The impact of a lay counselor led collaborative care intervention for common mental disorders in public and private primary care: a qualitative evaluation nested in the MANAS trial in Goa, India

Collaborative care approaches for people with severe mental illness

BACKGROUND

Collaborative care for severe mental illness (SMI) is a community-based intervention that promotes interdisciplinary working across primary and secondary care. Collaborative care interventions aim to improve the physical and/or mental health care of individuals with SMI. This is an update of a 2013 Cochrane review, based on new searches of the literature, which includes an additional seven studies.

OBJECTIVES

To assess the effectiveness of collaborative care approaches in comparison with standard care (or other non-collaborative care interventions) for people with diagnoses of SMI who are living in the community.

SEARCH METHODS

We searched the Cochrane Schizophrenia Study-Based Register of Trials (10 February 2021). We searched the Cochrane Common Mental Disorders (CCMD) controlled trials register (all available years to 6 June 2016). Subsequent searches on Ovid MEDLINE, Embase and PsycINFO together with the Cochrane Central Register of Controlled Trials (with an overlap) were run on 17 December 2021.

SELECTION CRITERIA

Randomised controlled trials (RCTs) where interventions described as 'collaborative care' were compared with 'standard care' for adults (18+ years) living in the community with a diagnosis of SMI. SMI was defined as schizophrenia, other types of schizophrenia-like psychosis or bipolar affective disorder. The primary outcomes of interest were: quality of life, mental state and psychiatric admissions at 12 months follow-up.

DATA COLLECTION AND ANALYSIS

Pairs of authors independently extracted data. We assessed the quality and certainty of the evidence using RoB 2 (for the primary outcomes) and GRADE. We compared treatment effects between collaborative care and standard care. We divided outcomes into short-term (up to six months), medium-term (seven to 12 months) and long-term (over 12 months). For dichotomous data we calculated the risk ratio (RR) and for continuous data we calculated the standardised mean difference (SMD), with 95% confidence intervals (CIs). We used random-effects meta-analyses due to substantial levels of heterogeneity across trials. We created a summary of findings table using GRADEpro.

MAIN RESULTS

Eight RCTs (1165 participants) are included in this review. Two met the criteria for type A collaborative care (intervention comprised of the four core components). The remaining six met the criteria for type B (described as collaborative care by the trialists, but not comprised of the four core components). The composition and purpose of the interventions varied across studies. For most outcomes there was low- or very low-certainty evidence. We found three studies that assessed the quality of life of participants at 12 months. Quality of life was measured using the SF-12 and the WHOQOL-BREF and the mean endpoint mental health component scores were reported at 12 months. Very low-certainty evidence did not show a difference in quality of life (mental health domain) between collaborative care and standard care in the medium term (at 12 months) (SMD 0.03, 95% CI -0.26 to 0.32; 3 RCTs, 227 participants). Very low-certainty evidence did not show a difference in quality of life (physical health domain) between collaborative care and standard care in the medium term (at 12 months) (SMD 0.08, 95% CI -0.18 to 0.33; 3 RCTs, 237 participants). Furthermore, in the medium term (at 12 months) low-certainty evidence did not show a difference between collaborative care and standard care in mental state (binary) (RR 0.99, 95% CI 0.77 to 1.28; 1 RCT, 253 participants) or in the risk of being admitted to a psychiatric hospital at 12 months (RR 5.15, 95% CI 0.67 to 39.57; 1 RCT, 253 participants). One study indicated an improvement in disability (proxy for social functioning) at 12 months in the collaborative care arm compared to usual care (RR 1.38, 95% CI 0.97 to 1.95; 1 RCT, 253 participants); we deemed this low-certainty evidence. Personal recovery and satisfaction/experience of care outcomes were not reported in any of the included studies. The data from one study indicated that the collaborative care treatment was more expensive than standard care (mean difference (MD) international dollars (Int$) 493.00, 95% CI 345.41 to 640.59) in the short term. Another study found the collaborative care intervention to be slightly less expensive at three years.

AUTHORS' CONCLUSIONS

This review does not provide evidence to indicate that collaborative care is more effective than standard care in the medium term (at 12 months) in relation to our primary outcomes (quality of life, mental state and psychiatric admissions). The evidence would be improved by better reporting, higher-quality RCTs and the assessment of underlying mechanisms of collaborative care. We advise caution in utilising the information in this review to assess the effectiveness of collaborative care.

Quality of life, social support, and pathways of care among persons with psychiatric disorders-A cross-sectional study

Background

Patients with psychiatric disorders have varied psychosocial realities embedded in the community context. Help-seeking behavior is extremely crucial in determining the prognosis and outcome of interventions.

Objectives

(1) To assess the levels of quality of life, perceived social support, and decision to first seek help. (2) To assess the association of socio-demographic variables with these domains.

Materials and Methods

A cross-sectional descriptive survey with 100 psychiatric patients in a tertiary care setting employed three scales, namely WHOQOL-BREF, PSSS, and WHO Pathways Encounter form.

Results

Patients had higher levels of quality of life and perceived social support. The majority of patients chose health professionals over faith healers at the onset of symptoms, had higher reliance on family members, and continued with hospital visits till the third follow-up. Sex, occupation, and marital status were associated with perceived social support, and duration of illness was associated with help-seeking behavior.

Conclusions

Community-based interventions must include holistic services and reduce the gap between onset and first contact, leading to higher quality of life and perceived social support.

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.

"Seeing a Brighter Future" - Experiences of Adolescents with Common Mental Disorders Receiving the Problem-Solving Therapy "Youth Friendship Bench" in Zimbabwe

In Zimbabwe common mental disorders are prevalent among adolescents and the treatment gap is large. The recently introduced Youth Friendship Bench intervention (YouFB) addresses this gap by task-shifting youth lay health workers to offer a culturally contextualised, manual-based, six-session problem-solving therapy to adolescents, 16-19 years of age. The aim of this study was to explore participants´ experiences of YouFB to attain a first insight into this novel intervention. Interviews with nine adolescents were analysed using qualitative content analysis on a latent level. The experience of YouFB was positive, perceived to offer hope and relief from feelings of isolation and uncertainty, increase manageability of problems, and contribute to feelings of autonomy, resulting in a feeling of optimism about the future. The notion among participants that this brief intervention had such a positive influence on their lives, sparks interest because of its applicability in low-resource settings.

Intimate partner violence types and symptoms of common mental disorders in a rural community of Chiapas, Mexico: Implications for global mental-health practice

This paper examines the scope and characteristics of male-to-female intimate partner violence in southern rural Chiapas, Mexico, and its association with depression and anxiety symptoms, highlighting the role of partner controlling behaviors. Participants were selected by random sampling. One-hundred and forty-one women >15 years participated in the study. Data was obtained through an adapted version of the National Survey of the Dynamics of Household Relationships (ENDIREH) intimate partner violence scale, the Patient Health Questionnaire-9 for depression symptoms and the Generalized Anxiety Disorder-7 for anxiety symptoms. Quantitative results indicated a 66.4% lifetime prevalence of physical and/or sexual IPV among ever-partnered women 15 years or older (95% CI: 57.5-74.5%). Forty percent (95% CI: 32.0-49.7%) of them reported having experienced physical and/or sexual violence with high partner control (HC-IPV), and 25.8% (95% CI: 18.5-34.3%) reported having experienced physical and/or sexual violence with low or moderate partner control (MC-IPV). Lifetime experience of HC-IPV was significantly associated with moderate-severe depression symptoms (RR = 5.8) and suicidality (RR = 2.08). While partner alcohol abuse was associated with a 3.06 times higher risk of lifetime physical and/or sexual IPV, 30.9% of women mentioned that their partners were never drunk when violence occurred. Interestingly, high partner alcohol abuse was more frequent among women who reported HC-IPV compared to MC-IPV. Implications for global mental health practice are discussed.

Primary-level worker interventions for the care of people living with mental disorders and distress in low- and middle-income countries

BACKGROUND

Community-based primary-level workers (PWs) are an important strategy for addressing gaps in mental health service delivery in low- and middle-income countries.  OBJECTIVES: To evaluate the effectiveness of PW-led treatments for persons with mental health symptoms in LMICs, compared to usual care.  SEARCH METHODS: MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, ICTRP, reference lists (to 20 June 2019).   SELECTION CRITERIA: Randomised trials of PW-led or collaborative-care interventions treating people with mental health symptoms or their carers in LMICs.  PWs included: primary health professionals (PHPs), lay health workers (LHWs), community non-health professionals (CPs).  DATA COLLECTION AND ANALYSIS: Seven conditions were identified apriori and analysed by disorder and PW examining recovery, prevalence, symptom change, quality-of-life (QOL), functioning, service use (SU), and adverse events (AEs).  Risk ratios (RRs) were used for dichotomous outcomes; mean difference (MDs), standardised mean differences (SMDs), or mean change differences (MCDs) for continuous outcomes.  For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥0.80 large clinical effects.  Analysis timepoints: T1 (<1 month), T2 (1-6 months), T3 ( >6 months) post-intervention.  MAIN RESULTS: Description of studies 95 trials (72 new since 2013) from 30 LMICs (25 trials from 13 LICs).  Risk of bias Most common: detection bias, attrition bias (efficacy), insufficient protection against contamination.  Intervention effects *Unless indicated, comparisons were usual care at T2.  "Probably", "may", or "uncertain" indicates "moderate", "low," or "very low" certainty evidence.   Adults with common mental disorders (CMDs) LHW-led interventions a. may increase recovery (2 trials, 308 participants; RR 1.29, 95%CI 1.06 to 1.56); b. may reduce prevalence (2 trials, 479 participants; RR 0.42, 95%CI 0.18 to 0.96); c. may reduce symptoms (4 trials, 798 participants; SMD -0.59, 95%CI -1.01 to -0.16); d. may improve QOL (1 trial, 521 participants; SMD 0.51, 95%CI 0.34 to 0.69); e. may slightly reduce functional impairment (3 trials, 1399 participants; SMD -0.47, 95%CI -0.8 to -0.15); f. may reduce AEs (risk of suicide ideation/attempts); g. may have uncertain effects on SU. Collaborative-care a. may increase recovery (5 trials, 804 participants; RR 2.26, 95%CI 1.50 to 3.43); b. may reduce prevalence although the actual effect range indicates it may have little-or-no effect (2 trials, 2820 participants; RR 0.57, 95%CI 0.32 to 1.01); c. may slightly reduce symptoms (6 trials, 4419 participants; SMD -0.35, 95%CI -0.63 to -0.08); d. may slightly improve QOL (6 trials, 2199 participants; SMD 0.34, 95%CI 0.16 to 0.53); e. probably has little-to-no effect on functional impairment (5 trials, 4216 participants; SMD -0.13, 95%CI -0.28 to 0.03); f. may reduce SU (referral to MH specialists);  g. may have uncertain effects on AEs (death). Women with perinatal depression (PND) LHW-led interventions a. may increase recovery (4 trials, 1243 participants; RR 1.29, 95%CI 1.08 to 1.54); b. probably slightly reduce symptoms (5 trials, 1989 participants; SMD -0.26, 95%CI -0.37 to -0.14); c. may slightly reduce functional impairment (4 trials, 1856 participants; SMD -0.23, 95%CI -0.41 to -0.04); d. may have little-to-no effect on AEs (death);  e. may have uncertain effects on SU. Collaborative-care a. has uncertain effects on symptoms/QOL/SU/AEs. Adults with post-traumatic stress (PTS) or CMDs in humanitarian settings LHW-led interventions a. may slightly reduce depression symptoms (5 trials, 1986 participants; SMD -0.36, 95%CI -0.56 to -0.15); b. probably slightly improve QOL (4 trials, 1918 participants; SMD -0.27, 95%CI -0.39 to -0.15); c. may have uncertain effects on symptoms (PTS)/functioning/SU/AEs. PHP-led interventions a. may reduce PTS symptom prevalence (1 trial, 313 participants; RR 5.50, 95%CI 2.50 to 12.10) and depression prevalence (1 trial, 313 participants; RR 4.60, 95%CI 2.10 to 10.08);  b. may have uncertain effects on symptoms/functioning/SU/AEs.   Adults with harmful/hazardous alcohol or substance use LHW-led interventions a. may increase recovery from harmful/hazardous alcohol use although the actual effect range indicates it may have little-or-no effect (4 trials, 872 participants; RR 1.28, 95%CI 0.94 to 1.74); b. may have little-to-no effect on the prevalence of methamphetamine use (1 trial, 882 participants; RR 1.01, 95%CI 0.91 to 1.13) and  functional impairment (2 trials, 498 participants; SMD -0.14, 95%CI -0.32 to 0.03); c. probably slightly reduce risk of harmful/hazardous alcohol use (3 trials, 667 participants; SMD -0.22, 95%CI -0.32 to -0.11);  d. may have uncertain effects on SU/AEs. PHP/CP-led interventions a. probably have little-to-no effect on recovery from harmful/hazardous alcohol use (3 trials, 1075 participants; RR 0.93, 95%CI 0.77 to 1.12) or QOL (1 trial, 560 participants; MD 0.00, 95%CI -0.10 to 0.10); b. probably slightly reduce risk of harmful/hazardous alcohol and substance use (2 trials, 705 participants; SMD -0.20, 95%CI -0.35 to -0.05; moderate-certainty evidence); c. may have uncertain effects on prevalence (cannabis use)/SU/AEs. PW-led interventions for alcohol/substance dependence a. may have uncertain effects.  Adults with severe mental disorders *Comparisons were specialist-led care at T1. LHW-led interventions a. may have little-to-no effect on caregiver burden (1 trial, 253 participants; MD -0.04, 95%CI -0.18 to 0.11);  b. may have uncertain effects on symptoms/functioning/SU/AEs.  PHP-led or collaborative-care a. may reduce functional impairment (7 trials, 874 participants; SMD -1.13, 95%CI -1.78 to -0.47); b. may have uncertain effects on recovery/relapse/symptoms/QOL/SU.  Adults with dementia and carers PHP/LHW-led carer interventions a. may have little-to-no effect on the severity of behavioural symptoms in dementia patients (2 trials, 134 participants; SMD -0.26, 95%CI -0.60 to 0.08); b. may reduce carers' mental distress (2 trials, 134 participants; SMD -0.47, 95%CI -0.82 to -0.13);  c. may have uncertain effects on QOL/functioning/SU/AEs. Children with PTS or CMDs LHW-led interventions a. may have little-to-no effect on PTS symptoms (3 trials, 1090 participants; MCD -1.34, 95%CI -2.83 to 0.14); b. probably have little-to-no effect on depression symptoms (3 trials, 1092 participants; MCD -0.61, 95%CI -1.23 to 0.02) or on functional impairment (3 trials, 1092 participants; MCD -0.81, 95%CI -1.48 to -0.13);  c. may have little-or-no effect on AEs. CP-led interventions a. may have little-to-no effect on depression symptoms (2 trials, 602 participants; SMD -0.19, 95%CI -0.57 to 0.19) or on AEs;  b. may have uncertain effects on recovery/symptoms(PTS)/functioning.

AUTHORS' CONCLUSIONS

PW-led interventions show promising benefits in improving outcomes for CMDs, PND, PTS, harmful alcohol/substance use, and dementia carers in LMICs.

Mental-physical multimorbidity treatment adherence challenges in Brazilian primary care: A qualitative study with patients and their healthcare providers

Improved understanding of multimorbidity (MM) treatment adherence in primary health care (PHC) in Brazil is needed to achieve better healthcare and service outcomes. This study explored experiences of healthcare providers (HCP) and primary care patients (PCP) with mental-physical MM treatment adherence. Adults PCP with mental-physical MM and their primary care and community mental health care providers were recruited through maximum variation sampling from nine cities in São Paulo State, Southeast of Brazil. Experiences across quality domains of the Primary Care Assessment Tool-Brazil were explored through semi-structured in-depth interviews with 19 PCP and 62 HCP, conducted between April 2016 and April 2017. Through thematic conent analysis ten meta-themes concerning treatment adherence were developed: 1) variability and accessibility of treatment options available through PHC; 2) importance of coming to terms with a disease for treatment initation; 3) importance of person-centred communication for treatment initiation and maintenance; 4) information sources about received medication; 5) monitoring medication adherence; 6) taking medication unsafely; 7) perceived reasons for medication non-adherence; 8) most challenging health behavior change goals; 9) main motives for initiation or maintenance of treatment; 10) methods deployed to improve treatment adherence. Our analysis has advanced the understanding of complexity inherent to treatment adherence in mental-physical MM and revealed opportunities for improvement and specific solutions to effect adherence in Brazil. Our findings can inform research efforts to transform MM care through optimization.

"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.

Methodology for Development of a Community Level Intervention Module for Physical Illness in Persons with Mental Illness (CLIPMI)

BACKGROUND AND OBJECTIVES

Medical illnesses seen in persons with psychiatric disorders are important but often ignored causes of increased morbidity and mortality. Hence, a community level intervention program addressing the issue is proposed.

MATERIALS AND METHODS

Patients with severe mental illnesses will be identified by a door-to-door survey and assessed for comorbid physical illnesses like anemia, hypertension, diabetes, and so on. They will then be randomized into two groups. The treatment as usual (TAU) group will not receive intervention from the trained community level workers, while the Intervention group will receive it.

RESULTS

The two groups will be compared for the prevalence and severity of comorbid physical illnesses. The expected outcome is compared to the TAU group, the intervention group will have a greater reduction in the morbidity due to physical illnesses and improved mental health.

CONCLUSION

If successful, the module can be incorporated into the community level mental health delivery system of the District Mental Health Program (DMHP).

Implementation outcomes and strategies for depression interventions in low- and middle-income countries: a systematic review

BACKGROUND

We systematically reviewed implementation research targeting depression interventions in low- and middle-income countries (LMICs) to assess gaps in methodological coverage.

METHODS

PubMed, CINAHL, PsycINFO, and EMBASE were searched for evaluations of depression interventions in LMICs reporting at least one implementation outcome published through March 2019.

RESULTS

A total of 8714 studies were screened, 759 were assessed for eligibility, and 79 studies met inclusion criteria. Common implementation outcomes reported were acceptability (n = 50; 63.3%), feasibility (n = 28; 35.4%), and fidelity (n = 18; 22.8%). Only four studies (5.1%) reported adoption or penetration, and three (3.8%) reported sustainability. The Sub-Saharan Africa region (n = 29; 36.7%) had the most studies. The majority of studies (n = 59; 74.7%) reported outcomes for a depression intervention implemented in pilot researcher-controlled settings. Studies commonly focused on Hybrid Type-1 effectiveness-implementation designs (n = 53; 67.1), followed by Hybrid Type-3 (n = 16; 20.3%). Only 21 studies (26.6%) tested an implementation strategy, with the most common being revising professional roles (n = 10; 47.6%). The most common intervention modality was individual psychotherapy (n = 30; 38.0%). Common study designs were mixed methods (n = 27; 34.2%), quasi-experimental uncontrolled pre-post (n = 17; 21.5%), and individual randomized trials (n = 16; 20.3).

CONCLUSIONS

Existing research has focused on early-stage implementation outcomes. Most studies have utilized Hybrid Type-1 designs, with the primary aim to test intervention effectiveness delivered in researcher-controlled settings. Future research should focus on testing and optimizing implementation strategies to promote scale-up of evidence-based depression interventions in routine care. These studies should use high-quality pragmatic designs and focus on later-stage implementation outcomes such as cost, penetration, and sustainability.

Ethical issues in the design and conduct of stepped-wedge cluster randomized trials in low-resource settings

Background

Stepped-wedge cluster randomized trials (SW-CRTs) are increasingly popular in health-related research in both high- and low-resource settings. There may be specific ethical issues that researchers face when designing and conducting SW-CRTs in low-resource settings. Knowledge of these issues can help to improve the ethical conduct of SW-CRTs in a global health context.

Methods

We performed an ethical analysis of two studies using SW-CRT designs in low-resource settings: the Que Vivan Las Madres study conducted from 2014 to 2017 in Guatemala and the Atmiyata study conducted from 2017 to 2018 in rural parts of India. For both case studies, we identified and evaluated the classification of the study as research or nonresearch and the ethical issues regarding the justification of the design, including the delayed rollout of an intervention that had a promising effect.

Results

In our case studies, some minor ethical issues surfaced about the registration and stakeholder pressure on the order of randomization, but both included good justification for the design and delayed rollout. Our analysis did, however, demonstrate that careful consideration of the role of randomization and registration of the trials is important.

Discussion

SW-CRTs can provide an opportunity for rigorous evaluation of interventions destined to be rolled out on the basis of limited evidence. Furthermore, in SW-CRTs, the underlying objective is often to provide a robust evaluation of the effectiveness for generalized dissemination, and this makes the SW-CRT no less a research study than any other form of cluster randomized trial.

Conclusion

The design and conduct of stepped-wedge cluster randomized trials raises at least two ethical issues that need special consideration in both high- and low-resource settings: the justification for using the design, specifically the delayed rollout of the intervention to the control group, and the classification of the study as research or nonresearch. In our case studies, these issues did not seem to raise special ethical scrutiny in low-resource settings. Further ethical evaluation will hopefully result in specific ethical guidelines for the use of SW-CRTs in both high- and low-resource settings to contribute to responsible functioning of these trials and adequate protection of participants.

Development and feasibility assessment of a collaborative stepped care intervention for management of depression in the mental health in primary care (MeHPriC) project, Lagos, Nigeria

BACKGROUND

This study aimed to develop and test the feasibility of a primary care worker-led psychological intervention as the main feature of a collaborative stepped care for depression that is effective, affordable, culturally acceptable, tailored to patients' clinical condition and easily integrate-able into the primary care schedule in Nigeria.

METHODS

Using the Medical Research Council framework, in the first stage (modelling/theoretical development), experts reviewed and distilled evidence from literature to form the intervention components. In the second (formative) stage, local stakeholders were consulted on the practical application and feasibility of the proposed intervention. The third (piloting) stage involved testing for the clinical efficacy and acceptability of the components of the draft intervention.

RESULTS

The final intervention components included a 2-stage screening (red-flagging and further evaluation), psychoeducation, low-intensity psychological therapy (problem-solving therapy for primary care), antidepressant prescription, proactive mobile telephony adherence support and referral to the mental health specialist if needed. At 3 months, 71.6% of depressed patients on the intervention improved. The intervention was perceived to be acceptable and useful by over 70% of health workers and clients and had high ratings (>70% score) by expert panels on intervention simplicity, facilitation strategies, and quality of delivery.

CONCLUSIONS

The development and feasibility testing of our integrated intervention encompassed review of current literature, expert opinions and consultation with local stakeholders and end users. Our intervention package was largely deemed acceptable, relevant, useful, and feasible. Important lessons learnt with this process will help in future intervention developments.

Testing the Effectiveness of Implementing a Model of Mental Healthcare Involving Trained Lay Health Workers in Treating Major Mental Disorders Among Youth in a Conflict-Ridden, Low-Middle Income Environment: Part II Results

OBJECTIVES

To report the outcomes of young people (aged 14-30 years) treated for major mental disorders in a lay health worker (LHW) intervention model in a rural district of conflict-ridden Kashmir, India.

METHODS

Over a 12-month follow-up, LHWs collected data on symptoms, functioning, quality of life and disability, and patients' and families' service engagement and satisfaction.

RESULTS

Forty trained LHWs (18 males and 22 females) identified 262 individuals who met the criteria for a diagnosis of a major mental disorder, connected them with specialists for treatment initiation (within 14 days), and provided follow-up and support to patients and families. Significantly more patients (14-30 years) were identified during the 14 months of the project than those in all age groups in the preceding 2 years. At 12 months, 205 patients (78%) remained engaged with the service and perceived it as very helpful. Repeated measures ANOVA showed significant improvements in scores on the global assessment of functioning (GAF) scale (F[df, 3.449] = 104.729, p < 0.001) and all 4 domains of the World Health Organization quality of life (WHOQOL) brief version (WHOQOL-BREF) of the survey-Physical F(df, 1.861) = 40.82; Psychological F(df, 1.845) = 55.490; Social F(df, 1.583) = 25.189; Environment F(df, 1.791) = 40.902, all ps < 0.001-and a decrease in disability (F[df, 1.806] = 4.364, p = 0.016). An interaction effect between time and sex was observed for the physical health domain of the WHOQOL-BREF.

DISCUSSION AND CONCLUSIONS

Our results show that an LHW-based service model, implemented in a rural setting of a low-to-middle income region plagued by long-term conflict, benefits young people with major mental disorders. We discuss the implications of our findings in the context of similar environments and the challenges encountered.

Organisation of primary health care systems in low- and middle-income countries: review of evidence on what works and why in the Asia-Pacific region

INTRODUCTION

This paper synthesises evidence on the organisation of primary health care (PHC) service delivery in low-income and middle-income countries (LMICs) in the Asia Pacific and identifies evidence of effective approaches and pathways of impact in this region.

METHODS

We developed a conceptual framework describing key inputs and outcomes of PHC as the basis of a systematic review. We searched exclusively for intervention studies from LMICs of the Asia-Pacific region in an effort to identify 'what works' to improve the coverage, quality, efficiency, equity and responsiveness of PHC. We conducted a narrative synthesis to identify key characteristics of successful interventions.

RESULTS

From an initial list of 3001 articles, we selected 153 for full-text review and included 111. We found evidence on the impact of non-physician health workers (NPHWs) on coverage and quality of care, though better integration with other PHC services is needed. Community-based services are most effective when well integrated through functional referral systems and supportive supervision arrangements, and have a reliable supply of medicines. Many studies point to the importance of community engagement in improving service demand. Few studies adopted a 'systems' lens or adequately considered long-term costs or implementation challenges.

CONCLUSION

Based on our findings, we suggest five areas where more practical knowledge and guidance is needed to support PHC systems strengthening: (1) NPHW workforce development; (2) integrating non-communicable disease prevention and control into the basic package of care; (3) building managerial capacity; (4) institutionalising community engagement; (5) modernising PHC information systems.

Programmes that bring mental health services to primary care populations in the international setting

The last decade has witnessed an exponential growth of evidence-based care packages for mental, neurological, and substance use disorders (MNS) aimed at primary care populations; however, few have been taken to scale. Several barriers to successful integration and scale-up, such as low acceptability, poor clinical engagement process, lack of targeted resources, and poor stakeholder and policy support have been cited. This review describes and highlights common features of some of the promising programmes that deliver mental health services through primary health clinics, communities, and digital platforms, with an emphasis on those that show some evidence of complete or partial scale-up. Three distinct overarching themes and initiatives are discussed in relation to the above; primary health facilities, community (outside of primary healthcare), and digital/internet-based platforms, with a focus on how the three may interact synergistically to enhance successful integration and scale-up.

Lay Health Worker Involvement in Evidence-Based Treatment Delivery: A Conceptual Model to Address Disparities in Care

Mobilizing lay health workers (LHWs) to deliver evidence-based treatments (EBTs) is a workforce strategy to address mental health disparities in underserved communities. LHWs can be leveraged to support access to EBTs in a variety of ways, from conducting outreach for EBTs delivered by professional providers to serving as the primary treatment providers. This critical review provides an overview of how LHW-supported or -delivered EBTs have been leveraged in low-, middle-, and high-income countries (HICs). We propose a conceptual model for LHWs to address drivers of service disparities, which relate to the overall supply of the EBTs provided and the demand for these treatments. The review provides illustrative case examples that demonstrate how LHWs have been leveraged globally and domestically to increase access to mental health services. It also discusses challenges and recommendations regarding implementing LHW-supported or -delivered EBTs.

Lay Health Worker Involvement in Evidence-Based Treatment Delivery: A Conceptual Model to Address Disparities in Care

Mobilizing lay health workers (LHWs) to deliver evidence-based treatments (EBTs) is a workforce strategy to address mental health disparities in underserved communities. LHWs can be leveraged to support access to EBTs in a variety of ways, from conducting outreach for EBTs delivered by professional providers to serving as the primary treatment providers. This critical review provides an overview of how LHW-supported or -delivered EBTs have been leveraged in low-, middle-, and high-income countries (HICs). We propose a conceptual model for LHWs to address drivers of service disparities, which relate to the overall supply of the EBTs provided and the demand for these treatments. The review provides illustrative case examples that demonstrate how LHWs have been leveraged globally and domestically to increase access to mental health services. It also discusses challenges and recommendations regarding implementing LHW-supported or -delivered EBTs.

Lay Health Workers' Experience of Delivering a Problem Solving Therapy Intervention for Common Mental Disorders Among People Living with HIV: A Qualitative Study from Zimbabwe

There is growing evidence supporting the use of lay health workers (LHWs) to address the treatment gap for common mental disorders (CMD) through task-shifting. This study looks at the experience of LHWs delivering a problem solving therapy (PST) intervention for CMD for people living with HIV (PLWH) in a primary health care setting. Semi-structured interviews of LHWs (n = 7) and PLWH (10) who received PST were carried out using thematic content analysis. Over a 4 year period LHWs developed indigenous concepts of PST which were: Opening the mind (Kuvhura pfungwa), uplifting (kusimudzira), strengthening and strengthening further (kusimbisa and kusimbisisa) respectively. Using terms locally conceived through knowledge sharing amongst LHWs made it acceptable to deliver PST as part of their daily work. Indigenous terms conceived and developed by LWHs to describe components and processes of PST contribute to the therapy's acceptability and continued use in primary care facilities.

The global pendulum swing towards community health workers in low- and middle-income countries: a scoping review of trends, geographical distribution and programmatic orientations, 2005 to 2014

BACKGROUND

There has been a substantial increase in publications and interest in community health workers (CHWs) in low- and middle-income countries (LMIC) over the last years. This paper examines the growth, geographical distribution and programmatic orientations of the indexed literature on CHWs in LMIC over a 10-year period.

METHODS

A scoping review of publications on CHWs from 2005 to 2014 was conducted. Using an inclusive list of terms, we searched seven databases (including MEDLINE, CINAHL, Cochrane) for all English-language publications on CHWs in LMIC. Two authors independently screened titles/abstracts, downloading full-text publications meeting inclusion criteria. These were coded in an Excel spreadsheet by year, type of publication (e.g. review, empirical), country, region, programmatic orientation (e.g. maternal-child health, HIV/AIDS, comprehensive) and CHW roles (e.g. prevention, treatment) and further analysed in Stata14. Drawing principally on the subset of review articles, specific roles within programme areas were identified and grouped.

FINDINGS

Six hundred seventy-eight publications from 46 countries on CHWs were inventoried over the 10-year period. There was a sevenfold increase in annual number of publications from 23 in 2005 to 156 in 2014. Half the publications were reporting on initiatives in Africa, a third from Asia and 11 % from the Americas (mostly Brazil). The largest single focus and driver of the growth in publications was on CHW roles in meeting the Millennium Development Goals of maternal, child and neonatal survival (35 % of total), followed by HIV/AIDS (16 %), reproductive health (6 %), non-communicable diseases (4 %) and mental health (4 %). Only 17 % of the publications approached CHW roles in an integrated fashion. There were also distinct regional (and sometimes country) profiles, reflecting different histories and programme traditions.

CONCLUSIONS

The growth in literature on CHWs provides empirical evidence of ever-increasing expectations for addressing health burdens through community-based action. This literature has a strong disease- or programme-specific orientation, raising important questions for the design and sustainable delivery of integrated national programmes.

Prevalence and correlates of probable common mental disorders in a population with high prevalence of HIV in Zimbabwe

BACKGROUND

In 2014 close to 10 million people living with HIV (PLWH) in sub-Saharan Africa were on highly active anti-retroviral therapy (HAART). The incidence of non-communicable diseases has increased markedly in PLWH as mortality is reduced due to use of HAART. Common mental disorders (CMD) are highly prevalent in PLWH. We aimed to determine factors associated with probable CMD and depression, assessed by 2 locally validated screening tools in a population with high prevalence of HIV in Harare, Zimbabwe.

METHODS

We carried out a cross-sectional survey of a systematic random sample of patients utilizing the largest primary health care facility in Harare. Adults aged ≥18 years attending over a 2-week period were eligible, excluding those who were critically ill or unable to give written informed consent. Two locally validated screening tools the Shona symptom questionnaire (SSQ-14) and the Patient Health Questionnaire (PHQ-9) were administered by trained research assistants to identify probable CMD and depression.

RESULTS

Of the 264 participants, 165 (62.5 %) were PLWH, and 92 % of these were on HAART. The prevalence of probable CMD (SSQ14 > = 9) and depression (PHQ9 > = 11) were higher among people living with HIV than among those without HIV (67.9 and 68.5 % vs 51.4 and 47.2 % respectively). Multivariable analysis showed female gender and recent negative life events to be associated with probable CMD and depression among PLWH (gender: OR = 2.32 95 % CI:1.07-5.05; negative life events: OR = 4.14; 95 % CI 1.17-14.49) and with depression (gender: OR = 1.84 95 % CI:0.85-4.02; negative life events: OR = 4.93.; 95 % CI 1.31-18.50) CONCLUSION: Elevated scores on self-report measures for CMD and depression are highly prevalent in this high HIV prevalence population. There is need to integrate packages of care for CMD and depression in existing primary health care programs for HIV/AIDS.

SUNDAR: mental health for all by all

This article describes the rationale and principles for the SUNDAR approach adopted by Sangath, an Indian non-governmental organisation: to use lay people, with appropriate training and supervision, to deliver psychosocial interventions for a range of mental health conditions. This approach has been evaluated in a number of randomised controlled trials and is now being scaled up. At the core of this innovation is revisiting the questions of what constitutes mental healthcare, who provides mental healthcare and where mental healthcare is provided. In doing so, SUNDAR offers a vision for a mental healthcare system which is empowering, inclusive, equitable and effective.