned a full length MAP1D gene. Expression and purification of full length recombinant protein shows that the sequence encodes an enzyme with MAP activity. MAP1D is overexpressed in colon cancer cell lines and in colon tumors as compared to matched normal tissue samples. Downregulation of MAP1D expression by shRNA in HCT-116 colon carcinoma cells reduces anchorage-independant growth in soft agar. These data suggest that MAP1D is a potentially oncogenic, novel member of the MAP gene family that may play an important role in colon tumorigenesis.

Identification of a novel beta-chemokine, MEC, down-regulated in primary breast tumors

Chemokines represent a family of low molecular weight secreted proteins that primarily function in the activation and migration of leukocytes. A number of additional functions of chemokines have also been identified including growth of tumor cells, angiogenesis and development. An iterative search for new chemokines has identified a cDNA that encodes a new member of the CC(beta) chemokine family. The gene has been named MEC, for mammary enriched chemokine. MEC expression was found at high levels in many mammary gland samples and was also detected at lower levels in several other epithelial-enriched tissues, such as salivary gland, colon, and prostate. Northern blot analysis demonstrates that MEC expression was highly reduced or eliminated in a majority of human breast tumors as compared to normal adjacent tissue. In situ hybridization demonstrates that MEC was abundantly expressed in normal mammary ductal epithelium, but expression was absent or reduced in various mammary tumor types of epithelial origin. These observations suggest that MEC may be useful as a diagnostic tool in oncology, and may play a role in regulating mammary carcinogenesis. The absence of MEC may also contribute to the host's immune response to tumors.

Induction of apoptosis and cell cycle-specific change in expression of p53 in normal lymphocytes and MOLT-4 leukemic cells by nitrogen mustard

DNA damage in the cell activates expression of the p53 tumor suppressor gene, whose role is associated with cell arrest in G1 or apoptosis. The aim of this study was to examine the cell cycle position-related changes in expression of p53, as well as induction of apoptosis, in mitogen-stimulated normal human lymphocytes and in human leukemic MOLT-4 cells (which express mutated p53), following DNA damage by the alkylating agent nitrogen mustard. Measurement of p53 expression and DNA content by flow cytometry followed by bivariate analysis of the data made it possible to correlate the drug-induced changes in p53 expression in individual cells with their cell cycle position without the need for cell synchronization. Expression of p53 was detected immunocytochemically using the AB-6 mAb, which reacts with the product of the wild-type p53 tumor suppressor gene and with most of its mutated forms. Exposure of normal lymphocytes to 5 microM nitrogen mustard caused their arrest in G1, an increase in p53 expression which was maximal in such cells, and significant apoptosis in cells located beyond the arrest point (S and G2 + M cells). In contrast, neither arrest in G1 nor significant apoptosis of MOLT-4 cells was seen after administration of either 0.5 or 5 microM nitrogen mustard for up to 24 h, although the drug reduced the rate of cell progression in the S-phase at both concentrations. Expression of p53 was highest for S and G2 + M MOLT-4 cells in response to the nitrogen mustard. Although a severalfold lower level of p53 was detected in lymphocytes compared to MOLT-4 cells prior to drug treatment, the relative increase in p53 expression in response to the drug was 2-fold higher in lymphocytes. These data suggest that DNA damage caused by nitrogen mustard provides a signal that results in stabilization of wild-type p53, preferentially in G1 cells, causes cell arrest in G1, and induces apoptosis of the cells that either were in the S-phase at the time of drug administration and/or escaped G1 arrest. The increase in expression of mutated p53, in response to DNA damage, is unrelated to the cell cycle position, and neither provides a signal for cell arrest in G1 nor a trigger for immediate apoptosis.

Induction of cell differentiation potentiates apoptosis triggered by prior exposure to DNA-damaging drugs

At the end of their life span, differentiated cells die by apoptosis. Subsets of cells also die, in some cell systems, shortly after exposure to differentiating agents. This suggests that early during differentiation the cells may undergo "priming," during which synthesis and/or activation and accumulation of effectors of apoptosis occurs. The objective of the present study was to test the hypothesis that the signal for apoptosis provided by DNA-damaging drugs given prior to induction of differentiation will be more effective in triggering apoptosis than when given following induction of differentiation. Human promyelocytic HL-60 cells were treated with the topoisomerase I inhibitor camptothecin, the alkylating agent nitrogen mustard, or 5'-azacytidine, an antimetabolite affecting predominantly RNA metabolism. Following drug removal, the cells were postincubated with n-butyrate, which induces differentiation of HL-60 cells along the monocytic pathway, or with all-trans-retinoic acid, which triggers myelocytic differentiation. Multiparameter flow cytometry using two different methods of analysis of apoptosis-associated DNA breakage in situ, as well as evaluation of cell morphology and DNA gel electrophoresis, were used to ascertain the mode of cell death. Increases of 100-200% in the percentage of apoptotic cells were seen when cells were first treated with camptothecin or nitrogen mustard, followed by n-butyrate or retinoic acid, compared to the combined percentage of apoptotic cells when these agents were used individually.(ABSTRACT TRUNCATED AT 250 WORDS)

Induction of apoptosis by 5-azacytidine: drug concentration-dependent differences in cell cycle specificity

There are conflicting data in the literature as to whether cytotoxicity of the cytidine antimetabolite 5'-azacytidine (AZC) is a consequence of its incorporation into RNA, DNA, or both. Because apoptosis appears to be the predominant mode of tumor cell death after treatment with most antitumor drugs, and in the case of some drugs, the proclivity of the cell to undergo apoptosis varies depending on the cell cycle position, this study was aimed toward elucidating whether induction of apoptosis by AZC is cell cycle phase specific. Human promyelocytic leukemic HL-60 cells were treated with varying concentrations of AZC, and flow cytometric methods that identify apoptotic cels and provide information about the cell cycle distribution of the apoptotic and nonapoptotic cell populations were used. At 2-6 microM concentrations of AZC, the cells in the G1 phase preferentially underwent apoptosis, whereas the cells in G2-M were particularly resistant. Although incorporation of bromouridine into RNA was suppressed at that low AZC concentration, the rate of 5'-bromo-2-deoxyuridine incorporation into DNA was not significantly affected. At an AZC concentration of 8-40 microM, no cell cycle phase specificity in induction of apoptosis was apparent, but both the rate of 5'-bromo-2-deoxyuridine incorporation into DNA and bromouridine into RNA were reduced in proportion to drug concentration. The data suggest that the mechanism of cell killing by AZC may be different, depending on its concentration. Namely, whereas incorporation of AZC into RNA may play a predominant role in the induction of cytotoxicity of G1 cells at low drug concentrations, the perturbation of both RNA and DNA metabolism may be responsible for triggering cell death in the G1 and S phases, as is seen at higher concentrations of this antimetabolite.

Expression of cyclins A, D2 and D3 in individual normal mitogen stimulated lymphocytes and in MOLT-4 leukemic cells analyzed by multiparameter flow cytometry

Cyclins are regulatory subunits of the cyclin dependent kinases (CDKs), the enzymes that drive the cell through the respective phases and check-points of the cell cycle. The expression of cyclins in non-tumor cells, regulated by timely induction of their synthesis and proteolysis, is scheduled, occurring at discrete periods of the cell cycle. Using multiparameter flow cytometry we have recently observed that expression of cyclins B1 and E in individual normal lymphocytes mitogenically stimulated by phytohemagglutinin (PHA) and lymphocytic leukemic MOLT-4 cells was similar, restricted to particular phases of the cycle: cyclin B1 was detected only in G2+M- and cyclin E in late G1 and early S-phase cells. In the present study we have measured the expression of cyclins A, D2 and D3 in these cells. The presence of cyclin A was restricted to late S and G2 phases, both in the case of lymphocytes and of MOLT-4 cells. Over 95% of the non-stimulated lymphocytes were both cyclin D2 and D3 negative. Mitogenic stimulation with PHA-induced expression of cyclins D2 and D3 in over 50% cells, which corresponds to the percentage of cells that respond to this mitogen in cultures. Expression of these proteins peaked between 8 and 24 h after addition of PHA, and then decreased at the time of cell entrance to S. During exponential growth (48-72 h after stimulation with PHA) expression of the D-type cyclins was diminished: only between 5-10% of the lymphocytes had levels of cyclin D3 as high as G1 cells between 8-24 h after PHA stimulation. Populations of proliferating lymphocytes and MOLT-4 cells were very heterogeneous in terms of expression of D-type cyclins by individual cells. While expression of cyclin D2 in exponentially growing MOLT-4 cells was similar to that of proliferating lymphocytes, the percent of cells expressing cyclin D3 as well as the degree of expression, was higher in MOLT-4 cells, regardless of the phase of the cycle. These results, with our earlier observations of the untimely expression of cyclins B1 and E in several other tumor lines, suggest that altered expression of cyclins may be a frequent feature of malignancy.