Task sharing in psychotherapy as a viable global mental health approach in resource-poor countries and also in high-resource settings

A multisector community-engaged collaborative for mental health integration in primary care and housing developments: Protocol for a stepped-wedge randomized controlled trial (the Harlem Strong Program)

BACKGROUND

Addressing mental health disparities following COVID-19 requires adaptive, multi-sectoral, equity-focused, and community-based approaches. Mental health task-sharing in gateway settings has been found to address mental health care gaps in low- and middle-income countries, but is not a common practice in the U.S., especially in non-medical settings, such as low-income housing developments (LIH). This research study will evaluate the effectiveness of a multisectoral community-engaged collaborative for task-sharing mental health care on consumer, provider, and implementation outcomes, as well as identify barriers and facilitators for implementation.

METHODS

In this stepped-wedge randomized controlled trial with technology supplementation, LIH and primary care sites will be randomly assigned to one of five sequences of three implementation strategies: (1) Education and Resources (E&R), which involves online training and resources on basic mental health task-sharing skills, (2) Multisectoral Community Collaborative Care (MCC), which consists of all E&R resources plus additional community responsive implementation supports and participation in a multisectoral coalition and (3) MCC + Technology, which combines the MCC condition resources with a community crowdsourced technology solution to support implementation. The primary outcome is the effectiveness in meeting consumers' needs through direct service (e.g., adequately addressing depression and anxiety symptoms), and through implementation to increase access to mental health care (reach). The secondary outcome examines additional consumer outcomes including health functioning and social risks, as well as implementation outcomes including provider skills, program adoption, and factors related to barriers and facilitators of quality implementation. A total of 700 consumers receiving mental health care at 20 sites will be surveyed at baseline, 6-, and 12-month follow-ups. Additionally, 100 providers will be evaluated at baseline, 6-, 12-, and 24-month follow-ups before training and after randomization.

DISCUSSION

We hypothesize that MCC and MCC + Technology conditions will demonstrate significantly higher efficacy in changing primary outcomes compared to E&R, and the MCC + Technology supplement will show significantly higher levels of reach of mental health tasks compared to the MCC condition alone. These findings will demonstrate the feasibility of mental health integration into accessible, non-medical community settings such as LIH. Moreover, it will help establish a multilevel system solution based on community engagement and planning with a multisectoral collaboration that can be sustained community-wide.

TRIAL REGISTRATION

NCT05833555 on Clinicaltrials.gov. Registered April 26, 2023.

Policy Recommendations for Coordinated and Sustainable Growth of the Behavioral Health Workforce

Policy Points Demand for behavioral health services outpaces the capacity of the existing workforce, and the unmet need for behavioral health services is expected to grow. This paper summarizes research and policy evidence demonstrating that the long-standing challenges that impede behavioral health workforce development and retention (i.e., low wages, high workloads, training gaps) are being replicated by growing efforts to expand the workforce through task-sharing delivery to nonspecialist behavioral health providers (e.g., peer specialists, promotores de salud). In this paper, we describe policy opportunities to sustain behavioral health workforce growth to meet demand while supporting fair wages, labor protections, and rigorous training.

A Pilot Study of the Coping Together Virtual Family Intervention: Exploring Changes in Family Functioning and Individual Well-Being

In this pilot study, we tested a virtual family strengthening and mental health promotion intervention, Coping Together (CT), during the COVID-19 pandemic. We explored changes at the family and individual levels, as well as mechanisms of change. Participants included 18 families (24 caregivers, 24 youth) with children aged 7 to 18 years. Community health workers delivered the 8-session CT intervention using videoconferencing software. We used qualitative semi-structured interviews with 14 of the families to explore changes and mechanisms of change using a thematic content analysis approach. We also administered pre-post surveys with the 18 families to explore the direction of changes, using only descriptive statistics in this small sample. Qualitative findings supported positive changes across family and individual level outcomes including family functioning, relationship quality, and individual psychosocial well-being. Results also confirmed several hypothesized mechanisms of change with improved communication providing the foundation for increased hope and improved problem solving and coping. Pre-post survey results were mixed, showing positive, but very small, changes in family closeness, caregiver-child communication, and levels of hope; almost no change was observed on measures of caregiver and child mental health. Families reported few problems at baseline quantitatively despite qualitative descriptions of pre-intervention difficulties. Results provide preliminary support for benefits of CT with the most consistent improvements seen across family relationships. Findings were mixed related to individual-level mental health benefits. Results have implications for revising content on mental health coping strategies and suggest the need to revise the quantitative measurement strategy for this non-clinical sample.

What works for whom and why? Treatment effects and their moderators among forcibly displaced people receiving psychological and psychosocial interventions: study protocol for an individual patient data meta-analysis

INTRODUCTION

Forcibly displaced people (FDP) have a high risk of developing mental disorders such as post-traumatic stress (PTS) disorder. Providing adequate mental healthcare for FDP is crucial but despite overall efficacy of many existing interventions, a large proportion of FDP does not benefit from treatment, highlighting the necessity of further investigating factors contributing to individual differences in treatment outcome. Yet, the few studies that have explored moderators of treatment effects are often insufficiently powered. Therefore, the present Individual Patient Data meta-analysis (IPD-MA) will investigate treatment effects and their moderators-variables related to beneficiaries, providers, intervention and study characteristics in relation to PTS outcomes.

METHODS AND ANALYSIS

A systematic literature search will be conducted from database inception in the databases PsycINFO, Cochrane, Embase, PTSDpubs and Web of Science. Only studies published in English, German, French, Spanish, Portuguese, and Dutch will be considered. Retrieved records will be screened for eligibility. Randomised controlled trials on adult FDP receiving psychological and psychosocial interventions aimed at alleviating symptoms such as PTS compared with a control condition without intervention will be included in this IPD-MA. Subsequently, authors of eligible studies will be contacted to request individual patient data (IPD). All datasets obtained will be synthesised into one large dataset which will be analysed using a one-stage approach by conducting mixed-effects linear regression models (ie, primary analysis). Additionally, aggregate data meta-analyes will be run using a two-stage approach by conducting multivariate regression models including all IPD (transformed) and available meta-data from study reports (ie, secondary analysis). PTS will serve as primary outcome measure, while mental health outcomes other than PTS, attendance, attrition, treatment non-response and adverse outcomes will be examined as secondary outcomes.

ETHICS AND DISSEMINATION

This IPD-MA does not require ethical approval. The results will be published in international peer-reviewed journals.

PROSPERO REGISTRATION NUMBER

CRD42022299510.

Healthcare and community stakeholders' perceptions of barriers and facilitators to implementing a behavioral activation intervention for people with dementia and depression: a qualitative study using Normalization Process Theory

BACKGROUND

Depression is commonly experienced by people with dementia, and associated with lower quality of life and functional decline. However, access to evidence-based psychological interventions for people with dementia and depression is limited. One potential solution is guided low-intensity behavioral activation. Following the new Medical Research Council Framework, considering factors such as potential barriers and facilitators to implementation is recommended during the development of new interventions. Aims of this study were to: (1) develop an understanding of existing healthcare and community support in the Swedish context for people with dementia and their informal caregivers; and (2) identify barriers and facilitators to intervention uptake informed by Normalization Process Theory.

METHODS

Semi-structured interviews and focus groups were held with healthcare (n = 18) and community (n = 7) stakeholders working with people with dementia and/or informal caregivers. Interview questions were informed by Normalization Process Theory. Data was analysed utilizing a two-step deductive analysis approach using the Normalization Process Theory coding manual, with inductive categories applied to data related to the main mechanisms of the theory, but not captured by its sub-constructs.

RESULTS

Twelve deductive and three inductive categories related to three Normalization Process Theory primary mechanisms (Coherence, Cognitive Participation, and Collective Action) were identified. Identified barriers to intervention uptake included: (1) additional burden for informal caregivers; (2) lack of appropriate workforce to provide guidance; (3) lack of time and financial resources; (4) people with dementia not recognising their diagnosis of dementia and/or a need for support; and (5) stigma. Identified facilitators to intervention uptake included: (1) intervention has potential to fill a large psychological treatment gap in Sweden; (2) objectives and potential benefits understood and agreed by most stakeholders; and (3) some healthcare professionals recognized their potential role in providing intervention guidance.

CONCLUSIONS

Several barriers and facilitators for future implementation, specific to the intervention, individuals and families, as well as professionals, were identified during intervention development. Barriers were mapped into evidence-based implementation strategies, which will be adopted to overcome identified barriers. A feasibility study further examining implementation potential, acceptability and feasibility, alongside clinical, methodological, and procedural uncertainties associated with the intervention will be conducted.

TRIAL REGISTRATION

Not applicable.

Global health reciprocal innovation to address mental health and well-being: strategies used and lessons learnt

Over the past two decades there have been major advances in the development of interventions promoting mental health and well-being in low- and middle-income countries (LMIC), including delivery of care by non-specialist providers, incorporation of mobile technologies and development of multilevel community-based interventions. Growing inequities in mental health have led to calls to adopt similar strategies in high-income countries (HIC), learning from LMIC. To overcome shared challenges, it is crucial for projects implementing these strategies in different global settings to learn from one another. Our objective was to examine cases in which mental health and well-being interventions originating in or conceived for LMIC were implemented in the USA. The cases included delivery of psychological interventions by non-specialists, HIV-related stigma reduction programmes, substance use mitigation strategies and interventions to promote parenting skills and family functioning. We summarise commonly used strategies, barriers, benefits and lessons learnt for the transfer of these innovative practices among LMIC and HIC. Common strategies included intervention delivery by non-specialists and use of digital modalities to facilitate training and increase reach. Common barriers included lack of reimbursement mechanisms for care delivered by non-specialists and resistance from professional societies. Despite US investigators' involvement in most of the original research in LMIC, only a few cases directly involved LMIC researchers in US implementation. In order to achieve greater equity in global mental health and well-being, more efforts and targeted funding are needed to develop best practices for global health reciprocal innovation and iterative learning in HIC and LMIC.

Scale-up costs and societal benefits of psychological interventions for alcohol use and depressive disorders in India

There is growing evidence for cost-effective psychological interventions by lay health workers for managing mental health problems. In India, Counseling for Alcohol Problems (CAP) and Healthy Activity Program (HAP) have been shown to have sustained cost-effectiveness for improving harmful alcohol use among males and depression remission among both sexes, respectively. We conducted a retrospective analysis of annual costs and economic benefits of CAP and HAP national scale-up with 2019 as the baseline. The CAP and HAP per capita integration costs were obtained from original studies, prevalence and disability-adjusted life-years for alcohol use disorders (AUD) and depressive disorders for 20-64 years old males and females from Global Burden of Disease study, and treatment gaps from National Mental Health Survey. We calculated three outcomes: 1) Programmatic scale-up costs for covering total or unmet needs. 2) Societal benefits from averted disease burden using human capital and value of life-year approaches. 3) Combinations of net benefits as differences between societal benefits and scale-up costs. Values were transformed to 2019 international dollars. CAP scale-up costs ranged from Int$ 2.03 (95%UI: 1.67, 2.44) billion to Int$ 6.34 (5.21, 7.61) billion while HAP ones ranged from Int$ 6.85 (5.61, 8.12) billion to Int$ 23.21 (19.03, 27.52) billion. Societal benefits due to averted AUD burden ranged from Int$ 11.51 (8.75, 14.90) billion to Int$ 38.73 (29.43, 50.11) billion and those due to averted depression burden ranged from Int$ 30.89 (20.77, 43.32) billion to Int$ 105.27 (70.78, 147.61) billion. All scenarios showed net positive benefits for CAP (Int$ 6.05-36.38 billion) and HAP (Int$ 11.12-93.50 billion) scale-up. The novel national-level scale-up estimates have actionable implications for mental health financing in India.

Sport and physical exercise in sustainable mental health care of common mental disorders: Lessons from the COVID-19 pandemic

The large-scale disruptions to physical activity during the coronavirus pandemic have been found to be a leading predictor of common mental disorders. In addition, regular physical exercise has been found to alleviate anxiety, sadness and depression during the pandemic. These findings, together with numerous studies published before the pandemic on the effects of physical activity on mental health, should be considered in the provision of mental health care following the pandemic. Cross-sectional research has revealed that all types of exercise and sport are associated with a reduced mental health burden. Therefore, the effectiveness of exercise and sport participation in sustainable mental health care as well as the causal relationship between exercise, psychosocial health and common mental disorders merit further investigation. Physical activity and sport, with their global accessibility, significant and clinically meaningful efficacy as well as virtual absence of adverse effects, offer a promising option for the promotion of mental health, including the prevention and treatment of common mental disorders. Physical exercise and sport are likely to become valuable public mental health resources in the future.

Addition of mental health to the lady health worker curriculum in Pakistan: now or never

The technical advisory group of the World Health Organization (Geneva, Switzerland) has suggested person-centered and community-based mental health services in response to the long-term and far-reaching mental health impacts of the COVID-19 pandemic. Task shifting is a pragmatic approach to tackle the mental health treatment gap in low- and middle-income countries. Pakistan is dismally resourced to address the mental health challenges. Pakistan's government has established a lady health worker's program (LHW-P) which can be effectively utilized to provide some basic mental health services at community doorsteps. However, lady health workers' current curriculum does not include mental health as a subject. WHO's Mental Health Gap Intervention Guide (mhGAP-IG) Version 2.0 for mental, neurological, and substance use disorders in non-specialist health settings can be adapted and utilized to be included as part of the LHW-P curriculum in Pakistan. Thus, the historical lack of access to mental health support workers, counsellors, and specialists can be addressed. Additionally, this will also help to reduce the stigma associated with seeking mental health care outside the boundaries of home, mostly at a huge cost.

The Role of Latina Peer Mentors in the Implementation of the Alma Program for Women With Perinatal Depression

This study examines the role that compañeras (peer mentors) play in the implementation of a program, Alma, which was designed to support Latina mothers who are experiencing depression during pregnancy or early parenting and implemented in the rural mountain West of the United States. Drawing from the fields of dissemination and implementation and Latina mujerista (feminist) scholarship, this ethnographic analysis demonstrates how the Alma compañeras facilitate the delivery of Alma by creating and inhabiting intimate mujerista spaces with other mothers and create relationships of mutual and collective healing in the context of relationships de confianza (of trust and confidence). We argue that these Latina women, in their capacity as compañeras, draw upon their cultural funds of knowledge to bring Alma to life in ways that prioritizes flexibility and responsiveness to the community. Shedding light on contextualized processes by which Latina women facilitate the implementation of Alma illustrates how the task-sharing model is well suited to the delivery of mental health services for Latina immigrant mothers and how lay mental health providers can be agents of healing.

Decentralisation and community stakeholders’ engagement for better mental health services development in the conflict-affected regions of Ukraine

Purpose

The purpose of this paper is to explore how conflict-affected communities in Ukraine (the Lugansk region) can develop sustainable mental health services in decentralised settings. The main interest focuses on community stakeholders’ perception of their problems and solutions that communities can create to achieve better mental health coverage.

Design/methodology/approach

A series of roundtables (RTs) (4 RTs, 62 participants overall), accompanied by interactive brainstorming techniques, were conducted with communities’ representatives/stakeholders from the East of Ukraine (Lugansk region, a government-controlled area) during the year 2021. Participants (health, mental health, social care workers and administration representatives) were provided with the opportunity to discuss mental health services’ development challenges and create affordable solutions for their communities. Results of discussions were submitted to qualitative analysis and offered for review by participants.

Findings

Decentralisation in Ukraine led to allocating funds alongside responsibilities for developing the services to communities. Most of the communities appear not to be ready to acknowledge the role of mental health services, entirely relying on the existing weak psychiatric hospital-based system. Awareness-raising interactive capacity-building activities for the community leaders and decision-makers effectively promote community-based mental health services development. Five clusters of challenges were identified: leadership, coordination and collaboration problems; infrastructure, physical accessibility and financial problems; mental health and primary health-care workforce shortage and lack of competencies; low awareness of mental health and available services and high stigma; war, crises and pandemic-related problems. Communities stakeholders foresaw seven domains of action: increasing the role of communities and service users in the initiatives of governmental bodies; establishing in the communities local coordination/working groups dedicated to mental health service development; developing the community-based spaces (hubs) for integrated services provision; embedding the mental health services in the existing services (social, administrative and health care); mental health advocacy and lobbying led by local leaders and service users; increasing capacity of communities in financial management, fundraising; developing services by combining efforts and budgets of neighbouring communities.

Research limitations/implications

The study has potential limitations. Participants of the roundtables were mostly appointed by local authorities, so some of them didn`t have a motivation for mental health services development. Service users were involved only from the facilitators` side, not from the side of communities; therefore, it was impossible to include their view of problems and solutions. Obtained data were limited to the opinion of local professionals, administration workers and other local stakeholders. The human rights aspect was not clearly articulated in the tasks of the roundtables.

Originality/value

To the best of the authors’ knowledge, the paper is original in terms of its topic (connecting decentralisation and local stakeholders’ engagement for understanding the challenges of mental health services development) and research strategy (engagement of Ukrainian communities, qualitative analysis of the discussion results and applying the best practices and international recommendations to the local context).

Causes of Missed Nursing Care During COVID-19 Pandemic: A Qualitative Study in Iran

Background

The unpredictable and variable nature of COVID-19 and the lack of healthcare resources has led to inadequate care for patients. This study aimed to explain the causes of missed nursing care during the COVID-19 pandemic from the perspective of Iranian nurses.

Method

This qualitative study was conducted using semi-structured interviews with 14 nurses caring for patients with COVID-19 in three hospitals in Iran. Sampling was performed by the purposive method. Data were analyzed using the conventional content analysis method. The interviews were first recorded and transcribed, and then the data were analyzed using the Elo and Kyngas method. Data management was done with MAXQDA software version 10. To achieve trustworthiness, the criteria presented by Lincoln and Guba were used.

Findings

A total of 14 nurses participated in the study. The mean age of participants was 31.85 ± 4.95 years, and the mean number of years of work experience was 7.71 ± 4.44. Eleven participants were women. Among all participants, nine had a bachelor's degree and five had a master's degree. Four nurses had fixed shifts, while ten nurses had rotating shifts. The causes of missed nursing care were categorized into 4 groups. The category “unfulfilled care” comprised the reasons for forgetting care, neglecting care, arbitrary elimination of care, and compulsory elimination of care. The category of “care at improper time” consisted of interference of the care in patients' daily activities and interference with other healthcare providers' activities. The “incomplete cares” category comprised failure to complete the care period in hospital, interruption in care, and discontinuance of care after patient discharge. The last category, “incorrect care,” consisted of providing care regardless of the nursing process, providing care by unqualified professionals, and providing trial-and-error care.

Conclusion

This study illustrates an understanding of the causes of missed nursing care during the COVID-19 pandemic from the perspective of nurses. The increasing demand for care caused by the pandemic and problems in the work environment has led to the failure of nurses to provide complete, correct care and sometimes miss parts of care to patients. Therefore, nursing policymakers and managers should develop and implement appropriate care protocols and instructions to minimize missed nursing care.

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

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.

A qualitative analysis of collaborative efforts to build a school-based intervention for multiple common adolescent mental health difficulties in India

INTRODUCTION

In low- and middle-income countries (LMICs), the gap between need for mental health (MH) treatment and access to services is stark, particularly among children and adolescents. In service of addressing this treatment gap, the current study provides an in-depth illustration of later-stage collaborative design of a school-based, transdiagnostic MH intervention in New Delhi and Goa, India, using a combination of contextual insights from local stakeholders and knowledge derived from the global evidence base.

METHODS

Using an inductive-deductive approach to qualitative thematic analysis, we examined coded data from qualitative sources related to experiences of developing and implementing an intervention prototype. These sources included notes from meetings attended by treatment development team members and providers, written feedback on protocol materials (e.g., provider manual, student handouts), field notes reflecting researcher observations, and minutes from weekly clinical supervision meetings.

RESULTS

Results revealed that codes involving cultural/contextual considerations, protocol material and content, and intervention complexity arose consistently throughout treatment development and across document types, illustrating their central role in finalizing protocol design.

DISCUSSION

These findings have implications for the future of mental health treatment development and implementation globally.