Development of a scoring system for non-specialist ratings of clinical competence in global mental health: a qualitative process evaluation of the Enhancing Assessment of Common Therapeutic Factors (ENACT) scale

Perspectives on competency-based feedback for training non-specialists to deliver psychological interventions: multi-site qualitative study of the EQUIP competency-based approach

BACKGROUND

The use of feedback to address gaps and reinforce skills is a key component of successful competency-based mental health and psychosocial support intervention training approaches. Competency-based feedback during training and supervision for personnel delivering psychological interventions is vital for safe and effective care.

AIMS

For non-specialists trained in low-resource settings, there is a lack of standardised feedback systems. This study explores perspectives on competency-based feedback, using structured role-plays that are featured on the Ensuring Quality in Psychosocial and Mental Health Care (EQUIP) platform developed by the World Health Organization and United Nations Children's Fund.

METHOD

Qualitative data were collected from supervisors, trainers and trainees from multiple EQUIP training sites (Ethiopia, Kenya, Lebanon, Peru and Uganda), from 18 key informant interviews and five focus group discussions (N = 41 participants). Qualitative analysis was conducted in Dedoose, using a codebook with deductively and inductively developed themes.

RESULTS

Four main themes demonstrated how a competency-based structure enhanced the feedback process: (a) competency-based feedback was personalised and goal-specific, (b) competency-based feedback supported a feedback loop, (c) competency-based feedback supported a comfortable and objective feedback environment, and (d) competency-based feedback created greater opportunities for flexibility in training and supervision.

CONCLUSIONS

A better understanding of the role of feedback supports the implementation of competency-based training that is systematic and effective for trainers and supervisors, which ultimately benefits the learning process for trainees.

Effectiveness and cost-effectiveness of a transdiagnostic intervention for alcohol misuse and psychological distress in humanitarian settings: study protocol for a randomised controlled trial in Uganda

BACKGROUND

The war in South Sudan has displaced more than four million people, with Uganda hosting the largest number of South Sudanese refugees. Research in Uganda has shown elevated levels of alcohol misuse and psychological distress among these refugees. The World Health Organization (WHO) has developed a trans-diagnostic scalable psychological intervention called Problem Management Plus (PM +) to reduce psychological distress among populations exposed to adversities. Our study aims to evaluate the effectiveness and cost-effectiveness of the CHANGE intervention, which builds on PM + , to also address alcohol misuse through problem-solving therapy and selected behavioural strategies for dealing with alcohol use disorders. We hypothesise that the CHANGE intervention together with enhanced usual care (EUC) will be superior to EUC alone in increasing the percentage of days abstinent.

METHODS

A parallel-arm individually randomised controlled trial will be conducted in the Rhino Camp and Imvepi settlements in Uganda. Five hundred adult male South Sudanese refugees with (i) elevated levels of alcohol use (between 8 and 20 on the Alcohol Use Disorder Identification Test [AUDIT]); and (ii) psychological distress (> 16 on the Kessler Psychological Distress Scale) will be randomly assigned 1:1 to EUC or CHANGE and EUC. CHANGE will be delivered by lay healthcare providers over 6 weeks. Outcomes will be assessed at 3 and 12 months post-randomisation. The primary outcome is the percentage of days abstinent, measured by the timeline follow-back measure at 3 months. Secondary outcomes include percentage of days abstinent at 12 months and alcohol misuse (measured by the AUDIT), psychological distress (i.e. depression, anxiety, posttraumatic stress disorder), functional disability, perpetration of intimate partner violence, and health economic indicators at 3 and 12 months. A mixed-methods process evaluation will investigate competency, dose, fidelity, feasibility, and acceptability. Primary analyses will be intention-to-treat.

DISCUSSION

CHANGE aims to address alcohol misuse and psychological distress with male refugees in a humanitarian setting. If it is proven to be effective, it can help fill an important under-researched gap in humanitarian service delivery.

TRIAL REGISTRATION

ISRCTN ISRCTN10360385. Registered on 30 January 2023.

Supporting caregivers of children with developmental disabilities: Findings from a brief caregiver well-being programme in South Africa

LAY ABSTRACT

Young children with developmental disabilities and delays who live in low- and middle-income countries are at significant risk of not reaching their full potential. We know that daily interactions with their caregivers (parents or other people taking care of them) play an important role in promoting their development. However, having a child with developmental disabilities can have a negative impact on carers' mental health and well-being, which in turn can influence their capacity to care for their children. To date, very little attention has been given to the caregivers' capacity to care. The World Health Organization developed a Caregiver Skills Training programme which includes a brief, three-session module that focuses on improving caregivers' well-being and mental health. This well-being programme is based on acceptance and commitment therapy. Acceptance and commitment therapy shows increasing evidence of helping people respond to their stressors, thoughts, feelings and experiences a little differently and commit to small changes that are in line with their personal values. Acceptance and commitment therapy has shown promise in improving feelings of well-being in caregivers of children with developmental disabilities. We adapted the World Health Organization Caregiver Skills Training Caregiver well-being module to suit the South African context. The resultant 'Well Beans for Caregivers' was then delivered to caregivers from a rural, low-resource setting in South Africa. We found the intervention easy to implement, highly acceptable to caregivers and showed promising impacts on caregivers' well-being and mental health. This intervention has the potential to be implemented widely and sustainably to build caregivers' capacity to care for their children.

Technology-assisted cognitive-behavior therapy delivered by peers versus standard cognitive behavior therapy delivered by community health workers for perinatal depression: study protocol of a cluster randomized controlled non-inferiority trial

BACKGROUND

The lack of trained mental health professionals is a key barrier to scale-up of evidence-based psychological interventions in low and middle-income countries. We have developed an app that allows a peer with no prior experience of health-care delivery to deliver the cognitive therapy-based intervention for perinatal depression, the Thinking Healthy Programme (THP). This trial aims to assess the effectiveness and cost-effectiveness of this Technology-assisted peer-delivered THP versus standard face-to-face Thinking Healthy Programme delivered by trained health workers.

METHODS

We will employ a non-inferiority stratified cluster randomized controlled trial design comparing the two formats of intervention delivery. A total of 980 women in the second or third trimester of pregnancy with a diagnosis of Major Depressive Episode, evaluated with the Structured Clinical Interview for DSM-V Disorders (SCID), will be recruited into the trial. The unit of randomization will be 70 village clusters randomly allocated in a 1:1 ratio to the intervention and control arms. The primary outcome is defined as remission from major depressive episode at 3 months postnatal measured with the SCID. Data will also be collected on symptoms of anxiety, disability, quality of life, service use and costs, and infant-related outcomes such as exclusive breastfeeding and immunization rates. Data will be collected on the primary outcome and selected secondary outcomes (depression and anxiety scores, exclusive breastfeeding) at 6 months postnatal to evaluate if the improvements are sustained in the longer-term. We are especially interested in sustained improvement (recovery) from major depressive episode.

DISCUSSION

This trial will evaluate the effectiveness and cost-effectiveness of a technology-assisted peer-delivered cognitive behavioral therapy-based intervention in rural Pakistan. If shown to be effective, the novel delivery format could play a role in reducing the treatment gap for perinatal depression and other common mental disorders in LMIC.

TRIAL REGISTRATION

The trial was registered at Clinicaltrials.gov (NCT05353491) on 29 April 2022.

Mixed-methods evaluation of a group psychosocial intervention for refugee, migrant and host community women in Ecuador and Panamá: Results from the Entre Nosotras cluster randomized feasibility trial

Community-based psychosocial interventions are key elements of mental health and psychosocial support; yet evidence regarding their effectiveness and implementation in humanitarian settings is limited. This study aimed to assess the appropriateness, acceptability, feasibility and safety of conducting a cluster randomized trial evaluating two versions of a group psychosocial intervention. Nine community clusters in Ecuador and Panamá were randomized to receive the standard version of the Entre Nosotras intervention, a community-based group psychosocial intervention co-designed with community members, or an enhanced version of Entre Nosotras that integrated a stress management component. In a sample of 225 refugees, migrants and host community women, we found that both versions were safe, acceptable and appropriate. Training lay facilitators to deliver the intervention was feasible. Challenges included slow recruitment related to delays caused by the COVID-19 pandemic, high attrition due to population mobility and other competing priorities, and mixed psychometric performance of psychosocial outcome measures. Although the intervention appeared promising, a definitive cluster randomized comparative effectiveness trial requires further adaptations to the research protocol. Within this pilot study we identified strategies to overcome these challenges that may inform adaptations. This comparative effectiveness design may be a model for identifying effective components of psychosocial interventions.

Pretraining Skills as Predictors of Competence of Nonspecialists in Delivery of Mental Health Services

OBJECTIVE

Task-shared delivery of mental health care, which includes training people who are not mental health specialists to deliver components of care, has been identified as a core strategy for increasing access to mental health care globally. However, after standard training, nonspecialists attain variable and sometimes poor competence in task-shared mental health care. This study examined whether pretraining interpersonal skills (nonverbal communication, verbal communication, rapport building, and empathy-warmth) are related to posttraining competence in task-shared mental health care among nonspecialists in Nepal.

METHODS

Nonspecialists (e.g., auxiliary health workers and health assistants) (N=185) were assessed at pretraining and posttraining (4 months after training and supervision) in a task-shared mental health care program in Nepal. This study employed both a classification algorithm and a logistic regression model to examine the relationship between pretraining interpersonal skills and posttraining competence.

RESULTS

The classification model predicted posttraining competence at above-chance levels on the basis of pretraining interpersonal skills. In particular, pretraining nonverbal communication skill distinguished participants whose posttraining competence was rated as acceptable from those whose rating was not acceptable. Nonverbal communication was also a significant predictor in the regression model. No other interpersonal skills were significantly related to posttraining competence outcomes in the regression model.

CONCLUSIONS

Some pretraining interpersonal skills of nonspecialists may predict overall competence outcomes in task-shared mental health care. Future studies confirming the relationship between pretraining interpersonal skills and posttraining competence in care delivery could improve staff selection and training strategies in task-shared mental health care programs.

Adaptation and translation of a scalable measure for assessing health worker competence to deliver a brief psychological intervention: A case study from central India of its comparison to a performance-based measure

Efforts to reduce the global burden of common mental disorders have focused on scaling up evidence-based training programs for non-specialist providers to deliver brief psychological interventions. To evaluate these provider training programs, appropriate and scalable assessments of competency need to be developed alongside them. We followed a systematic approach for the cultural adaptation and translation into Hindi of a valid, English, multiple-choice applied knowledge measure to assess non-specialists' competence to deliver a brief psychological intervention for depression in rural India. We then explored the relationship between the performance of 30 non-specialist providers on the same written measure compared with a structured performance-based measure consisting of two role-plays. The results of the multiple-choice assessment had an overall mean score of 37.40 (SD = 11.31) compared to the mean scores of role-play A (the easier role-play) of 43.25 (SD = 14.50) and role-play B (the more difficult role-play) of 43.25 (SD = 13.00). Role-play performance-based measures and written applied knowledge measures represent different approaches with unique strengths and challenges to measuring competence. Scaling up training programs requires the development of scalable methods for competency assessment. Exploring the relationship between these two measures, our team found no apparent differences between the two modes of assessment. Continued comparison of these approaches is needed to determine the consistency of outcomes across the two formats and to link the scores on these measures with clinical performance as reflected by the quality of care and patient outcomes.Trial Registration: ClinicalTrials.gov Identifier: NCT04157816; 8th November 2019.

A Pilot Study of Training Peer Recovery Specialists in Behavioral Activation in the United States: Preliminary Outcomes and Predictors of Competence

BACKGROUND

The peer recovery specialist (PRS) workforce has rapidly expanded to increase access to substance-use disorder services for underserved communities. PRSs are not typically trained in evidence-based interventions (EBIs) outside of motivational interviewing, although evidence demonstrates the feasibility of PRS delivery of certain EBIs, such as a brief behavioral intervention, behavioral activation. However, characteristics that predict PRS competency in delivering EBIs such as behavioral activation remain unknown, and are critical for PRS selection, training, and supervision if the PRS role is expanded. This study aimed to explore the outcomes of a brief PRS training period in behavioral activation and identify predictors of competence.

METHOD

Twenty PRSs in the United States completed a two-hour training on PRS-delivered behavioral activation. Participants completed baseline and post-training assessments, including roleplay and assessments of PRS characteristics, attitudes towards EBIs, and theoretically relevant personality constructs. Roleplays were coded for competence (behavioral activation specific and PRS skills more broadly, i.e., PRS competence) and changes were assessed from baseline to post-training. Linear regression models tested factors predicting post-training competence, controlling for baseline competence.

RESULTS

There was a significant pre-post increase in behavioral activation competence (t = -7.02, p < 0.001). Years working as a PRS significantly predicted post-training behavioral activation skills (B = 0.16, p = 0.005). No variables predicted post-training PRS competence.

CONCLUSIONS

This study provides preliminary evidence that behavioral activation may be appropriate for dissemination to PRSs through brief trainings, particularly for PRSs with more work experience. However, additional research is needed to examine predictors of competence among PRSs.

Delivering the Thinking Healthy Programme as a universal group intervention integrated into routine antenatal care: a randomized-controlled pilot study

BACKGROUND

Women with perinatal depression and their children are at increased risk of poor health outcomes. There is a need to implement non-stigmatizing interventions into existing health systems which reduce psychosocial distress during pregnancy and prevent perinatal depression. We adapted the WHO-endorsed Thinking Healthy Programme (THP) to be delivered universally to all women attending routine online pregnancy schools in Istanbul, Turkey. This study aimed to evaluate the feasibility and acceptability of this intervention.

METHODS

This mixed-methods study incorporated a two-arm pilot randomized controlled trial and qualitative evaluation of the feasibility and acceptability of the adapted THP - Brief Group version (THP-BGV) to a range of stakeholders. We recruited pregnant women at 12-30 weeks' gestation through pregnancy schools within the University Hospital's catchment area. Women in the intervention arm received five online sessions of the THP-BGV delivered by antenatal nurses. The intervention employed principles of cognitive behaviour therapy to provide psychoeducation, behaviour activation, problem-solving strategies and group support to participants. In the control arm, women received usual care consisting of routine online educational pregnancy classes aided by the antenatal nurses. The women were assessed for depressive symptoms with the Edinburgh Postnatal Depression Scale at baseline and 4-6 weeks post-intervention and also evaluated for anxiety, perceived social support, partner relationship, level of disability and sleep quality. In-depth interviews were conducted with women and other key stakeholders.

RESULTS

Of the 99 consecutive women referred to the pregnancy schools, 91 (91.9%) were eligible and 88 (88.8%) consented to participate in the study and were randomized. Eighty-two (83%) completed the final assessments. Our main findings were that this preventive group intervention was feasible to be integrated into routine antenatal educational classes and it was valued by the women and delivery-agents. While the study was not powered to detect differences between intervention and control conditions, we found small trends towards reduction in anxiety and depressive symptoms favoring the intervention arm. No serious adverse events were reported.

CONCLUSIONS

Given the paucity of preventive interventions for perinatal depression in low and middle-income countries, a fully powered definitive randomized controlled trial of this feasible and acceptable intervention should be conducted.

TRIAL REGISTRATION

The study was registered at Clinical Trails.gov ( NCT04819711 ) (Registration Date: 29/03/2021).

HeAlth System StrEngThening in four sub-Saharan African countries (ASSET) to achieve high-quality, evidence-informed surgical, maternal and newborn, and primary care: protocol for pre-implementation phase studies

To achieve universal health coverage, health system strengthening (HSS) is required to support the of delivery of high-quality care. The aim of the National Institute for Health Research Global Research Unit on HeAlth System StrEngThening in Sub-Saharan Africa (ASSET) is to address this need in a four-year programme, with three healthcare platforms involving eight work-packages. Key to effective health system strengthening (HSS) is the pre-implementation phase of research where efforts focus on applying participatory methods to embed the research programme within the existing health system. To conceptualise the approach, we provide an overview of the key methods applied across work-package to address this important phase of research conducted between 2017 and 2021.Work-packages are being undertaken in publicly funded health systems in rural and urban areas in Ethiopia, Sierra Leone, South Africa, and Zimbabwe. Stakeholders including patients and their caregivers, community representatives, clinicians, managers, administrators, and policymakers are the main research participants.In each work-package, initial activities engage stakeholders and build relationships to ensure co-production and ownership of HSSIs. A mixed-methods approach is then applied to understand and address determinants of high-quality care delivery. Methods such as situation analysis, cross-sectional surveys, interviews and focus group discussions are adopted to each work-package aim and context. At the end of the pre-implementation phase, findings are disseminated using focus group discussions and participatory Theory of Change workshops where stakeholders from each work package use findings to select HSSIs and develop a programme theory.ASSET places a strong emphasis of the pre-implementation phase in order to provide an in-depth and systematic diagnosis of the existing heath system functioning, needs for strengthening and stakeholder engagement. This common approach will inform the design and evaluation of the HSSIs to increase effectiveness across work packages and contexts, to better understand what works, for whom, and how.

Competency-based pre-service education for clinical psychology training in low- and middle-income countries: Case study of Makerere University in Uganda

Reducing the global treatment gap for mental health conditions in low- and middle-income countries (LMICs) requires not only an expansion of clinical psychology training but also assuring that graduates of these programs have the competency to effectively and safely deliver psychological interventions. Clinical psychology training programs in LMICs require standardized tools and guidance to evaluate competency. The World Health Organization (WHO) and UNICEF developed the “Ensuring Quality in Psychological Support” (EQUIP) platform to facilitate competency-based training in psychosocial support, psychological treatments, and foundational helping skills, with an initial focus on in-service training for non-specialists. Our goal was to design the first application of EQUIP to implement competency-based training into pre-service education for clinical psychology trainees. With Makerere University in Uganda as a case study, we outline an approach to develop, implement, and evaluate a competency-based curriculum that includes seven steps: (1) Identify core clinical psychology competencies; (2) Identify evaluation methods appropriate to each competency; (3) Determine when competency evaluations will be integrated in the curriculum, who will evaluate competency, and how results will be used; (4) Train faculty in competency-based education including conducting competency assessments and giving competency-based feedback; (5) Pilot test and evaluate the competency-based education strategy with faculty and students; (6) Modify and implement the competency-based education strategy based on pilot results; and (7) Implement ongoing evaluation of the competency-based curriculum with continuous quality improvement. This approach will be formally evaluated and established as a foundation for pre-service training in other low-resource settings.

Improving inter-rater reliability of the enhancing assessment of common therapeutic factors (ENACT) measure through training of raters

Background

As evidence supports task-shifting approaches to reduce the global mental health treatment gap, counselor competency evaluation measures are critical to ensure evidence-based therapies are administered with quality and fidelity.

Objective

This article describes a training technique for evaluating lay counselors' competency for mental health lay practitioners without rating scale experience.

Methods

Mental health practitioners were trained to give the Enhancing Assessment of Common Therapeutic Factors (ENACT) test to assess counselor proficiency in delivering the Common Elements Treatment Approach (CETA) in-person and over the phone using standardized video and audio recordings. A two-day in-person training was followed by a one-day remote training session. Training includes a review of item scales through didactic instructions, active learning by witnessing and scoring role-plays, peer interactions, and trainer observation and feedback. The trainees rated video and audio recordings, and ICC values were calculated.

Results

The training technique presented in this research helped achieve high counselor competency scores among lay providers with no prior experience using rating scales. ICC rated both trainings satisfactory to exceptional (ICC: .71 - .89).

Conclusions

Raters with no past experience with rating scales can achieve high consistency when rating counselor competency through training. Effective rater training should include didactic learning, practical learning with trainer observation and feedback, and video and audio recordings to assess consistency.

ImpACT+, a coping intervention to improve clinical outcomes for women living with HIV and sexual trauma in South Africa: study protocol for a randomized controlled trial

Background

Addressing sexual trauma in the context of HIV care is essential to improve clinical outcomes and mental health among women in South Africa. Women living with HIV (WLH) report disproportionately high levels of sexual trauma and have higher rates of posttraumatic stress disorder. Adherence to antiretroviral therapy (ART) may be difficult for traumatized women, as sexual trauma compounds the stress associated with managing HIV and is often comorbid with other mental health disorders, further compromising care engagement and adherence. ART initiation represents a unique window of opportunity for intervention to enhance motivation, increase care engagement, and address the negative effects of trauma on avoidant coping behaviors. Mental health interventions delivered by non-specialists in low- and middle-income countries have potential to treat depression, trauma, and effects of intimate partner violence among WLH. This study will examine the effectiveness of Improving AIDS Care after Trauma (ImpACT +), a task-shared, trauma-focused coping intervention, to promote viral suppression among WLH initiating ART in a South African clinic setting.

Methods

This study will be conducted in Khayelitsha, a peri-urban settlement situated near Cape Town, South Africa. Using a hybrid type 1 effectiveness-implementation design, we will randomize 350 WLH initiating ART to the ImpACT + experimental condition or the control condition (three weekly sessions of adapted problem-solving therapy) to examine the effectiveness of ImpACT + on viral suppression, ART adherence, and the degree to which mental health outcomes mediate intervention effects. ImpACT + participants will receive six once-a-week coping intervention sessions and six monthly maintenance sessions over the follow-up period. We will conduct mental health and bio-behavioral assessments at baseline, 4, 8, and 12 months, with care engagement data extracted from medical records. We will explore scalability using the Consolidated Framework for Implementation Research (CFIR).

Discussion

This trial is expected to yield important new information on psychologically informed intervention models that benefit the mental health and clinical outcomes of WLH with histories of sexual trauma. The proposed ImpACT + intervention, with its focus on building coping skills to address traumatic stress and engagement in HIV care and treatment, could have widespread impact on the health and wellbeing of individuals and communities in sub-Saharan Africa.

Trial registration

Clinicaltrials.gov NCT04793217. Retrospectively registered on 11 March 2021.

Evaluation of competency-driven training for facilitators delivering a psychological intervention for children in Lebanon: a proof-of-concept study

AIMS

The mounting evidence for effective delivery of psychological interventions by non-specialists in low- and middle-income settings has led to a rapid expansion of mental health and psychosocial support trainings globally. As such, there is a demand for strategies on how to train and implement these services to attain adequate quality. This study aims to evaluate the added value of a competency-driven approach to training of facilitators for a group intervention for children with severe emotional distress in Lebanon.

METHODS

In a controlled before and after study, 24 trainees were randomly allocated to participate in either a competency-driven training (CDT) or training-as-usual (TAU) (1 : 1) for a psychological intervention for children with severe emotional distress. We assessed the change in demonstrated competencies, using standardised role-plays, before and after the training. Measures included the 13-item Working with children-Assessment of Competencies Tool (WeACT), the 15-item ENhancing Assessment of Common Therapeutic factors (ENACT) and the 6-item Group facilitation: Assessment of Competencies Tool (GroupACT). The trainer in the experimental arm used pre-training and during training competency assessment scores to make real-time adjustment to training delivery. Due to COVID-19 pandemic restrictions, all activities were done remotely.

RESULTS

CDT resulted in significantly better outcomes on increasing competencies on the WeACT (repeated measures analysis of variance; F_{(1, 22)} = 6.49, p < 0.018) and on the GroupACT (Mann-Whitney U = 22, p < 0.003), though not statistically significant on the ENACT. There is no significant between-group difference on the reduction of harmful behaviours, mainly because both forms of training appear equally successful in eliminating such behaviours.

CONCLUSIONS

This proof-of-concept study demonstrates the potential of CDT, using standardised assessment of trainee competencies, to contribute to better training outcomes without extending the duration of training. CDT can result in up to 18% greater increase in adequate competency, when compared to TAU. The study also yields recommendations for further enhancing the benefits of competency-driven strategies. A fully powered trial is needed to confirm these findings.

Implementation strategy in collaboration with people with lived experience of mental illness to reduce stigma among primary care providers in Nepal (RESHAPE): protocol for a type 3 hybrid implementation effectiveness cluster randomized controlled trial

BACKGROUND

There are increasing efforts for the integration of mental health services into primary care settings in low- and middle-income countries. However, commonly used approaches to train primary care providers (PCPs) may not achieve the expected outcomes for improved service delivery, as evidenced by low detection rates of mental illnesses after training. One contributor to this shortcoming is the stigma among PCPs. Implementation strategies for training PCPs that reduce stigma have the potential to improve the quality of services.

DESIGN

In Nepal, a type 3 hybrid implementation-effectiveness cluster randomized controlled trial will evaluate the implementation-as-usual training for PCPs compared to an alternative implementation strategy to train PCPs, entitled Reducing Stigma among Healthcare Providers (RESHAPE). In implementation-as-usual, PCPs are trained on the World Health Organization Mental Health Gap Action Program Intervention Guide (mhGAP-IG) with trainings conducted by mental health specialists. In RESHAPE, mhGAP-IG training includes the added component of facilitation by people with lived experience of mental illness (PWLE) and their caregivers using PhotoVoice, as well as aspirational figures. The duration of PCP training is the same in both arms. Co-primary outcomes of the study are stigma among PCPs, as measured with the Social Distance Scale at 6 months post-training, and reach, a domain from the RE-AIM implementation science framework. Reach is operationalized as the accuracy of detection of mental illness in primary care facilities and will be determined by psychiatrists at 3 months after PCPs diagnose the patients. Stigma will be evaluated as a mediator of reach. Cost-effectiveness and other RE-AIM outcomes will be assessed. Twenty-four municipalities, the unit of clustering, will be randomized to either mhGAP-IG implementation-as-usual or RESHAPE arms, with approximately 76 health facilities and 216 PCPs divided equally between arms. An estimated 1100 patients will be enrolled for the evaluation of accurate diagnosis of depression, generalized anxiety disorder, psychosis, or alcohol use disorder. Masking will include PCPs, patients, and psychiatrists.

DISCUSSION

This study will advance the knowledge of stigma reduction for training PCPs in partnership with PWLE. This collaborative approach to training has the potential to improve diagnostic competencies. If successful, this implementation strategy could be scaled up throughout low-resource settings to reduce the global treatment gap for mental illness.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04282915 . Date of registration: February 25, 2020.

ENhancing Assessment of Common Therapeutic factors (ENACT) tool: adaptation and psychometric properties in South Africa

Background

The ENhancing Assessment of Common Therapeutic factors (ENACT) tool measures a set of therapeutic competencies required for the effective psychological intervention, including delivery by non-specialists. This paper describes the systematic adaptation of the ENACT for the South African (SA) context and presents the tool's initial psychometric properties.

Methods

We employed a four-step process: (1) Item generation: 204 therapeutic factors were generated by SA psychologists and drawn from the original ENACT as potential items; (2) Item relevance: SA therapists identified 96 items that were thematically coded according to their relationship to one another and were assigned to six domains; (3) Item utility: The ENACT-SA scale was piloted by rating recordings of psychological therapy sessions and stakeholder input; and (4) Psychometric properties: Internal consistency and inter-rater reliability of the final 12-item ENACT-SA were explored using Cronbach's alpha and intraclass correlation co-efficient (ICC) for both clinical psychologists and registered counsellors.

Results

Although the original ENACT provided a framework for developing a tool for use in SA, several modifications were made to improve the applicability of the tool for the SA context, and optimise its adaptability other contexts. The adapted 12-item tool's internal consistency was good, while the inter-rater reliability was acceptable for both clinical psychologists and registered counsellors.

Conclusion

The ENACT-SA is a reliable tool to assess common factors in psychological treatments. It is recommended that the tool be used in conjunction with assessment protocols and treatment-specific competency measures to fully assess implementation fidelity and potential mechanisms of therapeutic change.

World Health Organisation-Caregiver Skills Training (WHO-CST) Program: Feasibility of Delivery by Non-Specialist Providers in Real-world Urban Settings in India

The World Health Organization-Caregiver Skills Training Program, a parent-mediated early intervention facilitated by non-specialist providers piloted in urban India was evaluated using mixed-methods for feasibility and effects on child and caregiver outcomes. Caregivers (n = 22) of children (2-9 years) with social-communication delays participated in a single-group pre-post study. High rates of caregiver attendance, improved caregiver fidelity, and facilitator competency suggested program feasibility. Caregivers voiced acceptability of various intervention-components. The intervention was associated with improved caregiver-reported skills and knowledge (p < 0.00), reduction in stress (p = 0.03), improved child developmental outcomes on communication and social interaction (p < 0.00), and adaptive behaviors (p < 0.00). Challenges about logistics and availability of time were highlighted. Implications of results in resource-poor settings and recommendations for future feasibility trials are discussed.

Collaboration With People With Lived Experience of Mental Illness to Reduce Stigma and Improve Primary Care Services: A Pilot Cluster Randomized Clinical Trial

IMPORTANCE

Collaboration with people with lived experience of mental illness (PWLE), also referred to as service users, is a growing priority to reduce stigma and improve mental health care.

OBJECTIVE

To examine feasibility and acceptability of conducting an antistigma intervention in collaboration with PWLE during mental health training of primary care practitioners (PCPs).

DESIGN, SETTING, AND PARTICIPANTS

This pilot cluster randomized clinical trial was conducted from February 7, 2016, to August 10, 2018, with assessors, PCPs, and patients blinded to group assignment. The participants were PCPs and primary care patients diagnosed with depression, psychosis, or alcohol use disorder at primary care facilities (the cluster unit of randomization) in Nepal. Statistical analysis was performed from February 2020 to February 2021.

INTERVENTIONS

In the control group, PCPs were trained on the World Health Organization Mental Health Gap Action Programme-Intervention Guide (mhGAP-IG). In the Reducing Stigma Among Healthcare Providers (RESHAPE) group, the mhGAP-IG trainings for PCPs were cofacilitated by PWLE who presented recovery testimonials through photographic narratives.

MAIN OUTCOMES AND MEASURES

Prespecified feasibility and acceptability measures were adequacy of randomization, retention rates, intervention fidelity, data missingness, and safety. Outcome measures for PCPs included the Social Distance Scale (SDS), accuracy of diagnoses of mental illness in standardized role-plays using the Enhancing Assessment of Common Therapeutic factors tool (ENACT), and accuracy of diagnosis with actual patients. The primary end point was 16 months posttraining.

RESULTS

Among the overall sample of 88 PCPs, 75 (85.2%) were men and 67 (76.1%) were upper caste Hindus; the mean (SD) age was 36.2 (8.8) years. Nine of the PCPs (10.2%) were physicians, whereas the remaining 79 PCPs (89.8%) were health assistants or auxiliary health workers. Thirty-four facilities were randomized to RESHAPE or the control group. All eligible PCPs participated: 43 in RESHAPE and 45 in the control group, with 76.7% (n = 33) and 73.3% (n = 33) retention at end line, respectively. Due to PCP dropout, 29 facilities (85.3%) were included in end line analysis. Of 15 PWLE trained as cofacilitators, 11 (73.3%) participated throughout the 3 months of PCP trainings. Among PCPs, mean SDS changes from pretraining to 16 months were -10.6 points (95% CI, -14.5 to -6.74 points) in RESHAPE and -2.79 points (-8.29 to 2.70 points) in the control group. Role-play-based diagnoses with ENACT were 78.1% (25 of 32) accurate in RESHAPE and 66.7% (22 of 33) in the control group. Patient diagnoses were 72.5% (29 of 40) accurate by PCPs in RESHAPE compared with 34.5% (10 of 29) by PCPs in the control group. There were no serious adverse events.

CONCLUSIONS AND RELEVANCE

This pilot cluster randomized clinical trial found that procedures were feasible and acceptable for PCPs to be trained by PWLE. These pilot results will help inform a full trial to evaluate benefits of collaboration with PWLE during training of PCPs to reduce stigma and improve diagnostic accuracy.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02793271.

Towards an integrated model for supervision for mental health and psychosocial support in humanitarian emergencies: A qualitative study

BACKGROUND

Despite recent advances in the development and provision of mental health and psychosocial support (MHPSS) in humanitarian settings, inadequate supervision remains a significant barrier to successful implementation. The present study sought to incorporate broad stakeholder engagement as part of the first phase of development of a new Integrated Model for Supervision (IMS) for use within MHPSS and protection services in humanitarian emergencies.

METHODS

Semi-structured interviews were conducted with 26 global mental health professionals. Data was analysed thematically, using a combination of inductive and deductive methods. Codes and themes were validated through co-author cross-checks and through a webinar with an expert advisory group.

RESULTS

Results reinforce the importance of effective supervision to enhance the quality of interventions and to protect supervisees' wellbeing. Participants generally agreed that regular, supportive supervision on a one-to-one basis and as a separate system from line management, is the ideal format. The interviews highlight a need for guidance in specific areas, such as monitoring and evaluation, and navigating power imbalances in the supervisory relationship. Several approaches to supervision were described, including some solutions for use in low-resource situations, such as group, peer-to-peer or remote supervision.

CONCLUSION

An integrated model for supervision (IMS) should offer a unified framework encompassing a definition of supervision, consolidation of best practice, and goals and guidance for the supervisory process.

Reassessing the Mental Health Treatment Gap: What Happens if We Include the Impact of Traditional Healing on Mental Illness?

In this Fresh Focus, we reassess what the mental health treatment gap may mean if we consider the role of traditional healing. Based on systematic reviews, patients can use traditional healers and qualitatively report improvement from general psychological distress and symptom reduction for common mental disorders. Given these clinical implications, some high-income countries have scaled up research into traditional healing practices, while at the same time in low-and middle-income countries, where the use of traditional healers is nearly ubiquitous, considerably less research funding has studied or capitalized on this phenomena. The World Health Organization 2003-2020 Mental Health Action Plan called for government health programs to include traditional and faith healers as treatment resources to combat the low- and middle-income country treatment gap. Reflection on the work which emerged during the course of this Mental Health Action Plan revealed areas for improvement. As we embark on the next Mental Health Action Plan, we offer lessons-learned for exploring potential relationships and collaborations between traditional healing and biomedicine.

Peer-delivered services for substance use in low- and middle-income countries: A systematic review

BACKGROUND AND AIMS

Addressing the burden of disease associated with substance use is a global priority, yet access to treatment is limited, particularly in low- and middle-income countries (LMICs). Peers, individuals with lived experience of substance use, may play an important role in expanding access to treatment, supporting outcomes, and reducing stigma. While peer-delivered services for substance use have been scaling up in high-income countries (HICs), less is known about their application in LMICs. This systematic review synthesizes the evidence of peer-delivered services for substance use in LMICs.

METHODS

PsycINFO, Embase, Global Health, PubMed, and six region-specific databases were searched, and articles that described peer-delivered services for substance use and related outcomes in LMICs were included. Risk of bias was evaluated using tools appropriate for each study design. To provide a more stringent evaluation of structured interventions, a subset of articles was analyzed using the Cochrane Effective Practice and Organization of Care (EPOC) framework.

RESULTS

The search yielded 6540 articles. These were narrowed down to 34 included articles. Articles spanned four continents, included quantitative and qualitative methodologies, and primarily targeted infectious disease risk behaviors. Ten articles were included in the EPOC sub-analysis. In the context of high risk of bias, some of these articles demonstrated positive impacts of the peer-delivered services, including reductions in risk behaviors and increases in infectious disease knowledge scores, while many others showed no significant difference in outcomes between peer intervention and control groups.

CONCLUSIONS

Peer-delivered services may be feasible for addressing substance use and reducing infectious disease risk behaviors in LMICs, where there are severe human resource shortages. Globally, peers' lived experience is valuable for engaging patients in substance use treatment and harm reduction services. Further research is needed to better characterize and quantify outcomes for peer-delivered services for substance use in LMICs.

Process evaluation of TeamUp: a movement-based psychosocial intervention for refugee children in the Netherlands

BACKGROUND

Nearly 60,000 people applied for asylum in the Netherland in 2015, confronting the governmental structures and services with great administrative, logistical and service provision challenges. Refugee children's psychosocial needs and wellbeing are often overlooked, and post-migration support is of pivotal importance.

METHODS

An easy accessible movement-based psychosocial intervention, called TeamUp, was developed for children aged 6-17 living in refugee reception centres. A mixed-method process evaluation was conducted of (1) implementation process, assessing attendance (n = 2183 children, and n = 209 children); (2) implementation quality, using structured observations at two time points to evaluate facilitator's (2a) individual-level fidelity (n = 81 facilitators); (2b) team-level fidelity (n = 22 teams); (2c) facilitators' competencies (n = 81); (2d) trainee perceived self-efficacy pre-post training (n = 73); and (3) perceptions on implementation and outcomes, employing a survey (n = 99), focus group discussions and key informant interviews with children (n = 94), facilitators (n = 24) and reception centre staff (n = 10).

RESULTS

Attendance lists showed a mean of 8.5 children per session, and children attending 31.3% of sessions. Structured observations demonstrated 49.2% and 58.2% individual-level fidelity, 72.5% and 73.0% team-level fidelity, and 82.9% and 88.4% adequacy in competencies, each at T1 and T2 respectively. The main reported challenges included managing children's energy regulation (e.g. offering settling moments) and challenging behaviour. Training participation significantly improved perceived self-efficacy for trainees. The facilitator survey demonstrated on average, high satisfaction and self-efficacy, low experienced burden, and high perceived capacity-building support. Qualitatively, TeamUp was positively perceived by all stakeholders and was regarded as contributing to children's psychosocial outcomes.

CONCLUSION

(1) Attendance and group size were lower than expected. (2) The intervention's facilitator fidelity ranged from moderate to adequate-exhibiting a need for specific fidelity and capacity strengthening-while facilitator competencies were high. Trainee's perceived self-efficacy improved significantly following a 2-day training. (3) Facilitators expressed high levels of satisfaction, self-efficacy and support, and low burden. The intervention was positively perceived by all stakeholders and to have a positive impact on children's psychosocial learning and wellbeing.

"Like a doctor, like a brother": Achieving competence amongst lay health workers delivering community-based rehabilitation for people with schizophrenia in Ethiopia

BACKGROUND

There are gaps in our understanding of how non-specialists, such as lay health workers, can achieve core competencies to deliver psychosocial interventions in low- and middle-income countries.

METHODS

We conducted a 12-month mixed-methods study alongside the Rehabilitation Intervention for people with Schizophrenia in Ethiopia (RISE) pilot study. We rated a total of 30 role-plays and 55 clinical encounters of ten community-based rehabilitation (CBR) lay workers using an Ethiopian adaptation of the ENhancing Assessment of Common Therapeutic factors (ENACT) structured observational rating scale. To explore factors influencing competence, six focus group discussions and four in-depth interviews were conducted with 11 CBR workers and two supervisors at three time-points. We conducted a thematic analysis and triangulated the qualitative and quantitative data.

RESULTS

There were improvements in CBR worker competence throughout the training and 12-month pilot study. Therapeutic alliance competencies (e.g., empathy) saw the earliest improvements. Competencies in personal factors (e.g., substance use) and external factors (e.g., assessing social networks) were initially rated lower, but scores improved during the pilot. Problem-solving and giving advice competencies saw the least improvements overall. Multimodal training, including role-plays, field work and group discussions, contributed to early development of competence. Initial stigma towards CBR participants was reduced through contact. Over time CBR workers occupied dual roles of expert and close friend for the people with schizophrenia in the programme. Competence was sustained through peer supervision, which also supported wellbeing. More intensive specialist supervision was needed.

CONCLUSION

It is possible to equip lay health workers with the core competencies to deliver a psychosocial intervention for people with schizophrenia in a low-income setting. A prolonged period of work experience is needed to develop advanced skills such as problem-solving. A structured intervention with clear protocols, combined with peer supervision to support wellbeing, is recommended for good quality intervention delivery. Repeated ENACT assessments can feasibly and successfully be used to identify areas needing improvement and to guide on-going training and supervision.

Protocol for process evaluation of integration of mental health into primary healthcare in two states in Nigeria: the mhSUN programme

BACKGROUND

Current international recommendations to address the large treatment gap for mental healthcare in low- and middle-income countries are to scale up integration of mental health into primary care. There are good outcome studies to support this, but less robust evidence for effectively carrying out integration and scale-up of such services, or for understanding how to address contextual issues that routinely arise.

AIMS

This protocol is for a process evaluation of a programme called Mental Health Scale Up Nigeria. The study aims are to determine the extent to which the intervention was carried out according to the plans developed (fidelity), to examine the effect of postulated moderating factors and local context, and the perception of the programme by primary care staff and implementers.

METHOD

We use a theoretical framework for process evaluation based on the Medical Research Council's Guidelines on Process Evaluation. A Theory of Change workshop was carried out in programme development, to highlight relevant factors influencing the process, ensure good adaptation of global normative guidelines and gain buy-in from local stakeholders. We will use mixed methods to examine programme implementation and outcomes, and influence of moderating factors.

RESULTS

Data sources will include the routine health information system, facility records (for staff, medication and infrastructure), log books of intervention activities, supervision records, patient questionnaires and qualitative interviews.

CONCLUSIONS

Evidence from this process evaluation will help guide implementers aiming to scale up mental health services in primary care in low- and middle-income countries.

Assessment of service provider competency for child and adolescent psychological treatments and psychosocial services in global mental health: evaluation of feasibility and reliability of the WeACT tool in Gaza, Palestine

BACKGROUND

There is a scarcity of evaluated tools to assess whether non-specialist providers achieve minimum levels of competency to effectively and safely deliver psychological interventions in low- and middle-income countries. The objective of this study was to evaluate the reliability and utility of the newly developed Working with children - Assessment of Competencies Tool (WeACT) to assess service providers' competencies in Gaza, Palestine.

METHODS

The study evaluated; (1) psychometric properties of the WeACT based on observed role-plays by trainers/supervisors (N = 8); (2) sensitivity to change among service provider competencies (N = 25) using pre-and-post training WeACT scores on standardized role-plays; (3) in-service competencies among experienced service providers (N = 64) using standardized role-plays.

RESULTS

We demonstrated moderate interrater reliability [intraclass correlation coefficient, single measures, ICC = 0.68 (95% CI 0.48-0.86)] after practice, with high internal consistency (α = 0.94). WeACT assessments provided clinically relevant information on achieved levels of competencies (55% of the competencies were scored as adequate pre-training; 71% post-training; 62% in-service). Pre-post training assessment saw significant improvement in competencies (W = -3.64; p < 0.001).

CONCLUSION

This study demonstrated positive results on the reliability and utility of the WeACT, with sufficient inter-rater agreement, excellent internal consistency, sensitivity to assess change, and providing insight needs for remedial training. The WeACT holds promise as a tool for monitoring quality of care when implementing evidence-based care at scale.

Barriers and drivers to capacity-building in global mental health projects

BACKGROUND

The global shortage of mental health workers is a significant barrier to the implementation and scale-up of mental health services. Partially as a result of this shortage, approximately 85% of people with mental, neurological and substance-use disorders in low- and middle-income countries do not receive care. Consequently, developing and implementing scalable solutions for mental health capacity-building has been identified as a priority in global mental health. There remains limited evidence to inform best practices for capacity building in global mental health. As one in a series of four papers on factors affecting the implementation of mental health projects in low- and middle-income countries, this paper reflects on the experiences of global mental health grantees funded by Grand Challenges Canada, focusing on the barriers to and drivers of capacity-building.

METHODS

Between June 2014 and May 2017, current or former Grand Challenges Canada Global Mental Health grantees were recruited using purposive sampling. N = 29 grantees participated in semi-structured qualitative interviews, representing projects in Central America and the Caribbean (n = 4), South America (n = 1), West Africa (n = 4), East Africa (n = 6), South Asia (n = 11) and Southeast Asia (n = 3). Based on the results of a quantitative analysis of project outcomes using a portfolio-level Theory of Change framework, six key themes were identified as important to implementation success. As part of a larger multi-method study, this paper utilized a framework analysis to explore the themes related to capacity-building.

RESULTS

Study participants described barriers and facilitators to capacity building within three broad themes: (1) training, (2) supervision, and (3) quality assurance. Running throughout these thematic areas were the crosscutting themes of contextual understanding, human resources, and sustainability. Additionally, participants described approaches and mechanisms for successful capacity building.

CONCLUSIONS

This study demonstrates the importance of capacity building to global mental health research and implementation, its relationship to stakeholder engagement and service delivery, and the implications for funders, implementers, and researchers alike. Investment in formative research, contextual understanding, stakeholder engagement, policy influence, and integration into existing systems of education and service delivery is crucial for the success of capacity building efforts.

Scaling up mental health care and psychosocial support in low-resource settings: a roadmap to impact

AIMS

Despite recent global attention to mental health and psychosocial support services and a growing body of evidence-support interventions, few mental health services have been established at a regional or national scale in low- and middle-income countries (LMIC). There are myriad challenges and barriers ranging from testing interventions that do not target priority needs of populations or policymakers to interventions that cannot achieve adequate coverage to decrease the treatment gap in LMIC.

METHOD

We propose a 'roadmap to impact' process that guides planning for interventions to move from the research space to the implementation space.

RESULTS

We establish four criteria and nine associated indicators that can be evaluated in low-resource settings to foster the greatest likelihood of successfully scaling mental health and psychosocial interventions. The criteria are relevance (indicators: population need, cultural and contextual fit), effectiveness (change in mental health outcome, change in hypothesised mechanism of action), quality (adherence, competence, attendance) and feasibility (coverage, cost). In the research space, relevance and effectiveness need to be established before moving into the implementation space. In the implementation space, ongoing monitoring of quality and feasibility is required to achieve and maintain a positive public health impact. Ultimately, a database or repository needs to be developed with these criteria and indicators to help researchers establish and monitor minimum benchmarks for the indicators, and for policymakers and practitioners to be able to select what interventions will be most likely to succeed in their settings.

CONCLUSION

A practicable roadmap with a sequence of measurable indicators is an important step to delivering interventions at scale and reducing the mental health treatment gap around the world.

Impact of integrated district level mental health care on clinical and functioning outcomes of people with depression and alcohol use disorder in Nepal: a non-randomised controlled study

BACKGROUND

Integration of mental health services into primary healthcare is proliferating in low-resource countries. We aimed to evaluate the impact of different compositions of primary care mental health services for depression and alcohol use disorder (AUD), when compared to usual primary care services.

METHODS

We conducted a non-randomized controlled study in rural Nepal. We compared treatment outcomes among patients screening positive and receiving: (a) primary care mental health services without a psychological treatment component (TG); (b) the same services including a psychological treatment (TG + P); and (c) primary care treatment as usual (TAU). Primary outcomes included change in depression and AUD symptoms, as well as disability. Disability was measured using the 12-item WHO Disability Assessment Schedule. Symptom severity was assessed using the 9-item Patient Health Questionnaire for depression, the 10-item Alcohol Use Disorders Identification Test for AUD. We used negative binomial regression models for the analysis.

RESULTS

For depression, when combining both treatment groups (TG, n = 77 and TG + P, n = 60) compared to TAU (n = 72), there were no significant improvements. When only comparing the psychological treatment group (TG + P) with TAU, there were significant improvements for symptoms and disability (aβ = - 2.64; 95%CI - 4.55 to - 0.74, p = 0.007; aβ = - 12.20; 95%CI - 19.79 to - 4.62; p = 0.002, respectively). For AUD, when combining both treatment groups (TG, n = 92 and TG + P, n = 80) compared to TAU (n = 57), there were significant improvements in AUD symptoms and disability (aβ = - 15.13; 95%CI - 18.63 to - 11.63, p < 0.001; aβ = - 9.26; 95%CI - 16.41 to - 2.12, p = 0.011; respectively). For AUD, there were no differences between TG and TG + P. Patients' perceptions of health workers' skills in common psychological factors were associated with improvement in depression patient outcomes (β = - 0.36; 95%CI - 0.55 to - 0.18; p < 0.001) but not for AUD patients.

CONCLUSION

Primary care mental health services for depression may only be effective when psychological treatments are included. Health workers' competencies as perceived by patients may be an important indicator for treatment effect. AUD treatment in primary care appears to be beneficial even without additional psychological services.

Common factors in psychological treatments delivered by non-specialists in low- and middle-income countries: Manual review of competencies

Delivery of psychological and psychosocial treatments by non-specialists in low-and middle-income countries (LMIC) is a growing strategy to address the global mental health treatment gap. However, little is known about which competencies are essential for non-specialists to effectively deliver treatment. Psychotherapy research in high-income countries suggests that effective treatment requires competency in common factors. Therefore, our objective was to identify how common factors are described in evidence-supported non-specialist interventions in LMICs. To meet this objective, we identified and coded common factors by reviewing 16 evidence-supported manuals for psychological treatments delivered by non-specialists in LMICs. World Health Organization (WHO) manuals and other non-proprietary manuals, with positive randomized control outcomes, were included in the review. Fifteen common factors were identified and described in most manuals: 'promoting hope and realistic expectancy of change' and 'confidentiality' were described in 15 manuals (94%), followed by 'giving praise' and 'psychoeducation' (88% of manuals), and 'rapport building' (81% of manuals). Descriptions of common factors were similar across manuals, suggesting that training and competency evaluation approaches can be harmonized across interventions. Compiling these descriptions from the manuals can inform foundational training in common factors for diverse cadres of non-specialists around the world.

Satisfaction in the Soul: Common Factors Theory Applied to Traditional Healers in Rural Nepal

To explore the relationship between traditional healers and conventional psychotherapy, we conducted a combined ethnographic study and structured observational rating of healers in the middle hill region of central Nepal. We conducted in-depth interviews and ethnographic observations of healing with 84 participants comprising 29 traditional healers and 55 other community members. Overall, our observations and participant responses yielded a range of interventions that improved health through belief, satisfaction in the soul, social support, transference, and symbolic narration. The findings from our overall ethnography suggest that healers offer a platform for their patients to accept a disease state, cope with it, and to experience palliation of distress. We additionally focused on one participant who saw multiple healers for a case study, during which we rated healing behavior using an observational measure of empathy, emotional validation, and therapeutic alliance. Using this measure, healers who were perceived as successful, scored high on alliance, empathy, promoting expectations of recovery, and use of cultural models of distress. The results of our structured observation suggest healers draw upon processes also observed in psychotherapy. Further research is needed to explore if these practices can be generalized to healers in other parts of Nepal and other settings. [spirituality, mental health, ethnopsychology, shamanism, mind-body relations].

Use of role plays to assess therapist competency and its association with client outcomes in psychological interventions: A scoping review and competency research agenda

A major challenge in scaling-up psychological interventions worldwide is how to evaluate competency among new workforces engaged in psychological services. One approach to measuring competency is through standardized role plays. Role plays have the benefits of standardization and reliance on observed behavior rather than written knowledge. However, role plays are also resource intensive and dependent upon inter-rater reliability. We undertook a two-part scoping review to describe how competency is conceptualized in studies evaluating the relationship of competency with client outcomes. We focused on use of role plays including achieving inter-rater reliability and the association with client outcomes. First, we identified 4 reviews encompassing 61 studies evaluating the association of competency with client outcomes. Second, we identified 39 competency evaluation tools, of which 21 were used in comparisons with client outcomes. Inter-rater reliability (intraclass correlation coefficient) was reported for 15 tools and ranged from 0.53 to 0.96 (mean ICC = 0.77). However, we found that none of the outcome comparison studies measured competency with standardized role plays. Instead, studies typically used therapy quality (i.e., session ratings with actual clients) as a proxy for competency. This reveals a gap in the evidence base for competency and its role in predicting client outcomes. We therefore propose a competency research agenda to develop an evidence-base for objective, standardized role plays to measure competency and its association with client outcomes. OPEN SCIENCE REGISTRATION #: https://osf.io/nqhu7/.

Wearable Digital Sensors to Identify Risks of Postpartum Depression and Personalize Psychological Treatment for Adolescent Mothers: Protocol for a Mixed Methods Exploratory Study in Rural Nepal

BACKGROUND

There is a high prevalence of untreated postpartum depression among adolescent mothers with the greatest gap in services in low- and middle-income countries. Recent studies have demonstrated the potential of nonspecialists to provide mental health services for postpartum depression in these low-resource settings. However, there is inconsistency in short-term and long-term benefits from the interventions. Passive sensing data generated from wearable digital devices can be used to more accurately distinguish which mothers will benefit from psychological services. In addition, wearable digital sensors can be used to passively collect data to personalize care for mothers. Therefore, wearable passive sensing technology has the potential to improve outcomes from psychological treatments for postpartum depression.

OBJECTIVE

This study will explore the use of wearable digital sensors for two objectives: First, we will pilot test using wearable sensors to generate passive sensing data that distinguish adolescent mothers with depression from those without depression. Second, we will explore how nonspecialists can integrate data from passive sensing technologies to better personalize psychological treatment.

METHODS

This study will be conducted in rural Nepal with participatory involvement of adolescent mothers and health care stakeholders through a community advisory board. The first study objective will be addressed by comparing behavioral patterns of adolescent mothers without depression (n=20) and with depression (n=20). The behavioral patterns will be generated by wearable digital devices collecting data in 4 domains: (1) the physical activity of mothers using accelerometer data on mobile phones, (2) the geographic range and routine of mothers using GPS (Global Positioning System) data collected from mobile phones, (3) the time and routine of adolescent mothers with their infants using proximity data collected from Bluetooth beacons, and (4) the verbal stimulation and auditory environment for mothers and infants using episodic audio recordings on mobile phones. For the second objective, the same 4 domains of data will be collected and shared with nonspecialists who are delivering an evidence-based behavioral activation intervention to the depressed adolescent mothers. Over 5 weeks of the intervention, we will document how passive sensing data are used by nonspecialists to personalize the intervention. In addition, qualitative data on feasibility and acceptability of passive data collection will be collected for both objectives.

RESULTS

To date, a community advisory board comprising young women and health workers engaged with adolescent mothers has been established. The study is open for recruitment, and data collection is anticipated to be completed in November 2019.

CONCLUSIONS

Integration of passive sensing data in public health and clinical programs for mothers at risk of perinatal mental health problems has the potential to more accurately identify who will benefit from services and increase the effectiveness by personalizing psychological interventions.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/14734.

Using technology to scale-up training and supervision of community health workers in the psychosocial management of perinatal depression: a non-inferiority, randomized controlled trial

BACKGROUND

The Thinking Healthy Programme (THP) is an evidence-based psychological intervention endorsed by the World Health Organization, tailored for non-specialist health workers in low- and middle-income countries. However, training and supervision of large numbers of health workers is a major challenge for the scale-up of THP. We developed a 'Technology-Assisted Cascaded Training and Supervision system' (TACTS) for THP consisting of a training application and cascaded supervision delivered from a distance.

METHODS

A single-blind, non-inferiority, randomized controlled trial was conducted in District Swat, a post-conflict area of North Pakistan. Eighty community health workers (called Lady Health Workers or LHWs) were randomly assigned to either TACTS or conventional face-to-face training and supervision by a specialist. Competence of LHWs in delivering THP post-training was assessed by independent observers rating a therapeutic session using a standardized measure, the 'Enhancing Assessment of Common Therapeutic factors' (ENACT), immediately post-training and after 3 months. ENACT uses a Likert scale to score an observed interaction on 18 dimensions, with a total score of 54, and a higher score indicating greater competence.

RESULTS

Results indicated no significant differences between health workers trained using TACTS and supervised from distance v. those trained and supervised by a specialist face-to-face (mean ENACT score M  =  24.97, s.d.  =  5.95 v. M =  27.27, s.d.  =  5.60, p  =  0.079, 95% CI 4.87-0.27) and at 3 months follow-up assessment (M  =  44.48, s.d.  =  3.97 v. M =  43.63, s.d.  =  6.34, p  =  0.53, CI -1.88 to 3.59).

CONCLUSIONS

TACTS can provide a promising tool for training and supervision of front-line workers in areas where there is a shortage of specialist trainers and supervisors.

How competent are non-specialists trained to integrate mental health services in primary care? Global health perspectives from Uganda, Liberia, and Nepal

Evaluations to objectively assess minimum competency are not routinely implemented for training and supervision in global mental health. Addressing this gap in competency assessment is crucial for safe and effective mental health service integration in primary care. To explore competency, this study describes a training and supervision program for 206 health workers in Uganda, Liberia, and Nepal in humanitarian settings impacted by political violence, Ebola, and natural disasters. Health workers were trained in the World Health Organization's mental health Gap Action Programme (mhGAP). Health workers demonstrated changes in knowledge (mhGAP knowledge, effect size, d = 1.14), stigma (Mental Illness: Clinicians' Attitudes, d = -0.64; Social Distance Scale, d = -0.31), and competence (ENhancing Assessment of Common Therapeutic factors, ENACT, d = 1.68). However, health workers were only competent in 65% of skills. Although the majority were competent in communication skills and empathy, they were not competent in assessing physical and mental health, addressing confidentiality, involving family members in care, and assessing suicide risk. Higher competency was associated with lower stigma (social distance), but competency was not associated with knowledge. To promote competency, this study recommends (1) structured role-plays as a standard evaluation practice; (2) standardized reporting of competency, knowledge, attitudes, and clinical outcomes; and (3) shifting the field toward competency-based approaches to training and supervision.

Culture and mental health in Nepal: an interdisciplinary scoping review

Efforts to address global mental health disparities have given new urgency to longstanding debates on the relevance of cultural variations in the experience and expression of distress for the design and delivery of effective services. This scoping review examines available information on culture and mental health in Nepal, a low-income country with a four-decade history of humanitarian mental health intervention. Structured searches were performed using PsycINFO, Web of Science, Medline, and Proquest Dissertation for relevant book chapters, doctoral theses, and journal articles published up to May 2017. A total of 38 publications met inclusion criteria (nine published since 2015). Publications represented a range of disciplines, including anthropology, sociology, cultural psychiatry, and psychology and explored culture in relation to mental health in four broad areas: (1) cultural determinants of mental illness; (2) beliefs and values that shape illness experience, including symptom experience and expression and help-seeking; (3) cultural knowledge of mental health and healing practices; and (4) culturally informed mental health research and service design. The review identified divergent approaches to understanding and addressing mental health problems. Results can inform the development of mental health systems and services in Nepal as well as international efforts to integrate attention to culture in global mental health.

A mobile clinic approach to the delivery of community-based mental health services in rural Haiti

This study evaluates the use of a mental health mobile clinic to overcome two major challenges to the provision of mental healthcare in resource-limited settings: the shortage of trained specialists; and the need to improve access to safe, effective, and culturally sound care in community settings. Employing task-shifting and supervision, mental healthcare was largely delivered by trained, non-specialist health workers instead of specialists. A retrospective chart review of 318 unduplicated patients assessed and treated during the mobile clinic’s first two years (January 2012 to November 2013) was conducted to explore outcomes. These data were supplemented by a quality improvement questionnaire, illustrative case reports, and a qualitative interview with the mobile clinic’s lead community health worker. The team evaluated an average of 42 patients per clinic session. The most common mental, neurological, or substance abuse (MNS) disorders were depression and epilepsy. Higher follow-up rates were seen among those with diagnoses of bipolar disorder and neurological conditions, while those with depression or anxiety had lower follow-up rates. Persons with mood disorders who were evaluated on at least two separate occasions using a locally developed depression screening tool experienced a significant reduction in depressive symptoms. The mental health mobile clinic successfully treated a wide range of MNS disorders in rural Haiti and provided care to individuals who previously had no consistent access to mental healthcare. Efforts to address these common barriers to the provision of mental healthcare in resource-limited settings should consider supplementing clinic-based with mobile services.

The Role of Communities in Mental Health Care in Low- and Middle-Income Countries: A Meta-Review of Components and Competencies

Community-based mental health services are emphasized in the World Health Organization’s Mental Health Action Plan, the World Bank’s Disease Control Priorities, and the Action Plan of the World Psychiatric Association. There is increasing evidence for effectiveness of mental health interventions delivered by non-specialists in community platforms in low- and middle-income countries (LMIC). However, the role of community components has yet to be summarized. Our objective was to map community interventions in LMIC, identify competencies for community-based providers, and highlight research gaps. Using a review-of-reviews strategy, we identified 23 reviews for the narrative synthesis. Motivations to employ community components included greater accessibility and acceptability compared to healthcare facilities, greater clinical effectiveness through ongoing contact and use of trusted local providers, family involvement, and economic benefits. Locations included homes, schools, and refugee camps, as well as technology-aided delivery. Activities included awareness raising, psychoeducation, skills training, rehabilitation, and psychological treatments. There was substantial variation in the degree to which community components were integrated with primary care services. Addressing gaps in current practice will require assuring collaboration with service users, utilizing implementation science methods, creating tools to facilitate community services and evaluate competencies of providers, and developing standardized reporting for community-based programs.

Assessing treatment fidelity and contamination in a cluster randomised controlled trial of motivational interviewing and cognitive behavioural therapy skills in type 2 diabetes

Background

Competencies in psychological techniques delivered by primary care nurses to support diabetes self-management were compared between the intervention and control arms of a cluster randomised controlled trial as part of a process evaluation. The trial was pragmatic and designed to assess effectiveness. This article addresses the question of whether the care that was delivered in the intervention and control trial arms represented high fidelity treatment and attention control, respectively.

Methods

Twenty-three primary care nurses were either trained in motivational interviewing (MI) and cognitive behavioural therapy (CBT) skills or delivered attention control. Nurses’ skills in these treatments were evaluated soon after training (treatment arm) and treatment fidelity was assessed after treatment delivery for sessions midway through regimen (both arms) using the Motivational Interviewing Treatment Integrity (MITI) domains and Behaviour Change Counselling Index (BECCI) based on consultations with 151 participants (45% of those who entered the study). The MITI Global Spirit subscale measured demonstration of MI principles: evocation, collaboration, autonomy/support.

Results

After training, median MITI MI-Adherence was 86.2% (IQR 76.9–100%) and mean MITI Empathy was 4.09 (SD 1.04). During delivery of treatment, in the intervention arm mean MITI Spirit was 4.03 (SD 1.05), mean Empathy was 4.23 (SD 0.89), and median Percentage Complex Reflections was 53.8% (IQR 40.0–71.4%). In the attention control arm mean Empathy was 3.40 (SD 0.98) and median Percentage Complex Reflections was 55.6% (IQR 41.9–71.4%).

Conclusions

After MI and CBT skills training, detailed assessment showed that nurses had basic competencies in some psychological techniques. There appeared to be some delivery of elements of psychological treatment by nurses in the control arm. This model of training and delivery of MI and CBT skills integrated into routine nursing care to support diabetes self-management in primary care was not associated with high competency levels in all skills.

Trial registration

ISRCTN75776892; date registered: 19/05/2010.

Reducing stigma among healthcare providers to improve mental health services (RESHAPE): protocol for a pilot cluster randomized controlled trial of a stigma reduction intervention for training primary healthcare workers in Nepal

Background

Non-specialist healthcare providers, including primary and community healthcare workers, in low- and middle-income countries can effectively treat mental illness. However, scaling-up mental health services within existing health systems has been limited by barriers such as stigma against people with mental illness. Therefore, interventions are needed to address attitudes and behaviors among non-specialists. Aimed at addressing this gap, REducing Stigma among HealthcAre Providers to ImprovE mental health services (RESHAPE) is an intervention in which social contact with mental health service users is added to training for non-specialist healthcare workers integrating mental health services into primary healthcare.

Methods

This protocol describes a mixed methods pilot and feasibility study in primary care centers in Chitwan, Nepal. The qualitative component will include key informant interviews and focus group discussions. The quantitative component consists of a pilot cluster randomized controlled trial (c-RCT), which will establish parameters for a future effectiveness study of RESHAPE compared to training as usual (TAU). Primary healthcare facilities (the cluster unit, k = 34) will be randomized to TAU or RESHAPE. The direct beneficiaries of the intervention are the primary healthcare workers in the facilities (n = 150); indirect beneficiaries are their patients (n = 100). The TAU condition is existing mental health training and supervision for primary healthcare workers delivered through the Programme for Improving Mental healthcarE (PRIME) implementing the mental health Gap Action Programme (mhGAP). The primary objective is to evaluate acceptability and feasibility through qualitative interviews with primary healthcare workers, trainers, and mental health service users. The secondary objective is to collect quantitative information on health worker outcomes including mental health stigma (Social Distance Scale), clinical knowledge (mhGAP), clinical competency (ENhancing Assessment of Common Therapeutic factors, ENACT), and implicit attitudes (Implicit Association Test, IAT), and patient outcomes including stigma-related barriers to care, daily functioning, and symptoms.

Discussion

The pilot and feasibility study will contribute to refining recommendations for implementation of mhGAP and other mental health services in primary healthcare settings in low-resource health systems. The pilot c-RCT findings will inform an effectiveness trial of RESHAPE to advance the evidence-base for optimal approaches to training and supervision for non-specialist providers.

Trial registration

ClinicalTrials.gov identifier, NCT02793271

Health system preparedness for integration of mental health services in rural Liberia

Background

There are increasing efforts and attention focused on the delivery of mental health services in primary care in low resource settings (e.g., mental health Gap Action Programme, mhGAP). However, less attention is devoted to systematic approaches that identify and address barriers to the development and uptake of mental health services within primary care in low-resource settings. Our objective was to prepare for optimal uptake by identifying barriers in rural Liberia. The country’s need for mental health services is compounded by a 14-year history of political violence and the largest Ebola virus disease outbreak in history. Both events have immediate and lasting mental health effects.

Methods

A mixed-methods approach was employed, consisting of qualitative interviews with 22 key informants and six focus group discussions. Additional qualitative data as well as quantitative data were collected through semi-structured assessments of 19 rural primary care health facilities. Data were collected from March 2013 to March 2014.

Results

Potential barriers to development and uptake of mental health services included lack of mental health knowledge among primary health care staff; high workload for primary health care workers precluding addition of mental health responsibilities; lack of mental health drugs; poor physical infrastructure of health facilities including lack of space for confidential consultation; poor communication support including lack of electricity and mobile phone networks that prevent referrals and phone consultation with supervisors; absence of transportation for patients to facilitate referrals; negative attitudes and stigma towards people with severe mental disorders and their family members; and stigma against mental health workers.

Conclusions

To develop and facilitate effective primary care mental health services in a post-conflict, low resource setting will require (1) addressing the knowledge and clinical skills gap in the primary care workforce; (2) improving physical infrastructure of health facilities at care delivery points; and (3) implementing concurrent interventions designed to improve attitudes towards people with mental illness, their family members and mental health care providers.

Detection of depression in low resource settings: validation of the Patient Health Questionnaire (PHQ-9) and cultural concepts of distress in Nepal

BACKGROUND

Despite recognition of the burden of disease due to mood disorders in low- and middle-income countries, there is a lack of consensus on best practices for detecting depression. Self-report screening tools, such as the Patient Health Questionnaire (PHQ-9), require modification for low literacy populations and to assure cultural and clinical validity. An alternative approach is to employ idioms of distress that are locally salient, but these are not synonymous with psychiatric categories. Therefore, our objectives were to evaluate the validity of the PHQ-9, assess the added value of using idioms of distress, and develop an algorithm for depression detection in primary care.

METHODS

We conducted a transcultural translation of the PHQ-9 in Nepal using qualitative methods to achieve semantic, content, technical, and criterion equivalence. Researchers administered the Nepali PHQ-9 to randomly selected patients in a rural primary health care center. Trained psychosocial counselors administered a validated Nepali depression module of the Composite International Diagnostic Interview (CIDI) to validate the Nepali PHQ-9. Patients were also assessed for local idioms of distress including heart-mind problems (Nepali, manko samasya).

RESULTS

Among 125 primary care patients, 17 (14 %) were positive for a major depressive episode in the prior 2 weeks based on CIDI administration. With a Nepali PHQ-9 cutoff ≥ 10: sensitivity = 0.94, specificity = 0.80, positive predictive value (PPV) =0.42, negative predictive value (NPV) =0.99, positive likelihood ratio = 4.62, and negative likelihood ratio = 0.07. For heart-mind problems: sensitivity = 0.94, specificity = 0.27, PPV = 0.17, NPV = 0.97. With an algorithm comprising two screening questions (1. presence of heart-mind problems and 2. function impairment due to heart-mind problems) to determine who should receive the full PHQ-9, the number of patients requiring administration of the PHQ-9 could be reduced by 50 %, PHQ-9 false positives would be reduced by 18 %, and 88 % of patients with depression would be correctly identified.

CONCLUSION

Combining idioms of distress with a transculturally-translated depression screener increases efficiency and maintains accuracy for high levels of detection. The algorithm reduces the time needed for primary healthcare staff to verbally administer the tool for patients with limited literacy. The burden of false positives is comparable to rates in high-income countries and is a limitation for universal primary care screening.