Barriers and Facilitators to Substance Use Disorder Treatment in Low-and Middle-Income Countries: A Qualitative Review Synthesis

Cost effectiveness of interventions to prevent the occurrence and the associated economic impacts of child maltreatment: A systematic review

BACKGROUND

Child maltreatment is a pressing public health concern that poses long-lasting health and economic impacts on children and society. While several preventive interventions have demonstrated their effectiveness in reducing the occurrence of child maltreatment and its associated economic impacts, the cost-effectiveness of such interventions remains unclear.

OBJECTIVE

This study aims to provide a comprehensive overview and a narrative synthesis of the available economic evidence on child maltreatment preventive interventions in both high-income and low-middle-income countries.

METHOD

Systematic searches were conducted in MEDLINE, PsycINFO, Embase, CINAHL, Web of Science, and Econlit to identify full economic evaluations and return-on-investment studies on child maltreatment preventive interventions. The methodological quality of eligible studies was assessed using Drummond's 10-point checklist. This review adhered to the PRISMA guidelines, and summarized findings in a narrative synthesis.

RESULTS

Twenty-six studies met the inclusion criteria. Of these, eight evaluated home visiting, four evaluated early childhood education (ECE), four assessed multi-component (MC), and three examined group-based parent education (GPE) interventions. The remaining studies assessed interventions to prevent abusive head trauma (AHT; n = 2), child sexual abuse (n = 2), physical abuse at school (n = 1), as well as individualized intensive parenting (IIP; n = 2), and counseling (n = 1) interventions. Two studies were conducted in low-middle-income countries, while the others were all in high-income countries.

CONCLUSIONS

The included studies generally exhibited high methodological quality. Only AHT, ECE, IIP, and MC interventions demonstrated promising cost-effectiveness credentials in preventing child maltreatment. More economic evaluations are needed for interventions with mixed findings (e.g. GPE) and in low-middle-income countries.

Examining facilitative services for entry into substance use disorder treatment: A cluster analysis of treatment facilities

OBJECTIVES

We examined services to facilitate access to entering substance use disorder (SUD) treatment among a national sample of SUD treatment facilities.

METHODS

We analyzed data from the National Survey of Substance Abuse Treatment Services (N-SSATS) 2020. Facilities were included in the sample based on criteria such as SUD treatment provision and being in the U.S. Cluster analysis was conducted using variables including ownership, levels of care, and whether facilities provide services or accept payment options aimed at reducing treatment barriers. National and state-level data on the percentage of facilities in each cluster were presented.

RESULTS

Among N = 15,788 SUD treatment facilities four distinct clusters were identified: Cluster 1 consisted of for-profit and government outpatient facilities with high proportions of services to reduce barriers (22.2%). Cluster 2, comprised of non-profit outpatient facilities, offered the most comprehensive array of services to minimize barriers to treatment among all four clusters (25.2%). Cluster 3 included facilities with diverse ownership and care levels and provided a moderate to high degree of services aimed at reducing entry barriers to treatment (26.0%). Cluster 4 was primarily for-profit outpatient facilities with a low proportion of these services (26.6%).

CONCLUSIONS

This study revealed facility-level groupings with different services to reduce barriers to SUD treatment across various clusters of SUD treatment facilities. While some facilities offered extensive services, others provided fewer. Differences in cluster distributions point to possible facilitators to treatment access for some persons seeking admission to specific treatment facilities. Efforts should be made to ensure that individuals seeking SUD treatment can access these services, and facilities should be adequately equipped to meet their diverse needs.

Service-level barriers to and facilitators of accessibility to treatment for problematic alcohol use: a scoping review

Introduction

Services to treat problematic alcohol use (PAU) should be highly accessible to optimize treatment engagement. We conducted a scoping review to map characteristics of services for the treatment of PAU that have been reported in the literature to be barriers to or facilitators of access to treatment from the perspective of individuals with PAU.

Methods

A protocol was developed a priori, registered, and published. We searched MEDLINE®, Embase, the Cochrane Library, and additional grey literature sources from 2010 to April 2022 to identify primary qualitative research and surveys of adults with current or past PAU requiring treatment that were designed to identify modifiable characteristics of PAU treatment services (including psychosocial and pharmacologic interventions) that were perceived to be barriers to or facilitators of access to treatment. Studies of concurrent PAU and other substance use disorders were excluded. Study selection was performed by multiple review team members. Emergent barriers were coded and mapped to the accessibility dimensions of the Levesque framework of healthcare access, then descriptively summarized.

Results

One-hundred-and-nine included studies reported an extensive array of unique service-level barriers that could act alone or together to prevent treatment accessibility. These included but were not limited to lack of an obvious entry point, complexity of the care pathway, high financial cost, unacceptably long wait times, lack of geographically accessible treatment, inconvenient appointment hours, poor cultural/demographic sensitivity, lack of anonymity/privacy, lack of services to treat concurrent PAU and mental health problems.

Discussion

Barriers generally aligned with recent reviews of the substance use disorder literature. Ranking of barriers may be explored in a future discrete choice experiment of PAU service users. The rich qualitative findings of this review may support the design of new or modification of existing services for people with PAU to improve accessibility.

Systematic Review Registration

Open Science Framework doi: 10.17605/OSF.IO/S849R.

A systematic review of factors prolonging or reducing the duration of untreated psychosis for people with psychosis in low- and middle-income countries

AIM

This review aims to identify factors that may prolong or reduce the duration of untreated psychosis for people with psychosis in low- and middle-income countries.

METHODS

Electronic searches of six databases were conducted, to find studies from low- and middle-income countries on people with psychotic disorders provided they statistically measured an association between factors that may prolong or reduce the duration of untreated psychosis. Studies were critically appraised and a narrative synthesis exploring differences between and within studies is presented. A socio-ecological model is used to convey the main findings.

RESULTS

Thirty studies of 16 473 participants in total were included in this review. Taken together participants were 51.5% male and 48.5% female. Various factors potentially associated with longer duration of untreated psychosis for people with psychosis in low- and middle-income countries were found. Examples of these factors are an insidious mode of onset, greater family stigma and low social class. Other factors, such as marital status, educational level, diagnostic type, predominant symptoms and employment status, yielded inconsistent results.

CONCLUSIONS

The methodological quality of the included studies limits the conclusions of this review. The results indicate an urgent need for further high-quality research in these countries. The socio-ecological model is a helpful framework for clinicians, scholars, and decision-makers to conceptualize factors that may affect the duration of untreated psychosis, highlight gaps in the literature as well as reflect on potential prevention strategies that may ultimately support early intervention services for people with psychosis in developing countries.

Qualitative evidence regarding the experience of receiving and providing care for mental health conditions in non-specialist settings in low-income and middle-income countries: a systematic review of reviews

QUESTION

This review of reviews synthesises qualitative evidence on the experiences of receiving and providing care and treatment for mental health conditions in non-specialist settings in low-income and middle-income countries (LMICs), and the factors that influence the provision and uptake of such services.

STUDY SELECTION AND ANALYSIS

Database searches were conducted in PubMed/MEDLINE, EMBASE, PsycINFO, CINAHL, Scopus, African Index Medicus and Global Index Medicus, supplemented by screening repositories of systematic reviews protocols and contacting authors. The evidence synthesis drew on deductive and inductive approaches: a framework analysis approach was used for the initial coding structure, after which the results synthesis was refined further through reviewing and regrouping the initial coding through thematic synthesis principles.

FINDINGS

Nine reviews met inclusion criteria and reported on a range of factors related to the provision and uptake of mental healthcare by non-specialist health workers in LMICs: (1) health worker competency, (2) availability of resources, (3) recipient-related and provider-related characteristics, (4) service accessibility, (5) sociocultural acceptability and (6) vulnerable groups for whom barrier to care were potentially exacerbated.

CONCLUSIONS

This review provides nuanced and contextualised insights regarding the experiences of receiving and providing care for mental health conditions in LMICs, including barriers influencing service provision and uptake. It is important to ensure mental healthcare in non-specialist settings in LMICs is delivered in a manner which is feasible, acceptable and culturally appropriate in order to improve access to care, reducing stigma and promoting better overall health and well-being for individuals and communities.

Meta-review on the efficacy of psychological therapies for the treatment of substance use disorders

This meta-review aimed to summarize the current state of knowledge provided by meta-analyzes on the efficacy of psychotherapies for substance use disorders. A systematic search was performed in PubMed, PsycINFO, Web of Science and Google Scholar. Meta-analyzes were included if they quantitatively examined the efficacy of a psychotherapy on substance use. Among the 6866 potential articles that were screened for eligibility, 23 meta-analyzes were eligible (78 effect sizes). Each meta-analysis included 2-156 studies, with samples ranging between approximately 130 to over 33,000 individuals. The quality of evidence was evaluated as being globally of low to moderate quality. Substances were categorized as: alcohol (k = 12), cannabis (k = 7), stimulants (k = 4), opioids (k = 3) and benzodiazepines (k = 1). Interventions comprised brief intervention, cognitive-behavioral therapy, contingency management, voucher-based reinforcement therapy, motivational interview, motivational enhancement therapy, significant other people involved in the treatment, and cue-expose therapy. Concerning solely significant results, small benefits were observed for significant other people involved in treatment, motivational interviewing, and the combination of cognitive-behavioral therapy with motivational interviewing for alcohol use disorder. Likewise, small-to-moderate effects were found for motivational approaches, and cognitive-behavioral therapy as well as the combination of cognitive-behavioral therapy and motivational enhancement therapy in the case of cannabis use disorder. Small effects were observed for contingency management as well as cognitive behavioral-therapy for amphetamine-type use disorder. Small effects were similarly found for contingency management for cocaine use disorder. Concerning opioid use disorder, moderate effects were observed for contingency management and voucher-based reinforcement intervention. For benzodiazepine use disorder, small effects were noted for cognitive-behavioral therapy with taper. Results often displayed small to moderate heterogeneity when reported and were generally compared to inactive controls, such as treatment-as-usual. In all, the psychosocial treatments for substance use disorders included in this meta-review have shown to be at best moderately effective over inactive controls in the short term. Nevertheless, further trials are needed as well as meta-analyzes on interventions not included in this meta-review.

Barriers to treatment for mental disorders in six countries of the Americas: A regional report from the World Mental Health Surveys

BACKGROUND

Mental health treatment is scarce and little resources are invested in reducing the wide treatment gap that exists in the Americas. The regional barriers are unknown. We describe the barriers for not seeking treatment among those with mental and substance use disorders from six (four low- and middle-income and two high-income) countries from the Americas. Regional socio-demographic and clinical correlates are assessed.

METHODS

Respondents (n = 4648) from seven World Mental Health surveys carried out in Argentina, Brazil, Colombia, Mexico, Peru, and the United States, who met diagnostic criteria for a 12-month mental disorder, measured with the Composite International Diagnostic Interview, and who did not access treatment, were asked about treatment need and, among those with need, structural and attitudinal barriers. Country-specific deviations from regional estimates were evaluated through logistic models.

RESULTS

In the Americas, 43% of those that did not access treatment did not perceive treatment need, while the rest reported structural and attitudinal barriers. Overall, 27% reported structural barriers, and 95% attitudinal barriers. The most frequent attitudinal barrier was to want to handle it on their own (69.4%). Being female and having higher severity of disorders were significant correlates of greater perceived structural and lower attitudinal barriers, with few country-specific variations.

LIMITATIONS

Only six countries in the Americas are represented; the cross-sectional nature of the survey precludes any causal interpretation.

CONCLUSIONS

Awareness of disorder or treatment need in various forms is one of the main barriers reported in the Americas and it specially affects persons with severe disorders.

Barriers and Facilitators to Substance Use Disorder Treatment: An Overview of Systematic Reviews

objective:

This investigation explored the barriers and facilitators to substance use disorder (SUD) treatment in the integrated paradigm.

methods:

A search technique for barriers and facilitators of SUD treatment was applied to the PubMed and Web of Science databases to identify relevant systematic reviews. The eligibility criteria included systematic review (SR) or SR plus meta-analysis (MA) articles published before the end of 2021, human research, and the English language. Each of the 12 relevant review articles met the inclusion criteria. AMSTAR was utilised to evaluate the methodological quality of the systematic reviews.

results:

Two authors analysed 12 SR/SR-MA articles to identify barriers or facilitators of SUD treatment. The cumulative summary results of these 12 evaluations revealed that barriers and facilitators may be classified into 3 levels: individual, social and structural. By analysing these review papers, 37 structural barriers, 21 individual barriers and 19 social barriers were uncovered, along with 15 structural facilitators, 9 social facilitators and 3 individual facilitators.

conclusions:

The majority of barriers indicated in the review articles included in this analysis are structural, as are the majority of facilitators. Consequently, the design of macro models for the treatment of substance use disorders may yield various outcomes and potentially affect society and individual levels.