Integrating mental health care into primary care systems in low- and middle-income countries: lessons from PRIME and AFFIRM

Effectiveness of group-based psycho-education on preventing postpartum depression among pregnant women by primary healthcare provider in primary healthcare institution: a cluster-randomized controlled trial

Background

In Ethiopia, one in five mothers suffers from postpartum depression, which needs to be prevented through interventions. According to the World Health Organization, maternal healthcare providers have a unique opportunity to provide psychosocial interventions to prevent the damaging effects of perinatal depression. Hence, this study assessed the effectiveness of prenatal group-based psycho-education in preventing postpartum depression (PPD) in primary healthcare units.

Methods

We conducted a two-arm cluster-randomized controlled trial, enrolling 550 pregnant women at 12-20 weeks of gestation with a normal score (0-4) and a mild score (5-9) on the Patient Health Questionnaire-9 (PHQ-9). The study utilized simple randomization techniques to assign clusters between arms in a 1:1 ratio. The data was collected through face-to-face interviews conducted at 12-20 weeks of gestation and 6 weeks postpartum. The intervention group received usual care plus five prenatal group-based psycho-education (PGBPE) classes, while the control group received only usual care. The PPD status between arms was compared using the chi-square test of association. A mixed-effects multilevel logistic regression model was also used to examine the predictors of the outcome variables.

Results

The overall response rate at the end line was 92.9%. Thus, compared to that in controls, the PPD in the intervention clusters was considerably lower (20 (7.6%) vs. 74 (28.9%)), P = 0.001)/65% (AOR = 0.35, 95% CI = 0.13-0.99), although no difference was detected at baseline. Social support (AOR = 0.04, 95% CI = 0.01-0.15), partner emotional support (AOR = 0.24, 95% CI = 0.12-0.51), PPD literacy (AOR = 0.25, 95% CI = 0.11-0.62), and self-esteem (AOR = 0.22, 95% CI = 0.11-0.47) were more likely to protect mothers from PPD. On the contrary, domestic work (AOR = 9.75, 95% CI = 3.37-28.16), neonates with complications (AOR = 5.79, 95% CI = 2.04-16.45), and unhealthy coping (AOR = 2.39, 95% CI = 1.06-5.42) exposed mothers to PPD.

Conclusion

The implementation of a PGBPE in primary healthcare units (PHCUs) was effective at preventing PPD. Therefore, this intervention method has to be promoted and used in PHCUs to prevent PPD.

Clinical Trial Registration

[Pan African Clinical Trial Registry], identifier [PACTR 202203616584913].

Perspectives of key informants before and after implementing UPSIDES peer support in mental health services: qualitative findings from an international multi-site study

BACKGROUND

Peer support is an essential part of recovery-oriented care worldwide. Contextual factors have an impact on the implementation of peer support work. However, research has paid little attention to similarities and differences of implementation factors in settings varying by income-level and cultural values. The aim of this study is to assess the factors influencing the implementation of a peer support intervention across study sites in low-, middle- and high-income countries in line with the Consolidation Framework for Implementation Research (CFIR).

METHOD

6 focus groups with a total of 54 key informants with relevant contextual (organisational) knowledge regarding implementation facilitators and barriers were conducted at six study sites Ulm and Hamburg (Germany), Butabika (Uganda), Dar es Salaam (Tanzania), Be'er Sheva (Israel), and Pune (India) before and 1.5 years after the start of UPSIDES peer support. Transcripts were analysed using qualitative content analysis.

RESULTS

Across study sites key informants reported benefits of peer support for service users and peer support workers as implementation facilitators. At study sites with lower resources, reduced workload for mental health workers and improved access to mental health services through peer support were perceived as implementation facilitators (CFIR Domain 1: Intervention characteristics). The degree of engagement of mental health workers (CFIR Domain 3: Inner Setting/Domain 4: Individuals involved) varied across study sites and was seen either as a barrier (low engagement) or a facilitator (high engagement). Across study sites, adequate training of peer support workers (CFIR Domain 5: Implementation process) was seen as animplementation facilitator, while COVID-19 as well as low resource availability were reported as implementation barriers (CFIR Domain 2: Outer setting).

CONCLUSIONS

This study highlights the importance of considering contextual factors when implementing peer support, including previous experience and perceived benefits. Particular attention should be given to organisational benefits such as workload reduction and the allocation of sufficient resources as key drivers in LMICs. In HICs, the potential of organisational benefits for successful implementation should be further investigated and promoted.

An integrated knowledge translation (iKT) approach to advancing community-based depression care in Vietnam: lessons from an ongoing research-policy collaboration

BACKGROUND

Evidence-based mental health policies are key to supporting the expansion of community-based mental health care and are increasingly being developed in low and middle-income countries (LMICs). Despite this, research on the process of mental health policy development in LMICs is limited. Engagement between researchers and policy makers via an integrated Knowledge Translation (iKT) approach can help to facilitate the process of evidence-based policy making. This paper provides a descriptive case study of a decade-long policy and research collaboration between partners in Vietnam, Canada and Australia to advance mental health policy for community-based depression care in Vietnam.

METHODS

This descriptive case study draws on qualitative data including team meeting minutes, a focus group discussion with research team leaders, and key informant interviews with two Vietnamese policy makers. Our analysis draws on Murphy et al.'s (2021) findings and recommendations related to stakeholder engagement in global mental health research.

RESULTS

Consistent with Murphy et al.'s findings, facilitating factors across three thematic categories were identified. Related to 'the importance of understanding context', engagement between researchers and policy partners from the formative research stage provided a foundation for engagement that aligned with local priorities. The COVID-19 pandemic acted as a catalyst to further advance the prioritization of mental heath by the Government of Vietnam. 'The nature of engagement' is also important, with findings demonstrating that long-term policy engagement was facilitated by continuous funding mechanisms that have enabled trust-building and allowed the research team to respond to local priorities over time. 'Communication and dissemination' are also crucial, with the research team supporting mental health awareness-raising among policy makers and the community, including via capacity building initiatives.

CONCLUSIONS

This case study identifies factors influencing policy engagement for mental health system strengthening in an LMIC setting. Sustained engagement with policy leaders helps to ensure alignment with local priorities, thus facilitating uptake and scale-up. Funding agencies can play a crucial role in supporting mental health system development through longer term funding mechanisms. Increased research related to the policy engagement process in global mental health will further support policy development and improvement in mental health care in LMICs.

Integrating mental health into primary care in Nigeria: Implementation outcomes and clinical impact of the HAPPINESS intervention

Background

The Health Action for Psychiatric Problems In Nigeria including Epilepsy and SubstanceS (HAPPINESS) intervention is a multicomponent, community-based, mobile technology-supported intervention that integrates mental health into primary health care centers in Nigeria using the World Health Organization's Mental Health Gap Action Programme-Intervention Guide (mhGAP-IG). This study evaluates its implementation and patient-level clinical impact using a quasi-experimental design (single cohort with pre- and post-measures).

Findings

The HAPPINESS intervention implementation demonstrated high feasibility with 84% adoption rate (% of participating primary health centers that completed its roll out) and 81% fidelity (% of clinicians who completed required intervention components according to the protocol). Retention rate in care at 12 months was 86%. Among patients with complete clinical records analyzed (n = 178), there was a statistically significant reduction in 9-item Patient Health Questionnaire scores from baseline (Md = 9.5) to 6 months (Md = 3.0) post-intervention (z = 80.5, p < 0.001), with a large effect size (r = 0.8) and statistically significant reduction in Brief Psychiatric Rating Scale scores from baseline (Md = 36.0) to 6 months (Md = 17.0) post-intervention (z = 128.5, p < 0.001), with a large effect size (r = 0.9).

Implications

Mobile technology-enhanced, mhGAP-IG-based efforts to scale-up mental health services in Nigeria are feasible and effective.

Design and Evaluation of Peer Supervision for Community Mental Health Workers: A Task-Shifting Strategy in Low-Resource Settings

The use of Lay Mental Health Workers (LMHWs) to tackle the treatment gap in low-resource settings is well established, and although they often receive training, the potential of proper supervision to improve outcomes remains untapped. Indeed, given the strain on expert resources, peer-supervision models based on supervisors' seniority of work experience have significant potential especially in relation to community knowledge and embedding of LMHWs. This study summarizes the evaluation of a pilot program for peer supervision on the basis of Social Cognitive Theories of Self-Efficacy for LMHWs in Kerala, India. Two experienced LMHWs worked as supervisors for a total of 12 LMHWs over the course of a year. These participants were subsequently interviewed to analyze their experiences in order to evaluate the potential of peer supervision and distil relevant information to improve future training of LMHWs. The findings include improved performance and emotional support for the participants.

Effectiveness of a coordinated ambulatory care program for patients with mental disorders or multiple sclerosis: results of a prospective non-randomized controlled trial in South Germany

Background

The Psychiatry, Neurology, Psychosomatics and Psychotherapy (PNP) program of the German statutory health insurance AOK BW promotes coordinated and evidence-based specialist care with the aim of providing individualized, guideline-based outpatient care, strengthening the collaboration between health care providers, as well as reducing care costs. The purpose of this study was to evaluate its effectiveness regarding patient-reported outcomes compared to the less specialized general practitioner program (GP) and usual care (UC).

Materials and methods

AOK insured patients, who were on sick leave due to a mental disorder (affective disorder, anxiety disorder, adjustment disorder, somatoform disorder, alcohol abuse disorder, schizophrenia) or multiple sclerosis were included in the prospective non-randomized controlled study. All patients either participated in the PNP program (intervention group, IG-PNP), the general practitioner program (control group, CG-GP) or usual care (control group, CG-UC). Entropy balancing was used to adjust for baseline imbalance between groups. Primary outcome was health-related quality of life, assessed by the Short-form health survey (SF-36) 12 months after diagnosis. Secondary outcomes included symptom severity, functional health, and treatment satisfaction.

Results

Of the 14,483 insured patients who were contacted, 1,104 patients participated at baseline and 725 at follow-up. The adjusted mean differences of SF-36 sum score did not significantly differ between groups: -1.89 (95%-CI = -4.60; 0.81, p = 0.170) between IG-PNP and CG-GP, and -1.42 (95%-CI = -4.05; 1.22, p = 0.293) between PNP and CG-UC. The adjusted mean differences of secondary outcomes did not differ between groups, except for a slightly higher increase of functional health in CG-UC.

Conclusion

We found no evidence that the PNP program is superior to the GP program or to usual care in terms of patient-reported outcomes or treatment satisfaction. The results are limited by the low response rate. Accordingly, future studies should strive for more representative samples. To improve the program, an integration of further collaborative care elements and guideline recommendations might be useful.

Clinical trial registration

DRKS (German Clinical Trials Register https://drks.de/search/en); identifier (DRKS00013114).

Pathways to care for psychosis in Malawi

People with psychosis in Malawi have very limited access to timely assessment and evidence-based care, leading to a long duration of untreated psychosis and persistent disability. Most people with psychosis in the country consult traditional or religious healers. Stigmatising attitudes are common and services have limited capacity, particularly in rural areas. This paper, focusing on pathways to care for psychosis in Malawi, is based on the Wellcome Trust Psychosis Flagship Report on the Landscape of Mental Health Services for Psychosis in Malawi. Its purpose is to inform Psychosis Recovery Orientation in Malawi by Improving Services and Engagement (PROMISE), a longitudinal study that aims to build on existing services to develop sustainable psychosis detection systems and management pathways to promote recovery.

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.

Closing the treatment gap for alcohol use disorders in low- and middle-income countries

The alcohol-attributable disease burden is greater in low- and middle-income countries (LMICs) as compared to high-income countries. Despite the effectiveness of interventions such as health promotion and education, brief interventions, psychological treatments, family-focused interventions, and biomedical treatments, access to evidence-based care for alcohol use disorders (AUDs) in LMICs is limited. This can be explained by poor access to general health and mental health care, limited availability of relevant clinical skills among health care providers, lack of political will and/or financial resources, historical stigma and discrimination against people with AUDs, and poor planning and implementation of policies. Access to care for AUDs in LMICs could be improved through evidence-based strategies such as designing innovative, local and culturally acceptable solutions, health system strengthening by adopting a collaborative stepped care approach, horizontal integration of care into existing models of care (e.g., HIV care), task sharing to optimise limited human resources, working with families of individuals with AUD, and leveraging technology-enabled interventions. Moving ahead, research, policy and practice in LMICs need to focus on evidence-based decision-making, responsiveness to context and culture, working collaboratively with a range of stakeholders to design and implement interventions, identifying upstream social determinants of AUDs, developing and evaluating policy interventions such as increased taxation on alcohol, and developing services for special populations (e.g., adolescents) with AUDs.

Mental Health Gap Action Programme intervention Guide (mhGAP-IG) for Child and Adolescent Mental Health in Low- and Middle-Income Countries (LMIC): A Systematic Review

BACKGROUND

The Mental Health Gap Action Programme (mhGAP) supports engagement of non-specialists in mental health services in Low- and Middle-Income countries. Given this aim, assessment of the effectiveness of approaches under its remit is warranted.

AIMS

We evaluated mhGAP approaches relating to child and adolescent mental health, focusing on provider / child outcomes, and barriers / facilitators of implementation.

METHODS

Thirteen databases were searched for reviews and primary research on mhGAP roll out for child and adolescent mental health.

RESULTS

Twelve studies were reviewed. Provider-level outcomes were restricted to knowledge gains, with limited evidence of other effects. Child-level outcomes included improved access to care, enhanced functioning and socio-emotional well-being. Organisational factors, clients and providers? attitudes and expectations, and transcultural considerations were barriers.

CONCLUSIONS

Further attention to the practical and methodological aspects of implementation of evaluation may improve the quality of evidence of the effectiveness of approaches under its remit.

Tailoring an evidence-based clinical intervention and training package for the treatment and prevention of comorbid heavy drinking and depression in middle-income country settings: the development of the SCALA toolkit in Latin America

BACKGROUND

Effective interventions exist for heavy drinking and depression but to date there has been limited translation into routine practice in global health systems. This evidence-to-practice gap is particularly evident in low- and middle-income countries. The international SCALA project (Scale-up of Prevention and Management of Alcohol Use Disorders and Comorbid Depression in Latin America) sought to test the impact of multilevel implementation strategies on rates of primary health care-based measurement of alcohol consumption and identification of depression in Colombia, Mexico, and Peru.

OBJECTIVE

To describe the process of development and cultural adaptation of the clinical intervention and training package.

METHODS

We drew on Barrero and Castro's four-stage cultural adaption model: 1) information gathering, 2) preliminary adaption, 3) preliminary adaption tests, and 4) adaption refinement. The Tailored Implementation in Chronic Diseases checklist helped us identify potential factors that could affect implementation, with local stakeholder groups established to support the tailoring process, as per the Institute for Healthcare Improvement's Going to Scale Framework.

RESULTS

In Stage 1, international best practice guidelines for preventing heavy drinking and depression, and intelligence on the local implementation context, were synthesised to provide an outline clinical intervention and training package. In Stage 2, feedback was gathered from local stakeholders and materials refined accordingly. These materials were piloted with local trainers in Stage 3, leading to further refinements including developing additional tools to support delivery in busy primary care settings. Stage 4 comprised further adaptions in response to real-world implementation, a period that coincided with the onset of the COVID-19 pandemic, including translating the intervention and training package for online delivery, and higher priority for depression screening in the clinical pathway.

CONCLUSION

Our experience highlights the importance of meaningful engagement with local communities, alongside the need for continuous tailoring and adaptation, and collaborative decision-making.

Mental health literacy among primary healthcare workers in South Africa and Zambia

BACKGROUND

In developing countries, mental health literacy (MHL) still needs to be improved due to the high prevalence of mental disorders. It is widely recognized that MHL can improve health outcomes for both individuals and populations. Healthcare professionals' development in MHL is crucial to the prevention of mental disorders. The aim of this study was to assess MHL of primary healthcare (PHC) workers in South Africa (SA) and Zambia and determinants thereof. Limited evidence is available on the levels of MHL among PHC workers in the sub-Saharan Africa region, which faces a large burden of mental disorders.

METHODS

The study population for this cross-sectional survey comprised PHC workers (n = 250) in five provinces of SA and Zambia. MHL was measured with the Mental Health Literacy Scale (MHLS). We conducted a multivariate analysis to explore determinants of MHL.

RESULTS

Results showed moderate MHL among PHC professionals, but with a wide range from low to high MHL. Knowledge-related items had a greater dispersion than other attributes of MHL. PHC workers with more education showed a greater ability to recognize mental health-related disorders. Those who had experience in the use of mental health-related assessment scales or screening tools reported a higher total MHL. The results confirmed strong internal consistency for the MHLS.

CONCLUSION

The results highlighted varying mental health perceptions and knowledge in PHC. Implementation of specifically developed formal training programs and interventions to improve MHL in PHC workers to strengthen their competence may help bridge the treatment gap.

Substance Use Disorders in Global Mental Health Delivery: Epidemiology, Treatment Gap, and Implementation of Evidence-Based Treatments

LEARNING OBJECTIVES

After participating in this activity, learners should be better able to:• Assess the treatment gap for patients with substance use disorders• Evaluate treatments and models of implementation for substance use disorders ABSTRACT: Substance use disorders (SUDs) account for substantial global morbidity, mortality, and financial and social burden, yet the majority of those suffering with SUDs in both low- and middle-income (LMICs) and high-income countries (HICs) never receive SUD treatment. Evidence-based SUD treatments are available, but access to treatment is severely limited. Stigma and legal discrimination against persons with SUDs continue to hinder public understanding of SUDs as treatable health conditions, and to impede global health efforts to improve treatment access and to reduce SUD prevalence and costs. Implementing SUD treatment in LMICs and HICs requires developing workforce capacity for treatment delivery. Capacity building is optimized when clinical expertise is partnered with regional community stakeholders and government in the context of a unified strategy to expand SUD treatment services. Workforce expansion for SUD treatment delivery harnesses community stakeholders to participate actively as family and peer supports, and as trained lay health workers. Longitudinal supervision of the workforce and appropriate incentives for service are required components of a sustainable, community-based model for SUD treatment. Implementation would benefit from research investigating the most effective and culturally adaptable models that can be delivered in diverse settings.

Primary care-based screening and management of depression amongst heavy drinking patients: Interim secondary outcomes of a three-country quasi-experimental study in Latin America

INTRODUCTION

Implementation of evidence-based care for heavy drinking and depression remains low in global health systems. We tested the impact of providing community support, training, and clinical packages of varied intensity on depression screening and management for heavy drinking patients in Latin American primary healthcare.

MATERIALS AND METHODS

Quasi-experimental study involving 58 primary healthcare units in Colombia, Mexico and Peru randomized to receive: (1) usual care (control); (2) training using a brief clinical package; (3) community support plus training using a brief clinical package; (4) community support plus training using a standard clinical package. Outcomes were proportion of: (1) heavy drinking patients screened for depression; (2) screen-positive patients receiving appropriate support; (3) all consulting patients screened for depression, irrespective of drinking status.

RESULTS

550/615 identified heavy drinkers were screened for depression (89.4%). 147/230 patients screening positive for depression received appropriate support (64%). Amongst identified heavy drinkers, adjusting for country, sex, age and provider profession, provision of community support and training had no impact on depression activity rates. Intensity of clinical package also did not affect delivery rates, with comparable performance for brief and standard versions. However, amongst all consulting patients, training providers resulted in significantly higher rates of alcohol measurement and in turn higher depression screening rates; 2.7 times higher compared to those not trained.

CONCLUSIONS

Training using a brief clinical package increased depression screening rates in Latin American primary healthcare. It is not possible to determine the effectiveness of community support on depression activity rates due to the impact of COVID-19.

Interventions to address the mental health of adolescents and young adults living with or affected by HIV: state of the evidence

INTRODUCTION

Adolescents and young adults (AYA) remain vulnerable to HIV-infection and significant co-morbid mental health challenges that are barriers to treatment and prevention efforts. Globally millions of AYA are living with HIV (AYALH) and/or have been affected by HIV in their families (AYAAH), with studies highlighting the need for mental health programmes. With no current guidelines for delivering mental health interventions for AYALH or AYAAH, a scoping review was undertaken to explore current evidence-based mental health interventions for AYALH and AYAAH to inform future work.

METHODS

The review, targeting work between 2014 and 2020, initially included studies of evidence-based mental health interventions for AYALH and AYAAH, ages 10 to 24 years, that used traditional mental health treatments. Given the few studies identified, we expanded our search to include psychosocial interventions that had mental health study outcomes.

RESULTS AND DISCUSSION

We identified 13 studies, seven focused on AYALH, five on AYAAH, and one on both. Most studies took place in sub-Saharan Africa. Depression was targeted in eight studies with the remainder focused on a range of emotional and behavioural symptoms. Few studies used evidence-based approaches such as Cognitive Behaviour Therapy; psychosocial approaches included mental health treatments, group-based and family strengthening interventions, economic empowerment combined with family strengthening, group-based mindfulness and community interventions. Eleven studies were randomized control trials with four pilot studies. There was variation in sample size, treatment delivery mode (individual focus, group-based, family focus), and measures of effectiveness across studies. Most used trained lay counsellors as facilitators, with few using trained mental health professionals. Eleven studies reported positive intervention effects on mental health.

CONCLUSIONS

Despite the need for mental health interventions for AYALH and AYAAH, we know surprisingly little about mental health treatment for this vulnerable population. There are some promising approaches, but more work is needed to identify evidence-based approaches and corresponding mechanisms of change. Given limited resources, integrating mental health treatment into healthcare settings and using digital health approaches may support more standardized and scalable treatments. Greater emphasis on implementation science frameworks is needed to create sustainable mental health treatment for AYALH and AYAAH globally.

Perception and barriers to the use of cognitive-behavioral therapy in the treatment of depression in primary healthcare centers and family medicine clinics in Saudi Arabia

BACKGROUND

General practitioners (GPs) and family medicine physicians (FMPs) have a vital role to play in co-ordinating the care for mental disorders. The objective of this study was to determine the perception of GPs and FMPs on the use of cognitive-behavioral therapy (CBT) for depression in Saudi Arabia, and the barriers against the implementation of CBT in such settings.

MATERIALS AND METHODS

All physicians working in Primary Healthcare Centers and Family Medicine Clinics in Saudi Arabia were targeted and invited to participate in this cross-sectional study. A self-administered online questionnaire was sent via E-mail through the Saudi Commission for Health Specialties and the Saudi Society of Family and Community Medicine. Data was collected using an existing validated questionnaire and was modified to fit the objectives of current study.

RESULTS

A total of 469 FMPs and GPs completed the survey; the mean age of respondents was 38 years. More than half of the FMPs' and GPs' (53%) showed a positive perception of the use of CBT in primary healthcare settings. Most participants (91.9%) were willing to use CBT if they had adequate education and training. More than half of the participants (59.5%) thought it was time-consuming, while 39% thought that CBT training was a very time-intensive process.

CONCLUSION

We conclude that more than half of the physicians clearly had a good perception of the effectiveness of CBT administration in primary healthcare settings. Younger physicians were more perceptive. The most agreed-on barrier to CBT implementation was the lack of training and education.

WHO mental health gap action programme (mhGAP) intervention guide: updated systematic review on evidence and impact

QUESTION

There is a large worldwide gap between the service need and provision for mental, neurological and substance use disorders. WHO's Mental Health Gap Action Programme (mhGAP) intervention guide (IG), provides evidence-based guidance and tools for assessment and integrated management of priority disorders. Our 2017 systematic review identified 33 peer-reviewed studies describing mhGAP-IG implementation in low-income and middle-income countries.

STUDY SELECTION AND ANALYSIS

We searched MEDLINE, Embase, PsycINFO, Web of Knowledge, Scopus, CINAHL, LILACS, ScieELO, Cochrane, PubMed databases, 3ie, Google Scholar and citations of our review, on 24 November 2020. We sought evidence, experience and evaluations of the mhGAP-IG, app or mhGAP Humanitarian IG, from any country, in any language. We extracted data from included papers, but heterogeneity prevented meta-analysis.

FINDINGS

Of 2621 results, 162 new papers reported applications of the mhGAP-IG. They described mhGAP training courses (59 references), clinical applications (n=49), research uses (n=27), contextual adaptations (n=13), economic studies (n=7) and other educational applications (n=7). Most were conducted in the African region (40%) and South-East Asia (25%). Studies demonstrated improved knowledge, attitudes and confidence post-training and improved symptoms and engagement with care, post-implementation. Research studies compared mhGAP-IG-enhanced usual care with task-shared psychological interventions and adaptation studies optimised mhGAP-IG implementation for different contexts. Economic studies calculated human resource requirements of scaling up mhGAP-IG implementation and other educational studies explored its potential for repurposing.

CONCLUSIONS

The diverse, expanding global mhGAP-IG literature demonstrates substantial impact on training, patient care, research and practice. Priorities for future research should be less-studied regions, severe mental illness and contextual adaptation of brief psychological interventions.

Barriers and drivers to stakeholder engagement in global mental health projects

Background

Engagement with diverse stakeholders, including policy makers, care providers and service users and communities, is essential for successful implementation of global mental health interventions. Despite being a fundamental factor in the implementation process, evidence about challenges and drivers to stakeholder engagement is limited in the global mental health literature.

Methods

We conducted semi-structured qualitative interviews with 29 recipients of Grand Challenges Canada Global Mental Health funding to assess barriers and drivers to global mental health implementation across a portfolio of projects. We used framework analysis to identify key themes related to implementation barriers and drivers. This paper reports on barriers and drivers to stakeholder engagement, with results related to capacity development and service delivery reported elsewhere in this journal.

Results

Barriers and drivers to stakeholder engagement were identified across four themes: (1) Contextual Considerations, (2) Resources, (3) Participation, Uptake and Empowerment, and (4) Stigma. While complex contextual challenges create barriers, mechanisms such as formative research can facilitate a deeper contextual understanding that supports effective implementation planning. Limited financial and human resources and competing priorities can lead to substantial challenges. Investing in and leveraging existing local resources and expertise can help to mitigate these barriers. The challenge of achieving active participation from stakeholders and diverging expectations about the nature of participation were identified as barriers, while providing opportunities for meaningful participation and empowerment acted as drivers. Stigma at the institutional, community and individual level was also identified as a substantial barrier to engagement.

Conclusion

The findings of this study are relevant to implementers in global mental health. They also have implications for global mental health funding agencies and policy organizations, who can support improved stakeholder engagement by investing in high-quality formative research, supporting capacity building for policy engagement, investing in longer-term funding schemes to support sustainable partnerships and scale-up, thus fostering successful engagement and supporting effective implementation of global mental health innovations.

Developing a task-sharing psychological intervention to treat mild to moderate symptoms of perinatal depression and anxiety in South Africa: a mixed-method formative study

BACKGROUND

Symptoms of depression and anxiety are highly prevalent amongst perinatal women in low-resource settings of South Africa, but there is no access to standardised counselling support for these conditions in public health facilities. The aim of this study is to develop a task-sharing psychological counselling intervention for routine treatment of mild to moderate symptoms of perinatal depression and anxiety in South Africa, as part of the Health Systems Strengthening in sub-Saharan Africa (ASSET) study.

METHODS

We conducted a review of manuals from seven counselling interventions for depression and anxiety in low- and middle-income countries and two local health system training programmes to gather information on delivery format and common counselling components used across task-sharing interventions. Semi-structured interviews were conducted with 20 health workers and 37 pregnant women from four Midwife Obstetric Units in Cape Town to explore perceptions and needs relating to mental health. Stakeholder engagements further informed the intervention design and appropriate service provider. A four-day pilot training with community-based health workers refined the counselling content and training material.

RESULTS

The manual review identified problem-solving, psychoeducation, basic counselling skills and behavioural activation as common counselling components across interventions using a variety of delivery formats. The interviews found that participants mostly identified symptoms of depression and anxiety in behavioural terms, and lay health workers and pregnant women demonstrated their understanding through a range of local idioms. Perceived causes of symptoms related to interpersonal conflict and challenging social circumstances. Stakeholder engagements identified a three-session counselling model as most feasible for delivery as part of existing health care practices and community health workers in ward-based outreach teams as the best placed delivery agents. Pilot training of a three-session intervention with community-based health workers resulted in minor adaptations of the counselling assessment method.

CONCLUSION

Input from health workers and pregnant women is a critical component of adapting existing maternal mental health protocols to the context of routine care in South Africa, providing valuable data to align therapeutic content with contextual needs. Multisector stakeholder engagements is vital to align the intervention design to health system requirements and guidelines.

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.

Nurse-Delivered Cognitive Behavioral Therapy for Adherence and Depression Among People Living With HIV (the Ziphamandla Study): Protocol for a Randomized Controlled Trial

BACKGROUND

There is an unmet need to develop effective, feasible, and scalable interventions for poor adherence and depression in persons living with HIV in low- and middle-income countries (LMIC).

OBJECTIVE

This study aims to investigate the effectiveness of a nurse-delivered cognitive behavioral therapy (CBT) intervention for adherence and depression (CBT-AD) among persons living with HIV who are failing first-line antiretroviral therapy (ART) in Cape Town, South Africa.

METHODS

This study is a 2-arm randomized controlled trial of CBT-AD integrated into the HIV primary care setting in South Africa. A total of 160 participants who did not achieve viral suppression from their first-line ART and have a unipolar depressive mood disorder will be randomized to receive either 8 sessions of CBT-AD or enhanced treatment as usual. Participants will be assessed for major depressive disorder using the Mini International Neuropsychiatric Interview at baseline and 4, 8, and 12 months. The primary outcomes are depression on the Hamilton Depression Scale (HAM-D; as assessed by a blinded assessor) at the 4-month assessment and changes in ART adherence (assessed via real-time, electronic monitoring with Wisepill) between baseline and the 4-month assessment. Secondary outcomes are HIV viral load and CD4 cell count at the 12-month assessment as well as ART adherence (Wisepill) and depression (HAM-D) over follow-up (4-, 8-, and 12-month assessments).

RESULTS

The trial commenced in August 2015 and recruitment began in July 2016. Enrollment was completed in June 2019.

CONCLUSIONS

Results of this study will inform whether an existing intervention (CBT-AD) can be effectively administered in LMIC by nurses with training and ongoing supervision. This will present unique opportunities to further explore the scale-up of a behavioral intervention to enhance ART adherence among persons living with HIV with major depression in a high-prevalence setting, to move toward achieving The Joint United Nations Programme on HIV/AIDS 90-90-90 goals.

TRIAL REGISTRATION

ClincialTrials.gov NCT02696824; https://clinicaltrials.gov/ct2/show/NCT02696824.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/14200.

Barriers and facilitators of mental health programmes in primary care in low-income and middle-income countries

Integration of services into primary health care for people with common mental disorders is considered a key strategy to improve access to mental health care in low-income and middle-income countries, yet services at the primary care level are largely unavailable. We did a systematic review to understand the barriers and facilitators in the implementation of mental health programmes. We searched five databases and included studies published between Jan 1, 1990, and Sept 1, 2017, that used qualitative methods to assess the implementation of programmes for adults with common mental disorders at primary health-care settings in low-income and middle-income countries. The Critical Appraisal Skills Programme Qualitative Checklist was used to assess the quality of eligible papers. We used the so-called best fit framework approach to synthesise findings according to the Consolidated Framework for Implementation Research. We identified 24 papers for inclusion. These papers described the implementation of nine programmes in 11 countries. Key factors included: the extent to which an organisation is ready for implementation; the attributes, knowledge, and beliefs of providers; complex service user needs; adaptability and perceived advantage of interventions; and the processes of planning and evaluating the implementation. Evidence on implementation of mental health programmes in low-income and middle-income countries is scarce. Synthesising results according to the Consolidated Framework for Implementation Research helped to identify key areas for future action, including investment in primary health-care strengthening, capacity building for health providers, and increased support to address the social needs of service users.

National Policies and Older People's Healthcare in Sub-Saharan Africa: A Scoping Review

Background:

Sub-Saharan Africa (SSA) is undergoing a rapid demographic change, with more people reaching old age. There is, however, little information available about healthcare policies with regards to this age group in this region of the world.

Objectives:

This scoping review aims to map the healthcare policies in sub-Saharan Africa (SSA) after the 2002 United Nations Madrid International Plan of Action on Ageing (MIPAA) with an eye towards to identifying strategies for promoting older people’s access to health care, integration of older people’s diseases into primary health care and the level of training and research in geriatrics and gerontology in SSA.

Methods:

This review adopted Arskey and O’Malley’s five-step methodology for scoping review and used the guide by Levac et al to operationalize the steps. Potentially relevant literature in English published between January 2003 and December 2017 was identified through PubMed, Google Scholar, EBSCOhost, and manual search. Articles that related to ageing in SSA in line with the aims of the review were included. The identified articles were independently assessed by the authors and the decision on the articles to be included was reached by a consensus.

Findings:

A total of 363 articles were identified through the databases and manual search of which only 4.7% (17/363) of the articles were included in the review. The findings showed that many SSA countries have formulated policies on healthy ageing and a few have policies to promote access to health care for the older people. The integration of non-communicable diseases (NCDs) management into primary health care (PHC) is encouraging but mental health appears to have been completely neglected. Training and research in gerontology and geriatrics are hardly supported by governments in SSA.

Conclusions:

Significant progress has been made by the SSA countries in policy formulation with regards to older persons but not much has been achieved with the implementation of the policies.

Innovative Models in Mental Health Delivery Systems: Task Sharing Care with Non-specialist Providers to Close the Mental Health Treatment Gap

PURPOSE OF REVIEW

Most people do not have access to adequate mental health care, and lack of skilled human resources is a major factor. We provide a narrative review of approaches to implementing task sharing-engaging non-specialist providers-to deliver mental health care.

RECENT FINDINGS

There is strong evidence both for the effectiveness of task sharing as a means of delivering care for a range of conditions across settings and for the effectiveness of non-specialist providers and health workers in delivering elements of culturally adapted psychosocial and psychological interventions for common and severe mental disorders. Key approaches to facilitate task sharing of care include balanced care, collaborative care, sustained training and supervision, use of trans-diagnostic interventions based on a dimensional approach to wellness and illness, and the use of emerging digital technologies. Non-specialist providers and health workers are well positioned to deliver evidence-based interventions for mental disorders, and a variety of delivery approaches can support, facilitate, and sustain this innovation. These approaches should be used, and evaluated, to increase access to mental health services.

The transcendent voice of recovery mentors in mental health: a philosophical reflection

In a globalized world health and illness know no frontiers. Pandemics have never been limited to political borders and the contemporary campaigns to prevent them can be effective only when addressed not only internationally but also with the application of integrated disease management in order to respond to problems caused by the silo approach. In any case, it appears that global health has been constantly in redefinition. With this commentary a phenomenological redefinition of global health is proposed as an integrative strategy. Phenomenology prioritizes and investigates from the first-person point of view how the human being experiences the world, as it explores the unique meaning of the lived experience of being human. We are particularly interested in verifying if and how, from a first-person point of view, the lived experience of mental illness and of recovery can contribute to a more integrated definition of global health. In the field of mental health, formal peer support is a mentor/mentee relationship, and as such it is an emotional and practical support between two people who share a common experience of a mental health challenge or illness. Peer support is a system of giving and receiving help founded on key principles of respect, shared responsibility, and mutual agreement of what is helpful. It is about understanding another's situation empathically through the shared experience of emotional and psychological pain. And when speaking in public, a recovery mentor accepts to disclose and to be recognized as a (former) mental health service user. That person knows that there is a possibility of being stigmatized, but yet remains courageously engaged towards the promotion of change and in solidarity with people who are suffering worldwide and who may not have this opportunity to speak freely.

Mixed-methods evaluation of mental healthcare integration into tuberculosis and maternal-child healthcare services of four South African districts

BACKGROUND

The South African National Mental Health Policy Framework and Strategic Plan 2013-2020 was adopted to address the country's substantial burden and inadequate treatment of mental illness. It outlines measures toward the goal of full integration of mental health services into primary care by 2020. To evaluate progress and challenges in implementation, we conducted a mixed-methods assessment of mental health service provision in tuberculosis and maternal-child healthcare services of four districts in South Africa.

METHODS

Forty clinics (ten per district) were purposively selected to represent both urban and rural locations. District-level program managers (DPMs) for mental health, tuberculosis, and maternal-child healthcare were qualitatively interviewed about district policy and procedures for management of mental illness and challenges in integrating mental health services into primary care. Clinic nurses and mental health practitioners (MHPs) completed a quantitative questionnaire to assess their engagement with stepped care for patients with mental illness. Qualitative and quantitative data were collected concurrently and compared to triangulate progress in implementation of integrated services.

RESULTS

A total of 59 nurses and 17 MHPs completed questionnaires, and nine DPMs were interviewed (total n = 85). DPMs indicated that nurses should screen for mental illness at every patient visit, although only 43 (73%) nurses reported conducting universal screening and 26 (44%) reported using a specific screening tool. For patients who screen positive for mental illness, DPMs described a stepped-care approach in which MHPs diagnose patients and then treat or refer them to specialized care. However, only 7 (41%) MHPs indicated that they diagnose mental illness and 14 (82%) offer any treatment for mental illness. Addressing challenges to current integration efforts, DPMs highlighted 1) insufficient funding and material resources, 2) poor coordination at the district administrative level, and 3) low mental health awareness in district administration and the general population.

CONCLUSIONS

Though some progress has been made toward integration of mental health services into primary care settings, there is a substantial lack of training and clarity of roles for nurses and MHPs. To enhance implementation, increased efforts must be directed toward improving district-level administrative coordination, mental health awareness, and financial and material resources.

"We find what we look for, and we look for what we know": factors interacting with a mental health training program to influence its expected outcomes in Tunisia

BACKGROUND

Primary care physicians (PCPs) working in mental health care in Tunisia often lack knowledge and skills needed to adequately address mental health-related issues. To address these lacunas, a training based on the Mental Health Gap Action Programme (mhGAP) Intervention Guide (IG) was offered to PCPs working in the Greater Tunis area between February and April 2016. While the mhGAP-IG has been used extensively in low- and middle-income countries (LMICs) to help build non-specialists' mental health capacity, little research has focused on how contextual factors interact with the implemented training program to influence its expected outcomes. This paper's objective is to fill that lack.

METHODS

We conducted a case study with a purposeful sample of 18 trained PCPs. Data was collected by semi-structured interviews between March and April 2016. Qualitative data was analyzed using thematic analysis.

RESULTS

Participants identified more barriers than facilitators when describing contextual factors influencing the mhGAP-based training's expected outcomes. Barriers were regrouped into five categories: structural factors (e.g., policies, social context, local workforce development, and physical aspects of the environment), organizational factors (e.g., logistical issues for the provision of care and collaboration within and across healthcare organizations), provider factors (e.g., previous mental health experience and personal characteristics), patient factors (e.g., beliefs about the health system and healthcare professionals, and motivation to seek care), and innovation factors (e.g., training characteristics). These contextual factors interacted with the implemented training to influence knowledge about pharmacological treatments and symptoms of mental illness, confidence in providing treatment, negative beliefs about certain mental health conditions, and the understanding of the role of PCPs in mental health care delivery. In addition, post-training, participants still felt uncomfortable with certain aspects of treatment and the management of some mental health conditions.

CONCLUSIONS

Findings highlight the complexity of implementing a mhGAP-based training given its interaction with contextual factors to influence the attainment of expected outcomes. Results may be used to tailor structural, organizational, provider, patient, and innovation factors prior to future implementations of the mhGAP-based training in Tunisia. Findings may also be used by decision-makers interested in implementing the mhGAP-IG training in other LMICs.

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.

Comparing dedicated and designated models of integrating mental health into chronic disease care: study protocol for a cluster randomized controlled trial

BACKGROUND

In low- and middle-income countries (LMIC), it is uncertain whether a "dedicated" approach to integrating mental health care (wherein a community health worker (CHW) has the sole responsibility of delivering mental health care) or a "designated" approach (wherein a CHW provides this service in addition to usual responsibilities) is most effective and cost-effective. This study aims to compare the effectiveness and cost-effectiveness of these two models of service integration relative to treatment as usual (TAU) for improving mental health and chronic disease outcomes among patients with HIV or diabetes.

METHODS/DESIGN

This is a cluster randomised trial. We will randomise 24 primary health care facilities in the Western Cape Province of South Africa to one of three study arms. Within each cluster, we will recruit 25 patients from HIV and 25 from diabetes services for a total sample of 1200 participants. Eligible patients will be aged 18 years or older, take medication for HIV or diabetes, and screen positive on the Alcohol Use Disorder Identification Test for hazardous/harmful alcohol use or depression on the Centre for Epidemiology Scale on Depression. Participants recruited in clinics assigned to the designated or dedicated approach will receive three sessions of motivational interviewing and problem-solving therapy, while those recruited at TAU-assigned clinics will be referred for further assessment. Participants will complete an interviewer-administered questionnaire at baseline, and at 6 and 12 months post-enrolment to assess change in self-reported outcomes. At these end points, we will test HIV RNA viral load for participants with HIV and HbA1c levels for participants with diabetes. Primary outcomes are reductions in self-reported hazardous/harmful alcohol use and risk of depression. Secondary outcomes are improvements in adherence to chronic disease treatment, biomarkers of chronic disease outcomes, and health-related quality of life. Mixed-effect linear regression models will model the effect of the interventions on primary and secondary outcomes. The cost-effectiveness of each approach will be assessed using incremental cost-effectiveness ratios.

DISCUSSION

Study findings will guide decision-making around how best to integrate mental health counselling into chronic disease care in a LMIC setting.

TRIAL REGISTRATION

Pan African Clinical Trials Registry, Trial registration number: ACTR201610001825403 . Registered 17 October 2016.