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

Learning Outcomes of e-Learning in Psychotherapy Training and Comparison With Conventional Training Methods: Systematic Review

BACKGROUND

Mental disorders pose a major public health problem in most western countries. The demand for services for common mental health disorders has been on the rise despite the widespread accessibility of medication. Especially, the supply and demand for evidence-based psychotherapy do not align. Large-scale increase of modern psychotherapy is difficult with current methods of training which are often expensive, time consuming, and dependent on a small number of top-level professionals as trainers. E-learning has been proposed to enhance psychotherapy training accessibility, quality, and scalability.

OBJECTIVE

This systematic review aims to provide an overview of the current evidence regarding e-learning in psychotherapy training. In particular, the review examines the usability, acceptability, and learning outcomes associated with e-learning. Learning outcomes are assessed in different modalities including trainee experiences, knowledge acquisition, skill acquisition, and application of trained content in daily practice. Furthermore, the equivalence of web-based training and conventional training methods is evaluated.

METHODS

Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a search from Ovid, MEDLINE, PsycINFO, and Scopus databases between 2008 and June 2022 was conducted. Inclusion criteria required studies to describe e-learning systems for psychotherapy training and assess acceptability, feasibility, or learning outcomes. The risk of bias was evaluated for both randomized and nonrandomized studies. Learning outcomes were categorized using the Kirkpatrick model. Effect sizes comparing e-learning and traditional methods were calculated.

RESULTS

The search yielded 3380 publications, of which 34 fulfilled the inclusion criteria. Positive learning outcomes are generally associated with various e-learning programs in psychotherapy training including trainee satisfaction, knowledge, and skill acquisition, and in application of trained content in clinical practice. Learning outcomes generally show equivalence between e-learning and conventional training methods. The overall effect size, indicating this disparity, was 0.01, suggesting no significant difference. This literature displays a high level of heterogeneity in e-learning solutions and assessment methods.

CONCLUSIONS

e-Learning seems to have good potential to enhance psychotherapy training by increasing access, scalability, and cost-effectiveness while maintaining quality in terms of learning outcomes. Results are congruent with findings related to e-learning in health education in general where e-learning as a pedagogy is linked to an opportunity to carry out learner-centric practices. Recommendations for conducting psychotherapy training programs in blended settings supported by activating learning methods are presented. However, due to the heterogeneity and limitations in the existing literature, further research is necessary to replicate these findings and to establish global standards for e-learning, as well as for the assessment of training outcomes in psychotherapy education. Research is especially needed on the effects of training on patient outcomes and optimal ways to combine e-learning and conventional training methods in blended learning settings.

Training community health volunteers to use mobile platform during the COVID-19 pandemic: The Kenya experience

This study describes an alternative to face-to-face training method for community health volunteers (CHVs) as used by a collaborative group from the University of Nairobi, University of Washington and the Nairobi Metropolitan Mental Health Team during the COVID-19 lockdown in Kenya. This qualitative study describes the experiences of 17 CHVs enrolled in a training study, required to utilize different digital platforms (Google Meet or Jitsi) as a training forum for the first time. Verbatim extracts of the participants' daily experiences are extracted from a series of write-ups in the group WhatsApp just before the training. Daily failures and success experiences in joining a Google meet or Jitsi are recorded. Then, 17 participants, 10 women and 7 men, aged between 21 and 51 years (mean = 33), owning a smartphone, were enrolled in the study. None had used Jitsi or Google meet before. Different challenges were reported in login to either and a final decision to use Jitsi, which became the training platform. Training CHVs to deliver a psychosocial intervention using smartphones is possible. However, the trainer must establish appropriate and affordable methods when resources are constrained.

Digital psychiatry in low-and-middle-income countries: New developments and the way forward

Low- and middle-income countries (LMICs) bear the greater share of the global mental health burden but are ill-equipped to deal with it because of severe resource constraints leading to a large treatment gap. The remote provision of mental health services by digital means can effectively augment conventional services in LMICs to reduce the treatment gap. Digital psychiatry in LMICs has always lagged behind high-income countries, but there have been encouraging developments in the last decade. There is increasing research on the efficacy of digital psychiatric interventions. However, the evidence is not adequate to conclude that digital psychiatric interventions are invariably effective in LMICs. A striking development has been the rise in mobile and smartphone ownership in LMICs, which has driven the increasing use of mobile technologies to deliver mental health services. An innovative use of mobile technologies has been to optimize task-shifting, which involves delivering mental healthcare services in community settings using non-specialist health professionals. Emerging evidence from LMICs shows that it is possible to use digital tools to train non-specialist workers effectively and ensure that the psychosocial interventions they deliver are efficacious. Despite these promising developments, many barriers such as service costs, underdeveloped infrastructure, lack of trained professionals, and significant disparities in access to digital services impede the progress of digital psychiatry in LMICs. To overcome these barriers, digital psychiatric services in LMICs should address contextual factors influencing the delivery of digital services, ensure collaboration between different stakeholders, and focus on reducing the digital divide.

ESSENCE: An Implementation Research Program to Scale Up Depression Care in Rural Communities

BACKGROUND

Task sharing may involve training nonspecialist health workers (NSHWs) to deliver brief mental health interventions. This approach is promising for reducing the global mental health treatment gap. However, capacity is limited for training large cadres of frontline workers in low- and middle-income countries, hindering uptake of these interventions at scale.

METHODS

The ESSENCE (enabling translation of science to service to enhance depression care) project in Madhya Pradesh, India, aims to address these challenges through two sequential randomized controlled trials. First, a training trial will evaluate the effectiveness and cost-effectiveness of digital training, compared with conventional face-to-face training, in achieving clinical competency of NSHWs in delivering an intervention for depression. This initial trial will be followed by an implementation trial aimed at evaluating the effectiveness of a remote enhanced implementation support, compared with routine implementation support, in addressing barriers to delivery of depression care in primary care facilities.

RESULTS

This project involved developing and pilot testing a scalable smartphone-based program for training NSHWs to deliver a brief psychological intervention for depression screening. This initial research guided a randomized trial of a digital training approach with NSHWs to evaluate the effectiveness of this approach. This trial will be followed by a cluster-randomized trial to evaluate the effectiveness of remote implementation support in ensuring efficient delivery of depression care in primary care facilities.

NEXT STEPS

Findings from these trials may inform sustainable training and implementation support models to integrate depression care into primary care for scale-up in resource-constrained settings.

The effectiveness of mental health interventions involving non-specialists and digital technology in low-and middle-income countries - a systematic review

BACKGROUND

Combining non-specialists and digital technologies in mental health interventions could decrease the mental healthcare gap in resource scarce countries. This systematic review examined different combinations of non-specialists and digital technologies in mental health interventions and their effectiveness in reducing the mental healthcare gap in low-and middle-income countries.

METHODS

Literature searches were conducted in four databases (September 2023), three trial registries (January-February 2022), and using forward and backward citation searches (May-June 2022). The review included primary studies on mental health interventions combining non-specialists and digital technologies in low-and middle-income countries. The outcomes were: (1) the mental health of intervention receivers and (2) the competencies of non-specialists to deliver mental health interventions. Data were expressed as standardised effect sizes (Cohen's d) and narratively synthesised. Risk of bias assessment was conducted using the Cochrane risk-of-bias tools for individual and cluster randomised and non-randomised controlled trials.

RESULTS

Of the 28 included studies (n = 32 interventions), digital technology was mainly used in non-specialist primary-delivery treatment models for common mental disorders or subthreshold symptoms. The competencies of non-specialists were improved with digital training (d ≤ 0.8 in 4/7 outcomes, n = 4 studies, 398 participants). The mental health of receivers improved through non-specialist-delivered interventions, in which digital technologies were used to support the delivery of the intervention (d > 0.8 in 24/40 outcomes, n = 11, 2469) or to supervise the non-specialists' work (d = 0.2-0.8 in 10/17 outcomes, n = 3, 3096). Additionally, the mental health of service receivers improved through digitally delivered mental health services with non-specialist involvement (d = 0.2-0.8 in 12/27 outcomes, n = 8, 2335). However, the overall certainty of the evidence was poor.

CONCLUSION

Incorporating digital technologies into non-specialist mental health interventions tended to enhance non-specialists' competencies and knowledge in intervention delivery, and had a positive influence on the severity of mental health problems, mental healthcare utilization, and psychosocial functioning outcomes of service recipients, primarily within primary-deliverer care models. More robust evidence is needed to compare the magnitude of effectiveness and identify the clinical relevance of specific digital functions. Future studies should also explore long-term and potential adverse effects and interventions targeting men and marginalised communities.

Overcoming training bottlenecks: mixed-methods evaluation of digital training for non-specialists in postnatal depression self-help treatment

OBJECTIVES

This mixed-methods study evaluated the feasibility, acceptability and preliminary effectiveness of an interactive digital training programme for non-specialist supporters providing a guided self-help intervention for postnatal depression (PND).

METHODS

A total of 49 non-specialist trainees participated. Six digital training modules were flexibly delivered over a 5-week period. Training included a chatroom, moderated by a supervised assistant psychologist. Quantitatively, feasibility was assessed via participation and retention levels; acceptability was examined using course evaluation questionnaires; and effectiveness was measured pre-test-post-test quantitatively using a self-report questionnaire and pre-post using scenario questions. Participant focus groups explored feasibility, acceptability and effectiveness.

RESULTS

The training was feasible; 41 completed the course and 42 were assessed at follow-up. Quantitative course evaluation and thematic analysis of focus group feedback demonstrated high training acceptability. RANOVAs indicated training significantly improved knowledge and confidence pre- to post-test. There were demonstrable increases in specific skills at post-test as assessed via clinical scenarios.

CONCLUSION

This training is a feasible, acceptable and effective way to upskill non-specialists in supporting treatment for PND, however supervised practice is recommended to ensure participants embed knowledge competently into practice. The training offers an effective first step in upskilling non-specialist supporters to support women with PND treatment at scale.

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.

Human Resources for Health in Conflict Affected Settings: A Scoping Review of Primary Peer Reviewed Publications 2016-2022

BACKGROUND

Conflict has devastating effects on health systems, especially on healthcare workers (HCWs) working in under-resourced and hostile environments. However, little evidence is available on how policy-makers, often together with development partners, can optimize the organization of the health workforce and support HCWs to deliver accessible and trustworthy health services in conflict-affected settings (CAS).

METHODS

A scoping review was conducted to review recent evidence (2016-2022) on human resources for health (HRH) in CAS, and critically discuss HRH challenges in these settings. Thirty-six studies were included in the review and results were presented using an adapted version of the health labour market (HLM) framework.

RESULTS

Evidence from CAS highlights that conflict causes specific constraints in both the education sector and in the HLM, and deepens any existing disconnect between those sectors. Parallel and inadequate education and performance management systems, attacks on health facilities, and increased workload and stress, amongst other factors, affect HCW motivation, performance, distribution, and attrition. Short-term, narrowly focused policy-making undermines the long-term sustainability and resilience of the health workforce in CAS, and also contributes to the limited and narrow available research base.

CONCLUSION

While HRH and workforce issues in CAS include those found in many other low- and middle-income countries (LMICs), an additional set of challenges for HCWs, governance dynamics and institutional constraints in CAS 'multiply' negative effects on the health workforce. HRH policies, programmes and interventions must be aligned with the political and broader societal context, including the stage, severity and other dynamics of conflict. During conflict, it is important to try to monitor in- and outflow of HCWs and provide HCWs the support they need at local level or through remote measures. The post-conflict situation may present opportunities for improvement in HRH, but a clear understanding of political economy dynamics is required to better act on any such a window of opportunity.

Co-developed implementation guidelines to maximize acceptability, feasibility, and usability of mobile phone supervision in Kenya

Opportunities exist to leverage mobile phones to replace or supplement in-person supervision of lay counselors. However, contextual variables, such as network connectivity and provider preferences, must be considered. Using an iterative and mixed methods approach, we co-developed implementation guidelines to support the implementation of mobile phone supervision with lay counselors and supervisors delivering a culturally adapted trauma-focused cognitive behavioral therapy in Western Kenya. Guidelines were shared and discussed with lay counselors in educational outreach visits led by supervisors. We evaluated the impact of guidelines and outreach on the acceptability, feasibility, and usability of mobile phone supervision. Guidelines were associated with significant improvements in acceptability and usability of mobile phone supervision. There was no evidence of a significant difference in feasibility. Qualitative interviews with lay counselors and supervisors contextualized how guidelines impacted acceptability and feasibility - by setting expectations for mobile phone supervision, emphasizing importance, increasing comfort, and sharing strategies to improve mobile phone supervision. Introducing and discussing co-developed implementation guidelines significantly improved the acceptability and usability of mobile phone supervision. This approach may provide a flexible and scalable model to address challenges with implementing evidence-based practices and implementation strategies in lower-resourced areas.

Applying Human-Centered Design in Global Mental Health to Improve Reach Among Underserved Populations in the United States and India

INTRODUCTION

Human-centered design (HCD) refers to a diverse suite of interactive processes that engage end users in the development of a desired outcome. We showcase how 2 global mental health research teams applied HCD to develop mobile health tools, each directed at reducing treatment gaps in underserved populations. CASE STUDY 1: Refugees face higher risks for mental health problems, yet these communities face structural and cultural barriers that reduce access to and use of services. To address these challenges, the Research Program on Children and Adversity at the Boston College School of Social Work, in partnership with resettled refugee communities in the northeastern United States, used codesign methodology to digitally adapt delivery of the Family Strengthening Intervention for Refugees-a program designed to improve mental health and family functioning among resettled families. We describe how codesign methods support the development of more feasible, acceptable, and sustainable interventions. CASE STUDY 2: Sangath, an NGO in India focused on mental health services research, in partnership with Harvard Medical School, designed and evaluated a digital training program for community health workers to deliver an evidence-based, brief psychological treatment for depression as part of primary care in Madhya Pradesh, India. We describe how HCD was applied to program development and discuss our approach to scaling up training and capacity-building to deliver evidence-based treatment for depression in primary care.

IMPLICATIONS

HCD involves a variety of techniques that can be flexibly adapted to engage end users in the conceptualization, implementation, scale-up, and sustainment of global mental health interventions. Community solutions generated using HCD offer important benefits for key stakeholders. We encourage widespread adoption of HCD within global mental health policy, research, and practice, especially for addressing mental health disparities with underserved populations.

WhatsApp supervision for a lay-led Islamic trauma-focused intervention in Somaliland: Qualitative content analysis

Clinical supervision is critical for the uptake of psychotherapy but difficult to facilitate in countries with limited providers, resources, and internet infrastructure. Innovative supervision approaches are needed to increase access to mental health treatments in low-to-middle income countries (LMICs). This study examined the content and feasibility of remote WhatsApp text supervision conducted as part of an open clinical trial in Somaliland. Islamic Trauma Healing ITH) is a brief, group, lay-lead, trauma-focused, mosque-based intervention that has demonstrated initial efficacy in pilot studies in the United States and Somaliland. After a 2-day, in-person training, lay leaders led four groups of five to seven members focused on trauma-related psychopathology and community reconciliation. Somali lay leaders trained in ITH (n = 9) and the research team (n = 6) attended weekly WhatsApp supervision during the intervention. Content was logged and subjected to qualitative analysis by two coders. Comments related to intervention implementation indicated that lay leaders understood the treatment rationale, adhered to treatment procedures, and believed the intervention components to be helpful and culturally relevant. Themes related to engagement suggested perfect attendance across groups and high levels of participation. Lay leader psychoeducation and skill development; supervisor praise, support, and encouragement; and supervisee gratitude emerged as additional themes. Remote text supervision conducted via WhatsApp was technologically feasible and may have facilitated skill development and the effective implementation of this lay-led intervention. When tailored to the local context, remote supervision approaches hold promise for increasing access to services in LMICs with limited resources.

Scaling up community-delivered mental health support and care: A landscape analysis

Introduction

The mental health crisis has caused widespread suffering and has been further exacerbated by the COVID-19 pandemic. Marginalized groups are especially affected, with many concerns rooted in social determinants of mental health. To stem this tide of suffering, consideration of approaches outside the traditional biomedical model will be necessary. Drawing from task-sharing models of mental health care that have been pioneered in low-resource settings, community-initiated care (CIC) represents a potentially promising collection of approaches. This landscape analysis seeks to identify examples of CIC that have been implemented outside of the research context, with the aim of identifying barriers and facilitators of scale up.

Methods

A narrative review approach was used for this landscape analysis in which the PubMed database was searched and further supplemented with Google Scholar. Promising programs were then discussed over multiple rounds of meetings with the research team, consisting of collaborators with varied experiences in mental health. Using the selection criteria and feedback derived from group meetings, a final list of programs was identified and summarized according to common characteristics and features.

Results

The initial PubMed search yielded 16 results, supplemented by review of the first 100 entries in Google Scholar. Through 5 follow-up meetings among team members, consensus was reached on a final list of 9 programs, which were grouped into three categories based on similar themes and topics: (1) approaches for the delivery of psychosocial interventions; (2) public health and integrative approaches to mental health; and (3) approaches for addressing youth mental health. Key facilitators to scale up included the importance of sustainable financing and human resources, addressing social determinants and stigma, engaging diverse stakeholders, leveraging existing health infrastructure, using sustainable training models, ensuring cultural relevance and appropriateness, and leveraging digital technologies.

Discussion

This landscape analysis, though not an exhaustive summary of the literature, describes promising examples of efforts to scale up CIC outside of the research context. Going forward, it will be necessary to mobilize stakeholders at the community, health system, and government levels to effectively promote CIC.

Measurement and assessment of fidelity and competence in nonspecialist-delivered, evidence-based behavioral and mental health interventions: A systematic review

Nonspecialists have increasingly been used to deliver evidence-based, mental health and behavioral interventions in lower resource settings where there is a dearth of specialized providers and a corresponding gap in service delivery. Recent literature acknowledges that nonspecialist-delivered interventions are shown to be effective. However, few studies report on the fidelity (the degree to which an intervention was implemented as intended) and/or competence (general skills of nonspecialists), key concepts that measure quality of evidence-based intervention delivery. This study seeks to understand how both fidelity and competence have been assessed in nonspecialist-delivered, evidence-based interventions with an intended social or psychological behavior-change outcome. Our search results originally yielded 2317 studies, and ultimately, 16 were included in our final analysis. Generally, results from a narrative synthesis indicated that tools used in the studies demonstrated sufficient inter-rater reliability and intra-class correlation components. Included studies used and described a range of fidelity and competence tools. However, the ENhancing Assessment of Common Therapeutic factors tool was the most commonly used tool that measures competence of nonspecialists, and has been adapted to several other settings. The roles of supervisors in mentoring, monitoring, and supervising nonspecialists emerged as a key ingredient for ensuring fidelity. Most studies assessing fidelity were limited by small sample sizes due to low numbers of nonspecialists implementing interventions, however, more advanced statistical methods may not be needed and may actually impede community-based organizations from assessing fidelity data. Our results suggest interventions can share resources, tools, and compare findings regardless with proper supervision. While the two terms "fidelity" and "competence" are often used interchangeably, their differences are noteworthy. Ultimately, both competency and fidelity are critical for delivering evidence-based interventions, and nonspecialists are most effective when they can be evaluated and mentored on both throughout the course of the intervention.

The role of community health worker-based care in post-conflict settings: a systematic review

Countries affected by conflict often experience the deterioration of health system infrastructure and weaken service delivery. Evidence suggests that healthcare services that leverage local community dynamics may ameliorate health system-related challenges; however, little is known about implementing these interventions in contexts where formal delivery of care is hampered subsequent to conflict. We reviewed the evidence on community health worker (CHW)-delivered healthcare in conflict-affected settings and synthesized reported information on the effectiveness of interventions and characteristics of care delivery. We conducted a systematic review of studies in OVID MedLine, Web of Science, Embase, Scopus, The Cumulative Index to Nursing and Allied Health Literature (CINHAL) and Google Scholar databases. Included studies (1) described a context that is post-conflict, conflict-affected or impacted by war or crisis; (2) examined the delivery of healthcare by CHWs in the community; (3) reported a specific outcome connected to CHWs or community-based healthcare; (4) were available in English, Spanish or French and (5) were published between 1 January 2000 and 6 May 2021. We identified 1976 articles, of which 55 met the inclusion criteria. Nineteen countries were represented, and five categories of disease were assessed. Evidence suggests that CHW interventions not only may be effective but also efficient in circumventing the barriers associated with access to care in conflict-affected areas. CHWs may leverage their physical proximity and social connection to the community they serve to improve care by facilitating access to care, strengthening disease detection and improving adherence to care. Specifically, case management (e.g. integrated community case management) was documented to be effective in improving a wide range of health outcomes and should be considered as a strategy to reduce barrier to access in hard-to-reach areas. Furthermore, task-sharing strategies have been emphasized as a common mechanism for incorporating CHWs into health systems.

Technology-assisted task-sharing to bridge the treatment gap for childhood developmental disorders in rural Pakistan: an implementation science case study

Background

As in many low-income countries, the treatment gap for developmental disorders in Pakistan is nearly 100%. The World Health Organization (WHO) has developed the mental Health Gap Intervention guide (mhGAP-IG) to train non-specialists in the delivery of evidence-based mental health interventions in low-resource settings. However, a key challenge to scale-up of non-specialist-delivered interventions is designing training programs that promote fidelity at scale in low-resource settings. In this case study, we report the experience of using a tablet device-based application to train non-specialist, female family volunteers in leading a group parent skills training program, culturally adapted from the mhGAP-IG, with fidelity at scale in rural community settings of Pakistan.

Methods

The implementation evaluation was conducted as a part of the mhGAP-IG implementation in the pilot sub-district of Gujar Khan. Family volunteers used a technology-assisted approach to deliver the parent skills training in 15 rural Union Councils (UCs). We used the Proctor and RE-AIM frameworks in a mixed-methods design to evaluate the volunteers’ competency and fidelity to the intervention. The outcome was measured with the ENhancing Assessment of Common Therapeutic factors (ENACT), during training and program implementation. Data on other implementation outcomes including intervention dosage, acceptability, feasibility, appropriateness, and reach was collected from program trainers, family volunteers, and caregivers of children 6 months post-program implementation. Qualitative and quantitative data were analyzed using the framework and descriptive analysis, respectively.

Results

We trained 36 volunteers in delivering the program using technology. All volunteers were female with a mean age of 39 (± 4.38) years. The volunteers delivered the program to 270 caregivers in group sessions with good fidelity (scored 2.5 out of 4 on each domain of the fidelity measure). More than 85% of the caregivers attended 6 or more of 9 sessions. Quantitative analysis showed high levels of acceptability, feasibility, appropriateness, and reach of the program. Qualitative results indicated that the use of tablet device-based applications, and the cultural appropriateness of the adapted intervention content, contributed to the successful implementation of the program. However, barriers faced by family volunteers like community norms and family commitments potentially limited their mobility to deliver the program and impacted the program’ reach.

Conclusions

Technology can be used to train non-specialist family volunteers in delivering evidence-based intervention at scale with fidelity in low-resource settings of Pakistan. However, cultural and gender norms should be considered while involving females as volunteer lay health workers for the implementation of mental health programs in low-resource settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00343-w.

Technology-assisted peer therapy: a new way of delivering evidence-based psychological interventions

In low-income settings, ninety percent of individuals with clinical depression have no access to evidence-based psychological interventions. Reasons include lack of funds for specialist services, scarcity of trained mental health professionals, and the stigma attached to mental illness. In recent years there have been many studies demonstrating effective delivery of psychological interventions through a variety of non-specialists. While these interventions are cost-effective and less stigmatising, efforts to scale-up are hampered by issues of quality-control, and what has been described by implementation scientists as ‘voltage-drop’ and ‘programme-drift.’ Using principles of Human Centred Design in a rural setting in Pakistan, we worked with potential users to co-design a Tablet or Smartphone-based App that can assist a lay-person deliver the Thinking Healthy Programme, a World Health Organization-endorsed evidence-based intervention for perinatal depression. The active ingredients of this cognitive-therapy based intervention are delivered by a virtual ‘avatar’ therapist incorporated into the App which is operated by a ‘peer’ (a woman from the neighbourhood with no prior experience of healthcare delivery). Using automated cues from the App, the peer reinforces key therapeutic messages, helps with problem-solving and provides the non-specific but essential therapeutic elements of empathy and support. The peer and App therefore act as co-therapists in delivery of the intervention. The peer can deliver the intervention with good fidelity after brief automated in-built training. This approach has the potential to be applied to other areas of mental health and help bridge the treatment gap, especially in resource-poor settings. This paper describes the process of co-development with end-users and key features of the App.

Comment: silent burden no more: a global call to action to prioritize perinatal mental health

Common perinatal mental disorders are the most frequent complications of pregnancy, childbirth and the postpartum period, and the prevalence among women in low- and middle-income countries is the highest at nearly 20%. Women are the cornerstone of a healthy and prosperous society and until their mental health is taken as seriously as their physical wellbeing, we will not improve maternal mortality, morbidity and the ability of women to thrive. On the heels of several international efforts to put perinatal mental health on the global agenda, we propose seven urgent actions that the international community, governments, health systems, academia, civil society, and individuals should take to ensure that women everywhere have access to high-quality, respectful care for both their physical and mental wellbeing. Addressing perinatal mental health promotion, prevention, early intervention and treatment of common perinatal mental disorders must be a global priority.

Standardising Training of Nurses in an Evidence-Based Psychosocial Intervention for Perinatal Depression: Randomized Trial of Electronic vs. Face-to-Face Training in China

Background: Rates of perinatal depression in China are high. The Thinking Healthy Programme is a WHO-endorsed, evidence-based psychosocial intervention for perinatal depression, requiring five days of face-to-face training by a specialist trainer. Given the paucity of specialist trainers and logistical challenges, standardized training of large numbers of nurses is a major challenge for scaling up. We developed an electronic training programme (e-training) which eliminates the need for specialist-led, face-to-face training. The aim of this study was to evaluate the effectiveness of the e-training compared to conventional face-to-face training in nursing students. Methods: A single blind, non-inferiority, randomized controlled trial was conducted. One hundred nursing students from two nursing schools were randomly assigned to either e-training or conventional face-to-face training. Results: E-training was not inferior to specialist-led face-to-face training immediately post-training [mean ENhancing Assessment of Common Therapeutic factors (ENACT) score (M) 45.73, standard deviation (SD) 4.03 vs. M 47.08, SD 4.53; mean difference (MD) −1.35, 95% CI; (−3.17, 0.46), p = 0.14]. There was no difference in ENACT scores at three months [M = 42.16, SD 4.85 vs. M = 42.65, SD 4.65; MD = −0.481, 95% CI; (−2.35, 1.39), p = 0.61]. Conclusions: E-training is a promising tool with comparative effectiveness to specialist-led face-to-face training. E-training can be used for training of non-specialists for evidence-based psychosocial interventions at scale and utilized where there is a shortage of specialist trainers, but practice under supervision is necessary to maintain competence. However, continued practice under supervision may be necessary to maintain competence.

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.

Assessing costs of developing a digital program for training community health workers to deliver treatment for depression: A case study in rural India

Digital technology has emerged as a promising approach for training and building capacity of community health workers in low-income and middle-income countries (LMICs). Little is known about the cost of developing digital training programs in LMICs, which hinders the adoption, implementation, and scaling up of the programs in routine primary care settings. This study assessed the costs of developing a digital program for training community health workers to deliver a psychological treatment for depression in a rural district of Madhya Pradesh, India. We developed survey instruments to document required resources in development, including involved personnel (their roles, responsibilities, time spent, and salaries or payments), information technologies (e.g., smartphones, software programs), and infrastructure-related costs (e.g., vehicle, office space, utilities). Costs were estimated from an accounting perspective. Over a 10-month developmental period, the total costs were 208,814 USD, with the largest portion on human resources (61%, with 14% on management and supervision), followed by information technologies (33%), and infrastructure-related costs (6%). These findings could inform policymakers in LMICs on costs of developing online-training programs, which will be especially useful during the COVID-19 pandemic.

Acceptability and feasibility of using digital technology to train community practitioners to deliver a family-based intervention for adolescents with drug use disorders during the COVID-19 pandemic

INTRODUCTION

By adhering to government preventative messages to stay-at-home and social distancing during the COVID-19 pandemic, training practitioners in person in implementing a family-based intervention (i.e., Treatnet Family) is not possible. The present study examined the feasibility and acceptability of using digital technology to remotely deliver Treatnet Family training to practitioners in community counselling services in Indonesia.

METHOD

Fifteen practitioners, from the association of addiction counsellors in Indonesia, participated in the Treatnet Family workshop remotely. The training was delivered by four national Treatnet Family trainers remotely via a digital platform for five days with additional take-home assignments.

RESULTS

All practitioners reported that Treatnet Family training have enhanced their skills in working with adolescents and their family. Most practitioners reported having confidence in conducting Treatnet Family and in applying core skills of family-based intervention. Participating in the workshop enabled practitioners to learn the core skills of the Treatnet Family at their own pace. However, some practitioners also stated few disadvantages in remote training, including having limited time for the discussion and feeling overwhelmed with the assignments. Some find it hard to attend such training from their home due to distractions.

CONCLUSION

Digital technology is acceptable and feasible method for training community practitioners to deliver Treatnet Family to adolescents with SUDs and their families in Indonesia. These findings can inform the way to use digital technology to deliver core family-based skills to community practitioners in other low-resource settings.

Community health workers at the dawn of a new era: 7. Recent advances in supervision

BACKGROUND

Supervision is essential for optimizing performance and motivation of community health workers (CHWs). This paper, the seventh in our series, "Community health workers at the dawn of a new era", supplements the existing evidence on CHW supervision in low- and middle-income countries by reviewing what supervision approaches are employed in specific contexts, identifying potential facilitators of CHW supervision including mobile health (mHealth) interventions, and noting challenges of supervision including the relationship between supervision and other CHW programme elements.

METHODS

For this exploratory research study on CHW supervision, we reviewed the supervisory interventions described in a compendium of 29 case studies of large-scale CHW programmes, performed an electronic search of multiple databases to identify articles related to CHW supervision published between 15 June 2017 and 1 December 2020, and from those articles followed additional references that appeared to be relevant for our results.

RESULTS

We reviewed 55 case studies, academic articles, and grey literature resources as part of this exploratory research. A variety of supervision approaches have been adapted over time, which we grouped into five categories: external supervision, community supervision, group supervision, peer supervision, and dedicated supervision. These approaches are frequently used in combination. Digital (mHealth) technologies are being explored as potential facilitators of CHW supervision in both small- and large-scale programmes; however, evidence of their effectiveness remains limited to date. Inadequate support for supervisors is a major challenge, particularly given the numerous and varied roles they are expected to fulfil, spanning administrative, clinical, and supportive activities. Supervisors can help CHWs acquire other critical elements needed from the health system for them to perform more effectively: incentives to foster motivation, clarity of roles and tasks, adequate tools and supplies, appropriate knowledge and skills, and a safe work environment.

CONCLUSION

In the absence of a universal "best approach" for CHW supervision, our recommendation is that countries and programmes prioritize homegrown evolution over time to suit the local context. In some cases, this may involve scaling up novel approaches that have proven effective at small scale or testing approaches that have worked in other countries.

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.

Acceptability and Potential Effectiveness of eHealth Tools for Training Primary Health Workers From Nigeria at Scale: Mixed Methods, Uncontrolled Before-and-After Study

BACKGROUND

The in-service training of frontline health workers (FHWs) in primary health care facilities plays an important role in improving the standard of health care delivery. However, it is often expensive and requires FHWs to leave their posts in rural areas to attend courses in urban centers. This study reports the implementation of a digital health tool for providing video training (VTR) on maternal, newborn, and child health (MNCH) care to provide in-service training at scale without interrupting health services. The VTR intervention was supported by satellite communications technology and existing 3G mobile networks.

OBJECTIVE

This study aims to determine the feasibility and acceptability of these digital health tools and their potential effectiveness in improving clinical knowledge, attitudes, and practices related to MNCH care.

METHODS

A mixed methods design, including an uncontrolled pre- and postquantitative evaluation, was adopted. From October 2017 to May 2018, a VTR mobile intervention was delivered to FHWs in 3 states of Nigeria. We examined changes in workers' knowledge and confidence in delivering MNCH services through a pre- and posttest survey. Stakeholders' experiences with the intervention were explored through semistructured interviews that drew on the technology acceptance model to frame contextual factors that shaped the intervention's acceptability and usability in the work environment.

RESULTS

In total, 328 FHWs completed both pre- and posttests. FHWs achieved a mean pretest score of 51% (95% CI 48%-54%) and mean posttest score of 69% (95% CI 66%-72%), reflecting, after adjusting for key covariates, a mean increase between the pre- and posttest of 17 percentage points (95% CI 15-19; P<.001). Variation was identified in pre- and posttest scores by the sex and location of participants alongside topic-specific areas where scores were lowest. Stakeholder interviews suggested a wide acceptance of VTR Mobile (delivered via digital technology) as an important tool for enhancing the quality of training, reinforcing knowledge, and improving health outcomes.

CONCLUSIONS

This study found that VTR supported through a digital technology approach is a feasible and acceptable approach for supporting improvements in clinical knowledge, attitudes, and reported practices in MNCH. The determinants of technology acceptance included ease of use, perceived usefulness, access to technology and training contents, and the cost-effectiveness of VTR, whereas barriers to the adoption of VTR were poor electricity supply, poor internet connection, and FHWs' workload. The evaluation also identified the mechanisms of the impact of delivering VTR Mobile at scale on the micro (individual), meso (organizational), and macro (policy) levels of the health system. Future research is required to explore the translation of this digital health approach for the VTR of FHWs and its impact across low-resource settings to ameliorate the financial and time costs of training and support high-quality MNCH care delivery.

TRIAL REGISTRATION

ISRCTN Registry 32105372; https://www.isrctn.com/ISRCTN32105372.

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

BACKGROUND

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

AUTHORS' CONCLUSIONS

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

The Impact of the COVID-19 Pandemic on Pregnant Women with Perinatal Anxiety Symptoms in Pakistan: A Qualitative Study

The impact of coronavirus disease 2019 (COVID-19) on people with existing mental health conditions is likely to be high. We explored the consequences of the pandemic on women of lower socioeconomic status with prenatal anxiety symptoms living in urban Rawalpindi, Pakistan. This qualitative study was embedded within an ongoing randomized controlled trial of psychosocial intervention for prenatal anxiety at a public hospital in Rawalpindi. The participants were women with symptoms of anxiety who had received or were receiving the intervention. In total, 27 interviews were conducted; 13 women were in their third trimester of pregnancy, and 14 were in their postnatal period. The data were collected through in-depth interviews and analyzed using framework analysis. Key findings were that during the pandemic, women experienced increased perinatal anxiety that was linked to greater financial problems, uncertainties over availability of appropriate obstetric healthcare, and a lack of trust in health professionals. Women experienced increased levels of fear for their own and their baby's health and safety, especially due to fear of infection. COVID-19 appears to have contributed to symptoms of anxiety in women already predisposed to anxiety in the prenatal period. Efforts to address women's heightened anxiety due to the pandemic are likely to have public health benefits.

Effectiveness of Group Problem Management Plus, a brief psychological intervention for adults affected by humanitarian disasters in Nepal: A cluster randomized controlled trial

BACKGROUND

Globally, 235 million people are impacted by humanitarian emergencies worldwide, presenting increased risk of experiencing a mental disorder. Our objective was to test the effectiveness of a brief group psychological treatment delivered by trained facilitators without prior professional mental health training in a disaster-prone setting.

METHODS AND FINDINGS

We conducted a cluster randomized controlled trial (cRCT) from November 25, 2018 through September 30, 2019. Participants in both arms were assessed at baseline, midline (7 weeks post-baseline, which was approximately 1 week after treatment in the experimental arm), and endline (20 weeks post-baseline, which was approximately 3 months posttreatment). The intervention was Group Problem Management Plus (PM+), a psychological treatment of 5 weekly sessions, which was compared with enhanced usual care (EUC) consisting of a family psychoeducation meeting with a referral option to primary care providers trained in mental healthcare. The setting was 72 wards (geographic unit of clustering) in eastern Nepal, with 1 PM+ group per ward in the treatment arm. Wards were eligible if they were in disaster-prone regions and residents spoke Nepali. Wards were assigned to study arms based on covariate constrained randomization. Eligible participants were adult women and men 18 years of age and older who met screening criteria for psychological distress and functional impairment. Outcomes were measured at the participant level, with assessors blinded to group assignment. The primary outcome was psychological distress assessed with the General Health Questionnaire (GHQ-12). Secondary outcomes included depression symptoms, posttraumatic stress disorder (PTSD) symptoms, "heart-mind" problems, social support, somatic symptoms, and functional impairment. The hypothesized mediator was skill use aligned with the treatment's mechanisms of action. A total of 324 participants were enrolled in the control arm (36 wards) and 319 in the Group PM+ arm (36 wards). The overall sample (N = 611) had a median age of 45 years (range 18-91 years), 82% of participants were female, 50% had recently experienced a natural disaster, and 31% had a chronic physical illness. Endline assessments were completed by 302 participants in the control arm (36 wards) and 303 participants in the Group PM+ arm (36 wards). At the midline assessment (immediately after Group PM+ in the experimental arm), mean GHQ-12 total score was 2.7 units lower in Group PM+ compared to control (95% CI: 1.7, 3.7, p < 0.001), with standardized mean difference (SMD) of -0.4 (95% CI: -0.5, -0.2). At 3 months posttreatment (primary endpoint), mean GHQ-12 total score was 1.4 units lower in Group PM+ compared to control (95% CI: 0.3, 2.5, p = 0.014), with SMD of -0.2 (95% CI: -0.4, 0.0). Among the secondary outcomes, Group PM+ was associated with endline with a larger proportion attaining more than 50% reduction in depression symptoms (29.9% of Group PM+ arm versus 17.3% of control arm, risk ratio = 1.7, 95% CI: 1.2, 2.4, p = 0.002). Fewer participants in the Group PM+ arm continued to have "heart-mind" problems at endline (58.8%) compared to the control arm (69.4%), risk ratio = 0.8 (95% CI, 0.7, 1.0, p = 0.042). Group PM+ was not associated with lower PTSD symptoms or functional impairment. Use of psychosocial skills at midline was estimated to explain 31% of the PM+ effect on endline GHQ-12 scores. Adverse events in the control arm included 1 suicide death and 1 reportable incidence of domestic violence; in the Group PM+ arm, there was 1 death due to physical illness. Study limitations include lack of power to evaluate gender-specific effects, lack of long-term outcomes (e.g., 12 months posttreatment), and lack of cost-effectiveness information.

CONCLUSIONS

In this study, we found that a 5-session group psychological treatment delivered by nonspecialists modestly reduced psychological distress and depression symptoms in a setting prone to humanitarian emergencies. Benefits were partly explained by the degree of psychosocial skill use in daily life. To improve the treatment benefit, future implementation should focus on approaches to enhance skill use by PM+ participants.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03747055.

Effectiveness of a technology-assisted, family volunteers delivered, brief, multicomponent parents' skills training intervention for children with developmental disorders in rural Pakistan: a cluster randomized controlled trial

Background

Globally, there is a large documented gap between needs of families and children with developmental disorders and available services. We adapted the World Health Organization’s mental health Gap-Intervention Guidelines (mhGAP-IG) developmental disorders module into a tablet-based android application to train caregivers of children with developmental disorders. We aimed to evaluate the effectiveness of this technology-assisted, family volunteers delivered, parents’ skills training intervention to improve functioning in children with developmental disorders in a rural community of Rawalpindi, Pakistan.

Methods

In a single-blinded, cluster randomized controlled trial, 30 clusters were randomised (1:1 ratio) to intervention (n = 15) or enhanced treatment as usual (ETAU) arm (n = 15). After screening, 540 children (18 participants per cluster) aged 2–12 years, with developmental disorders and their primary caregivers were recruited into the trial. Primary outcome was child’s functioning, measured by Childhood Disability Assessment Schedule for Developmental Disorders (DD-CDAS) at 6-months post-intervention. Secondary outcomes were parents’ health related quality of life, caregiver-child joint engagement, socio-emotional well-being of children, family empowerment and stigmatizing experiences. Intention-to-treat analyses were done using mixed-models adjusted for covariates and clusters.

Results

At 6-months post-intervention, no statistically significant mean difference was observed on DD-CDAS between intervention and ETAU (mean [SD], 47.65 [26.94] vs. 48.72 [28.37], Adjusted Mean Difference (AMD), − 2.63; 95% CI − 6.50 to 1.24). However, parents in the intervention arm, compared to ETAU reported improved health related quality of life (mean [SD] 65.56 [23.25] vs. 62.17 [22.63], AMD 5.28; 95% CI 0.44 to 10.11). The results were non-significant for other secondary outcomes.

Conclusions

In the relatively short intervention period of 6 months, no improvement in child functioning was observed; but, there were significant improvements in caregivers’ health related quality of life. Further trials with a longer follow-up are recommended to evaluate the impact of intervention.

Trial registration Clinicaltrials.gov, NCT02792894. Registered April 4, 2016, https://clinicaltrials.gov/ct2/show/NCT02792894

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.

"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.

Improving access to psychosocial interventions for perinatal depression in low- and middle-income countries: lessons from the field

Over 90% women with perinatal depression in low and middle-income countries do not receive treatment. Scale-up of evidence-based psychosocial interventions is a key challenge. We developed the Thinking Healthy Programme (THP), a psychosocial intervention that can be delivered by non-specialist providers such as community health workers in primary and secondary care settings. Our research showed that three out of 4 women with perinatal depression who received the programme recovered, and there were beneficial effects on infant outcomes. In over a decade since the original research, policy and practice uptake of the programme globally has been promising. We describe factors contributing to this: the programme is relatively inexpensive and culturally transferable; the intervention can be integrated with existing maternal and child health programmes; the programme is amenable to 'task-sharing' via peers, nurses, community health-workers and other frontline workers; cascaded models of training and supervision, and the use of technology for training and delivery provide exciting future avenues for scaled-up implementation. These innovations are relevant to the neglected field of public mental health, especially in the post COVID19 era when rates of anxiety and depression are likely to rise globally.

Applying human-centered design to maximize acceptability, feasibility, and usability of mobile technology supervision in Kenya: a mixed methods pilot study protocol

BACKGROUND

Although research continues to support task-shifting as an effective model of delivering evidence-based practices (EBPs), little scholarship has focused how to scale up and sustain task-shifting in low- and middle-income countries, including how to sustainably supervise lay counselors. Ongoing supervision is critical to ensure EBPs are delivered with fidelity; however, the resources and expertise required to provide ongoing supervision may limit the potential to scale up and sustain task shifting. Opportunities may exist to leverage mobile technology to replace or supplement in-person supervision in low-resource contexts, but contextual variables, such as network connectivity and lay counselor preferences surrounding mobile technology, must be examined and considered when designing and implementing mobile technology supervision.

METHODS

This study builds from an existing randomized trial in Kenya, wherein teachers and community health volunteers have been trained to provide trauma-focused cognitive behavioral therapy as lay counselors. The study will use an iterative and mixed methods approach, with qualitative interviews and a Human-Centered Design (HCD) workshop informing a non-randomized pilot trial. Semi-structured interviews will be conducted with lay counselors and supervisors to understand how mobile technology is currently being used for supervision and determine the barriers and facilitators to mobile technology supervision. Data from these interviews will inform an HCD workshop, where lay counselors and supervisors "re-design" supervision to most effectively leverage mobile technology. Workshop participants will also participate in focus groups to gather perceptions on the use of HCD techniques. The final outcome of the workshop will be a set of refined workflows, which will be tested in a mixed method, nonrandomized pilot with newly trained lay counselors and existing supervisors. The pilot trial will evaluate the acceptability, feasibility, and usability of mobile technology supervision through self-report questionnaires as well as perceptions of effectiveness through qualitative interviews with a subset of lay counselors and all supervisors.

DISCUSSION

This study will provide a launching point for future research on supervision and methods to engage stakeholders to design and tailor interventions and implementation supports to fit low-resourced contexts.

TRIAL REGISTRATION

The parent trial from which this study builds was registered on ClinicalTrials.gov on August 9, 2017 ( NCT03243396 ).

Digital training for non-specialist health workers to deliver a brief psychological treatment for depression in India: Protocol for a three-arm randomized controlled trial

BACKGROUND

Training non-specialist health workers (NSHWs) at scale is a major barrier to increasing the coverage of depression care in India. This trial will test the effectiveness of two forms of digital training compared to conventional face-to-face training in changing the competence of NSHWs to deliver a brief evidence-based psychological treatment for depression.

METHODS

This protocol is for a three-arm, parallel group randomized controlled trial comparing three ways of training NSHWs to deliver the Healthy Activity Program (HAP), a brief manualized psychotherapy for depression, in primary care. The arms are: digital training (DGT); digital training combined with individualized coaching support (DGT+); and conventional face-to-face training (F2F). The target sample comprises N = 336 government contracted NSHWs in Madhya Pradesh, India. The primary outcome is change of competence to deliver HAP; secondary outcomes include cost-effectiveness of the training programs, change in participants' mental health knowledge, attitudes and behavior, and satisfaction with the training. Assessors blind to participant allocation status will collect outcomes pre- (baseline) and post- (endpoint) training to ascertain differences in outcomes between arms. Training program costs will be collected to calculate incremental costs of achieving one additional unit on the competency measure in the digital compared to face-to-face training programs. Health worker motivation, job satisfaction, and burnout will be collected as exploratory outcome variables.

DISCUSSION

This trial will determine whether digital training is an effective, cost-effective, and scalable approach for building workforce capacity to deliver a brief evidence-based psychological treatment for depression in primary care in a low-resource setting.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04157816.

Educational and Training Interventions Aimed at Healthcare Workers in the Detection and Management of People With Mental Health Conditions in South and South-East Asia: A Systematic Review

Background: To bridge significant mental health treatment gaps, it is essential that the healthcare workforce is able to detect and manage mental health conditions. We aim to synthesise evidence of effective educational and training interventions aimed at healthcare workers to increase their ability to detect and manage mental health conditions in South and South-East Asia. Methods: Systematic review of six electronic academic databases from January 2000 to August 2020 was performed. All primary research studies were eligible if conducted among healthcare workers in South and South-East Asia and reported education and training interventions to improve detection and management of mental health conditions. Quality of studies were assessed using Modified Cochrane Collaboration, ROBINS-I, and Mixed Methods Appraisal Tools and data synthesised by narrative synthesis. Results are reported according to Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. A review protocol was registered with the PROSPERO database (CRD42020203955). Findings: We included 48 of 3,654 screened articles. Thirty-six reported improvements in knowledge and skills in the detection and management of mental health conditions. Training was predominantly delivered to community and primary care health workers to identify and manage common mental health disorders. Commonly used training included the World Health Organization's mhGAP guidelines (n = 9) and Cognitive Behavioural Therapy (n = 8) and were successfully tailored and delivered to healthcare workers. Digitally delivered training was found to be acceptable and effective. Only one study analysed cost effectiveness. Few targeted severe mental illnesses and upskilling mental health specialists or offered long-term follow-up or supervision. We found 21 studies were appraised as low/moderate and 19 as high/critical risk of bias. Interpretation: In low resource country settings, upskilling and capacity building of primary care and community healthcare workers can lead to better detection and management of people with mental health disorders and help reduce the treatment gap. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42020203955.

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.

Digital Training for Non-Specialist Health Workers to Deliver a Brief Psychological Treatment for Depression in Primary Care in India: Findings from a Randomized Pilot Study

Introduction: Task sharing holds promise for scaling up depression care in countries such as India, yet requires training large numbers of non-specialist health workers. This pilot trial evaluated the feasibility and acceptability of a digital program for training non-specialist health workers to deliver a brief psychological treatment for depression. Methods: Participants were non-specialist health workers recruited from primary care facilities in Sehore, a rural district in Madhya Pradesh, India. A three-arm randomized controlled trial design was used, comparing digital training alone (DGT) to digital training with remote support (DGT+), and conventional face-to-face training. The primary outcome was the feasibility and acceptability of digital training programs. Preliminary effectiveness was explored as changes in competency outcomes, assessed using a self-reported measure covering the specific knowledge and skills required to deliver the brief psychological treatment for depression. Outcomes were collected at pre-training and post-training. Results: Of 42 non-specialist health workers randomized to the training programs, 36 including 10 (72%) in face-to-face, 12 (86%) in DGT, and 14 (100%) in DGT+ arms started the training. Among these participants, 27 (64%) completed the training, with 8 (57%) in face-to-face, 8 (57%) in DGT, and 11 (79%) in DGT+. The addition of remote telephone support appeared to improve completion rates for DGT+ participants. The competency outcome improved across all groups, with no significant between-group differences. However, face-to-face and DGT+ participants showed greater improvement compared to DGT alone. There were numerous technical challenges with the digital training program such as poor connectivity, smartphone app not loading, and difficulty navigating the course content-issues that were further emphasized in follow-up focus group discussions with participants. Feedback and recommendations collected from participants informed further modifications and refinements to the training programs in preparation for a forthcoming large-scale effectiveness trial. Conclusions: This study adds to mounting efforts aimed at leveraging digital technology to increase the availability of evidence-based mental health services in primary care settings in low-resource settings.

Design and Development of a Digital Program for Training Non-Specialist Health Workers to Deliver an Evidence-Based Psychological Treatment for Depression in Primary Care in India

Background

Digital technologies hold promise for building capacity of non-specialist health workers towards scaling up depression care in low-resource settings. The purpose of this study was to describe the systematic approach to designing a digital program for training non-specialist health workers to deliver an evidence-based brief psychological treatment for depression, called the Healthy Activity Program, in primary care in rural India.

Methods

The design and development of the training program involved 5 steps: 1) develop program blueprint; 2) create instructional content; 3) digitize content for a smartphone app; 4) develop a platform for uploading and hosting the digital content; and 5) user-testing and refinements to ensure program functioning. This was followed by field-testing and focus group discussions with non-specialist health workers recruited from primary care facilities in Madhya Pradesh, India, to inform further modifications and improvements to the digital training program.

Results

Training program development occurred over 12-months, and the final digital training consisted of 16 modules with videos, role-plays, and digital content tailored to the local culture and context. Focus group discussions with 19 non-specialist health workers generated three key action items and modifications to the digital training in response to participant feedback: 1) addressing technical challenges by making the digital content available offline; 2) account for low digital literacy by including a comprehensive orientation session about navigating the smartphone app; and 3) addition of remote coaching to support participants in completing the training.

Conclusions

This study illustrates a step-wise approach to combine evidence-based content with iterative feedback from stakeholders to develop a digital training program tailored to the context in a low-resource setting. Further research is needed to validate this approach and to evaluate the effectiveness of the final modified digital training program, while considering whether this approach can be adopted and replicated in other settings.

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.

Digital Innovations for Global Mental Health: Opportunities for Data Science, Task Sharing, and Early Intervention

PURPOSE

Globally, individuals living with mental disorders are more likely to have access to a mobile phone than mental health care. In this commentary, we highlight opportunities for expanding access to and use of digital technologies to advance research and intervention in mental health, with emphasis on the potential impact in lower resource settings.

RECENT FINDINGS

Drawing from empirical evidence, largely from higher income settings, we considered three emerging areas where digital technology will potentially play a prominent role: supporting methods in data science to further our understanding of mental health and inform interventions, task sharing for building workforce capacity by training and supervising non-specialist health workers, and facilitating new opportunities for early intervention for young people in lower resource settings. Challenges were identified related to inequities in access, threats of bias in big data analyses, risks to users, and need for user involvement to support engagement and sustained use of digital interventions.

SUMMARY

For digital technology to achieve its potential to transform the ways we detect, treat, and prevent mental disorders, there is a clear need for continued research involving multiple stakeholders, and rigorous studies showing that these technologies can successfully drive measurable improvements in mental health outcomes.

Acceptability and feasibility of digital technology for training community health workers to deliver brief psychological treatment for depression in rural India

INTRODUCTION

Digital technology offers opportunities to train community health workers to deliver psychological treatments towards closing the gap in existing mental health services in low-resource settings. This study explored the acceptability and feasibility of using digital technology for training community health workers to deliver evidence-based brief psychological treatment for depression in rural India.

METHODS

This study consisted of two sequential evaluations of digital training prototypes using focus group discussions to explore community health worker perspectives about the digital training platform and the program content. Through an iterative design process, feedback was collected about the first prototype to inform modifications to the second prototype. Qualitative data was analyzed using a framework analysis approach.

RESULTS

Thirty-two community health workers participated in three separate focus group discussions. Five overarching themes related to acceptability and feasibility of digital training revealed that training on detection and treatment of depression was considered important by study participants for addressing 'stress' and 'tension' within their communities, while the digital platform was viewed as useful and convenient despite limited familiarity with using digital technology. Moreover, participants suggested simple language for the program and use of interactive content and images to increase interest and improve engagement.

DISCUSSION

Digital technology appears acceptable and feasible for supporting training of community health workers to deliver evidence-based depression care in rural India. These findings can inform use of technology as a tool for developing the clinical skills of community health workers for treating depression in low-resource settings.

Delivering maternal mental health through peer volunteers: a 5-year report

BACKGROUND

Maternal depression affects one in five women in low-and middle income countries (LMIC) and has significant economic and social impacts. Evidence-based psychosocial interventions delivered by non-specialist health workers are recommended as first-line management of the condition, and recent studies on such interventions from LMIC show promising results. However, lack of human resource to deliver the interventions is a major bottle-neck to scale-up, and much research attention has been devoted to 'task-sharing' initiatives. A peer-delivered version of the World Health Organization's Thinking Healthy Programme for perinatal depression in Pakistan and India showed clinical, functional and social benefits to women at 3 months postpartum. The programme has been iteratively adapted and continually delivered for 5 years in Pakistan. In this report, we describe the extended intervention and factors contributing to the peers' continued motivation and retention, and suggest future directions to address scale-up challenges.

METHODS

The study was conducted in rural Rawalpindi. We used mixed methods to evaluate the programme 5 years since its initiation. The competency of the peers in delivering the intervention was evaluated using a specially developed Quality and Competency Checklist, an observational tool used by trainers to rate a group session on key areas of competencies. In-depth interviews explored factors contributing to the peer volunteers' continued motivation and retention, as well as the key challenges faced.

RESULTS

Our key findings are that about 70% of the peer volunteers inducted 5 years ago continued to be part of the programme, retaining their competency in delivering the intervention, with only token financial incentives. Factors contributing to sustained motivation included altruistic aspirations, enhanced social standing in the community, personal benefits to their own mental health, and the possibility for other avenues of employment. Long-term challenges included demotivation due to lack of certainty about the programme's future, increased requirement for financial incentivisation, the logistics of organising groups in the community, and resistance from some families to the need for ongoing care.

CONCLUSIONS

The programme, given the sustained motivation and competence of peer volunteers in delivering the intervention, has the potential for long-term sustainability in under-resourced settings and a candidate for scale-up.