Challenges and strategies for implementing mental health measurement for research in low-resource settings

Okweraliikirira and Okwenyamira: Idioms of Psychological Distress Among People Living with HIV in Rakai, Uganda

Introduction

Health and illness experiences are positioned within social and cultural contexts. Understanding the mental health and psychological distress of people living with HIV in highly affected communities is critical to addressing their needs and to ensure programming and interventions are targeted and appropriate.

Methods

Grounded in the ethnomedical theoretical perspective, we conducted qualitative interviews to understand the experience and expression of psychological distress by people living with HIV in Rakai, Uganda. Participants included adults living with HIV (n=20), health workers (counselors, peer health workers, nurses, n=10), and key informants (n=12). Interviews were audio recorded, transcribed/translated, coded, and analyzed using thematic analysis.

Results

Two idioms of distress, okweraliikirira (worry/apprehension) and okwenyamira (deep/manythoughts/lots of thoughts) were described as impacting people living with HIV. Both idioms were said to be alleviated by social support or counseling, but if left unaddressed could lead to more severe mental health problems and poor ART adherence.

Conclusion

People living with HIV understand their psychological distress through culturally specific idioms; such distress can have deleterious impacts on well-being. Incorporating idioms of distress into screening and treatment for people living with HIV may improve identification of individuals in need and overall health services to address this need.

Understanding global mental health: a conceptual review

Background

Mental health disorders are viewed as a global concern requiring globally led approaches to address them. Since the publication of the 2007 Lancet series on global mental health (GMH), the term has become widespread. Over the last two decades, GMH has become increasingly affiliated with policy reform, academic courses, funding bodies and research. However, it is not always obvious how those working in the field of GMH are using the term, resulting in a lack of clarity. Therefore, work is needed to synthesise the current understanding(s) of GMH to help characterise its meaning.

Aim

To synthesise the literature and identify the different ways GMH is understood.

Method

A conceptual review, using a systematic search and a content analysis, was conducted to develop a conceptual framework of the different conceptual understandings of GMH.

Results

We developed a conceptual framework of four understandings of GMH. These understandings of GMH are as follows: an area of research generating findings to establish a GMH evidence-base; implementation of research into practice; improving the mental health environment; learning from and supporting low-and-middle-income countries (LMICs).

Conclusion

Our review proposes a simple framework, clarifying the key characteristics of the GMH landscape. The findings highlight the diversity of usage of the term in the literature, as well as present the wide scope that comprises the field of GMH. Referring to this framework may help those engaged with GMH to be more specific with which aspect of the field they are concerned with.

Associations Between Anxiety and Adherence to Antiretroviral Medications in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis

Untreated mental health disorders among people living with HIV (PLHIV) may prevent low- and middle-income countries (LMICs) from achieving the UNAIDS 90-90-90 targets. Anxiety disorders may be associated with decreased adherence to antiretroviral therapy (ART). We sought to review and meta-analyze studies estimating associations between anxiety and ART adherence in LMICs. We searched PubMed, PsychINFO, CINAHL and EMBASE for relevant studies published before July 18, 2018. We defined anxiety as reported anxiety scores from screening questionnaires or having a clinical diagnosis of an anxiety disorder, and poor ART adherence as missed doses, poor visit attendance, or scores from structured adherence questionnaires. We used a random effects model to conduct a meta-analysis for calculating a pooled odds ratio, and conducted sensitivity analyses by time on ART, anxiety evaluation method, and study region. From 472 screened manuscripts, thirteen studies met our inclusion criteria. Eleven studies were included in the meta-analysis. PLHIV who reported anxiety had 59% higher odds of poor ART adherence compared with those who did not report anxiety disorder (pooled odds ratio [pOR]: 1.59, 95% confidence interval [CI] 1.29-1.96, p < 0.001). When excluding PLHIV who initiated ART within 6 months, reported anxiety remained strongly associated with poor ART adherence (pOR: 1.61, 95% CI 1.18-2.20, p = 0.003). Among PLHIV in LMICs, reported anxiety was associated with poor ART adherence. This association persisted after the ART initiation period. Increased resources for mental health may be important for achieving virologic suppression in LMICs.

Lifetime socioeconomic status and early life microbial environments predict adult blood telomere length in the Philippines

OBJECTIVES

Psychosocial stress is postulated to hasten senescence in part by accelerating the shortening of telomere length (TL). One pathway through which this may happen is via increasing inflammation and innate immune system activation-a pathway which recent studies suggest acts more strongly for those who grew up in low microbial environments. Thus, we hypothesized that: (1) Psychosocial stress will be inversely associated with TL, (2) early life microbial environments will predict TL, and (3) microbial environments will moderate the association between psychosocial stress and TL.

METHODS

We utilized data from the Cebu Longitudinal Health and Nutrition Survey based in the Philippines (N = 1410). We determined early life microbial environments by season of birth and exposure to animal feces. Psychosocial stress measures included perceived stress in adulthood, lifetime socioeconomic status (SES), and parental instability in childhood. TL was measured in blood from young adults by qPCR.

RESULTS

Contrary to predictions, we found that higher SES was associated with shorter TL and no association of TL with the other stress variables. Individuals born in the higher microbial exposure season had shorter TL, but early life microbial environments did not moderate the association between psychosocial stress and TL.

CONCLUSIONS

The unexpected inverse association between SES and TL suggests that higher SES, while indexing lower psychosocial stress, may impact TL more strongly through nonstress factors in the Philippines, such as unhealthy behavior. The inverse association between microbial environments and TL is consistent with other evidence connecting early life infections to decreased life expectancies.

Psychometric evaluation of the Major Depression Inventory among young people living in Coastal Kenya

Background: The lack of reliable, valid and adequately standardized measures of mental illnesses in sub-Saharan Africa is a key challenge for epidemiological studies on mental health.  We evaluated the psychometric properties and feasibility of using a computerized version of the Major Depression Inventory (MDI) in an epidemiological study in rural Kenya.

Methods: We surveyed 1496 participants aged 13-24 years in Kilifi County, on the Kenyan coast. The MDI was administered using a computer-assisted system, available in three languages. Internal consistency was evaluated using both Cronbach’s alpha and the Omega Coefficient. Confirmatory factor analysis was performed to evaluate the factorial structure of the MDI.

Results:  Internal consistency using both Cronbach’s Alpha (α= 0.83) and the Omega Coefficient (0.82; 95% confidence interval 0.81- 0.83) was above acceptable thresholds. Confirmatory factor analysis indicated a good fit of the data to a unidimensional model of MDI (χ ² (33, N = 1409) = 178.52 p < 0.001, TLI = 0.947, CFI = 0.961, and Root Mean Square Error of Approximation, RMSEA = .056), and this was confirmed using Item Response Models (Loevinger’s H coefficient 0.38) that proved the MDI was a unidimensional scale. Equivalence evaluation indicated invariance across sex and age groups. In our population, 3.6% of the youth presented with scores suggesting major depression using the ICD-10 scoring algorithm, and 8.7% presented with total scores indicating presence of depression (mild, moderate or severe).  Females and older youth were at the highest risk of depression.

Conclusions: The MDI has good psychometric properties.  Given its brevity, relative ease of usage and ability to identify at-risk youth, it may be useful for epidemiological studies of depression in Africa.  Studies to establish clinical thresholds for depression are recommended. The high prevalence of depressive symptoms suggests that depression may be an important public health problem in this population group.