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Purgato M, Prina E, Ceccarelli C, Cadorin C, Abdulmalik JO, Amaddeo F, Arcari L, Churchill R, Jordans MJ, Lund C, Papola D, Uphoff E, van Ginneken N, Tol WA, Barbui C. Primary-level and community worker interventions for the prevention of mental disorders and the promotion of well-being in low- and middle-income countries. Cochrane Database Syst Rev 2023; 10:CD014722. [PMID: 37873968 PMCID: PMC10594594 DOI: 10.1002/14651858.cd014722.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
BACKGROUND There is a significant research gap in the field of universal, selective, and indicated prevention interventions for mental health promotion and the prevention of mental disorders. Barriers to closing the research gap include scarcity of skilled human resources, large inequities in resource distribution and utilization, and stigma. OBJECTIVES To assess the effectiveness of delivery by primary workers of interventions for the promotion of mental health and universal prevention, and for the selective and indicated prevention of mental disorders or symptoms of mental illness in low- and middle-income countries (LMICs). To examine the impact of intervention delivery by primary workers on resource use and costs. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, Global Index Medicus, PsycInfo, WHO ICTRP, and ClinicalTrials.gov from inception to 29 November 2021. SELECTION CRITERIA Randomized controlled trials (RCTs) of primary-level and/or community health worker interventions for promoting mental health and/or preventing mental disorders versus any control conditions in adults and children in LMICs. DATA COLLECTION AND ANALYSIS Standardized mean differences (SMD) or mean differences (MD) were used for continuous outcomes, and risk ratios (RR) for dichotomous data, using a random-effects model. We analyzed data at 0 to 1, 1 to 6, and 7 to 24 months post-intervention. For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥ 0.80 large clinical effects. We evaluated the risk of bias (RoB) using Cochrane RoB2. MAIN RESULTS Description of studies We identified 113 studies with 32,992 participants (97 RCTs, 19,570 participants in meta-analyses) for inclusion. Nineteen RCTs were conducted in low-income countries, 27 in low-middle-income countries, 2 in middle-income countries, 58 in upper-middle-income countries and 7 in mixed settings. Eighty-three RCTs included adults and 30 RCTs included children. Cadres of primary-level workers employed primary care health workers (38 studies), community workers (71 studies), both (2 studies), and not reported (2 studies). Interventions were universal prevention/promotion in 22 studies, selective in 36, and indicated prevention in 55 RCTs. Risk of bias The most common concerns over risk of bias were performance bias, attrition bias, and reporting bias. Intervention effects 'Probably', 'may', or 'uncertain' indicates 'moderate-', 'low-', or 'very low-'certainty evidence. *Certainty of the evidence (using GRADE) was assessed at 0 to 1 month post-intervention as specified in the review protocol. In the abstract, we did not report results for outcomes for which evidence was missing or very uncertain. Adults Promotion/universal prevention, compared to usual care: - probably slightly reduced anxiety symptoms (MD -0.14, 95% confidence interval (CI) -0.27 to -0.01; 1 trial, 158 participants) - may slightly reduce distress/PTSD symptoms (SMD -0.24, 95% CI -0.41 to -0.08; 4 trials, 722 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD -0.69, 95% CI -1.08 to -0.30; 4 trials, 223 participants) Indicated prevention, compared to usual care: - may reduce adverse events (1 trial, 547 participants) - probably slightly reduced functional impairment (SMD -0.12, 95% CI -0.39 to -0.15; 4 trials, 663 participants) Children Promotion/universal prevention, compared to usual care: - may improve the quality of life (SMD -0.25, 95% CI -0.39 to -0.11; 2 trials, 803 participants) - may reduce adverse events (1 trial, 694 participants) - may slightly reduce depressive symptoms (MD -3.04, 95% CI -6 to -0.08; 1 trial, 160 participants) - may slightly reduce anxiety symptoms (MD -2.27, 95% CI -3.13 to -1.41; 1 trial, 183 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD 0, 95% CI -0.16 to -0.15; 2 trials, 638 participants) - may slightly reduce anxiety symptoms (MD 4.50, 95% CI -12.05 to 21.05; 1 trial, 28 participants) - probably slightly reduced distress/PTSD symptoms (MD -2.14, 95% CI -3.77 to -0.51; 1 trial, 159 participants) Indicated prevention, compared to usual care: - decreased slightly functional impairment (SMD -0.29, 95% CI -0.47 to -0.10; 2 trials, 448 participants) - decreased slightly depressive symptoms (SMD -0.18, 95% CI -0.32 to -0.04; 4 trials, 771 participants) - may slightly reduce distress/PTSD symptoms (SMD 0.24, 95% CI -1.28 to 1.76; 2 trials, 448 participants). AUTHORS' CONCLUSIONS The evidence indicated that prevention interventions delivered through primary workers - a form of task-shifting - may improve mental health outcomes. Certainty in the evidence was influenced by the risk of bias and by substantial levels of heterogeneity. A supportive network of infrastructure and research would enhance and reinforce this delivery modality across LMICs.
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Affiliation(s)
- Marianna Purgato
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
- Cochrane Global Mental Health, University of Verona, Verona, Italy
| | - Eleonora Prina
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Caterina Ceccarelli
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Camilla Cadorin
- Department of Neurosciences, Biomedicine and Movement Sciences, Verona, Italy
| | | | - Francesco Amaddeo
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | | | - Rachel Churchill
- Cochrane Common Mental Disorders, Centre for Reviews and Dissemination, University of York, York, UK
| | - Mark Jd Jordans
- Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Crick Lund
- King's Global Health Institute, Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Davide Papola
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
- Cochrane Global Mental Health, University of Verona, Verona, Italy
| | - Eleonora Uphoff
- Cochrane Common Mental Disorders, Centre for Reviews and Dissemination, University of York, York, UK
| | - Nadja van Ginneken
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK
| | - Wietse Anton Tol
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Corrado Barbui
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
- Cochrane Global Mental Health, University of Verona, Verona, Italy
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Baker-Henningham H, Bowers M, Francis T, Vera-Hernández M, Walker SP. The Irie Classroom Toolbox, a universal violence-prevention teacher-training programme, in Jamaican preschools: a single-blind, cluster-randomised controlled trial. Lancet Glob Health 2021; 9:e456-e468. [PMID: 33631132 PMCID: PMC7966677 DOI: 10.1016/s2214-109x(21)00002-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 12/15/2020] [Accepted: 12/18/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Violence is a leading global public health problem, and interventions in early childhood are important in the primary prevention of violence. We tested whether the Irie Classroom Toolbox, a violence-prevention teacher-training programme reduced violence against children by teachers and reduced class-wide child aggression in Jamaican preschools (catering to children aged 3-6 years). METHODS We did a single-blind, cluster-randomised controlled trial in 76 preschools in Kingston and St Andrew, randomly selected, using simple randomisation, from 120 eligible preschools. Inclusion criteria were two to four classes of children; at least ten children per class; and located in an urban area. We randomly assigned preschools (1:1) to either the Irie Classroom Toolbox intervention or waiting-list control that received no intervention, using a computer-generated randomisation sequence by an independent statistician masked to school identity. The Toolbox involved training teachers in classroom behaviour management and promoting child social-emotional competence. All assessors were masked to group assignment. All teachers and classrooms in the selected schools participated in the study. Within each school, we used simple randomisation to randomly select up to 12 children aged 4 years for evaluation of child outcomes. The Toolbox intervention was implemented from August to April the following year. Teacher and classroom measures were done at baseline (the summer school term; ie, May to June), post-intervention (after 8 months of intervention; ie, May to June of the following year), and 1-year follow-up (ie, May to June 2 years later). The primary outcomes were observations of violence against children (including physical violence and psychological aggression) by teachers occurring across one full school day, and class-wide child aggression occurring over five 20-min intervals on another school day, all measured at post-intervention and 1-year follow-up and analysed by intention to treat. This trial is registered with ISRCTN, number ISRCTN11968472. FINDINGS Between June 22, 2015, and April 29, 2016, (after baseline measurements were completed), we assigned 38 preschools (with 119 teachers) to the Toolbox intervention and 38 preschools (with 110 teachers) to control. 441 children in the intervention schools and 424 in the control schools were included in the evaluation. All schools were included in the post-intervention and follow-up analyses. There were fewer counts of violence against children by teachers in the intervention schools compared with control schools at post-intervention (median counts 3 [IQR 0-11] vs 15 [3-35]; effect size -67·12%, 95% CI -80·71 to -53·52, p<0·0001) and 1-year follow-up (median counts 3 [IQR 0-9] vs 6 [1-16]; effect size -53·86, 95% CI -71·08 to -36·65, p<0·0001). No differences between groups were found for class-wide child aggression at post-intervention (effect size 0·07, 95% CI -0·16 to 0·29, p=0·72) or 1-year follow-up (-0·14, -0·42 to 0·16, p=0·72). INTERPRETATION In Jamaican preschools, the Irie Classroom Toolbox effectively reduced violence against children by teachers. The Toolbox was designed for use with undertrained teachers working in low-resource settings and should be effective with early childhood practitioners in other LMICs. Additional research is needed to further develop the Toolbox to reduce class-wide child aggression. FUNDING Medical Research Council, Wellcome Trust, UK Aid, and the National Institute of Health Research.
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Affiliation(s)
- Helen Baker-Henningham
- School of Psychology, Bangor University, Bangor, UK,Caribbean Institute for Health Research, University of the West Indies, Mona, Kingston, Jamaica,Correspondence to: Prof Helen Baker-Henningham, School of Psychology, Bangor University, Bangor, LL57 2AS, UK
| | - Marsha Bowers
- Caribbean Institute for Health Research, University of the West Indies, Mona, Kingston, Jamaica
| | - Taja Francis
- Caribbean Institute for Health Research, University of the West Indies, Mona, Kingston, Jamaica
| | - Marcos Vera-Hernández
- Department of Economics, University College London, London, UK,Institute of Fiscal Studies, London, UK
| | - Susan P Walker
- Caribbean Institute for Health Research, University of the West Indies, Mona, Kingston, Jamaica
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Pundir P, Saran A, White H, Subrahmanian R, Adona J. Interventions for reducing violence against children in low- and middle-income countries: An evidence and gap map. CAMPBELL SYSTEMATIC REVIEWS 2020; 16:e1120. [PMID: 37016609 PMCID: PMC8356324 DOI: 10.1002/cl2.1120] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
BACKGROUND More than half of the children in the world experience some form of interpersonal violence every year. As compared with high-income countries, policy responses in low- and middle-income countries (LMICs) are limited due to resource constraints and paucity of evidence for effective interventions to reduce violence against children in their own contexts, amongst other factors. OBJECTIVES The aim of this evidence and gap map (EGM) is to provide an overview of the existing evidence available and to identify gaps in the evidence base on the effectiveness of interventions to reduce violence against children in LMICs. This report covers evidence published in English; a follow-up study is under preparation focusing on evidence in five additional languages-Arabic, Chinese, French, Portuguese and Spanish. METHODS The intervention-outcome framework for this EGM is based on INSPIRE-Seven Strategies for Ending Violence against Children, published by WHO and other partners in 2016. The seven strategies include implementation and enforcement of laws; norms and values, safe environment; parent-child and caregiver support; income and economic strengthening; response and support services; education and life skills. The search included both academic and grey literature available online. We included impact evaluations and systematic reviews that assessed the effectiveness of interventions to reduce interpersonal violence against children (0-18 years) in LMICs (World Bank, 2018b). Interventions targeting subpopulation of parents, teachers and caregivers of 0-18 years' age group were also included. A critical appraisal of all included studies was carried out using standardised tools. RESULTS The map includes 152 studies published in English of which 55 are systematic reviews and 97 are impact evaluations. Most studies in the map are from Sub-Saharan Africa. Education and life skills are the most widely populated intervention area of the map followed by income and economic strengthening interventions. Very few studies measure impact on economic and social outcomes, and few conduct cost-analysis. CONCLUSION More studies focusing on low-income and fragile and conflict-affected settings (FCS) and studying and reporting on cost-analysis are required to address gaps in the evidence. Most interventions covered in the literature focused on addressing a wide range of forms of violence and harm, which limited understanding of how and for whom the interventions work in a given context, for specific forms of violence. More impact evaluation studies are required that assess specific forms of violence, gendered effects of interventions and on diverse social groups in a given context, utilising mixed methods.
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Francis T, Baker-Henningham H. Design and Implementation of the Irie Homes Toolbox: A Violence Prevention, Early Childhood, Parenting Program. Front Public Health 2020; 8:582961. [PMID: 33304875 PMCID: PMC7701241 DOI: 10.3389/fpubh.2020.582961] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 10/06/2020] [Indexed: 11/23/2022] Open
Abstract
This paper describes the development of the Irie Homes Toolbox, a violence prevention program targeting parents of children aged two to six years. The intervention was designed to complement an existing, teacher-training, violence prevention program, the Irie Classroom Toolbox, thus promoting an integrated approach across home and school settings. The Irie Homes Toolbox was developed through a four-stage process by integrating data from theory, formative research, and practice to ensure the intervention is acceptable, feasible, relevant, and effective in the context. The perspectives of Jamaican preschool teachers and parents of preschool children, who are the end users, were integrated into the design of the intervention throughout the development process. Stage one involved integrating theory and formative research to inform the initial intervention design. Stages two and three involved iterative cycles of design, implementation and evaluation of the intervention content, process of delivery, structure and materials. Stage four involved a further cycle of learning through a process evaluation conducted as part of a cluster-randomized controlled trial. Data from each of these four stages was used to inform the design and ongoing revisions of the toolbox with the aim of developing a low-cost, scalable and sustainable intervention for the Jamaican context. The resulting program is theory-informed and uses empirically derived content and behavior change principles operationalized for the context in which it will be delivered. The Irie Homes Toolbox is suitable for integration into the existing preschool provision in Jamaica, thus utilizing an existing service and existing staff and increasing the likelihood for wide-scale dissemination.
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Affiliation(s)
- Taja Francis
- Caribbean Institute for Health Research, University of the West Indies, Kingston, Jamaica
| | - Helen Baker-Henningham
- Caribbean Institute for Health Research, University of the West Indies, Kingston, Jamaica
- School of Psychology, Bangor University, Bangor, United Kingdom
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Haslam D, Mejia A, Thomson D, Betancourt T. Self-Regulation in Low- and Middle-Income Countries: Challenges and Future Directions. Clin Child Fam Psychol Rev 2019; 22:104-117. [PMID: 30725308 DOI: 10.1007/s10567-019-00278-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Self-regulation is developed early in life through family and parenting interactions. There has been considerable debate on how to best conceptualize and enhance self-regulation. Many consider self-regulation as the socio-emotional competencies required for healthy and productive living, including the flexibility to regulate emotions, control anger, maintain calm under pressure, and respond adaptively to a variety of situations. Its enhancement is the focus of many child and family interventions. An important limitation of the self-regulation field is that most empirical and conceptual research comes from high-income countries (HICs). Less is known about the manifestation, measurement and role of self-regulation in many collectivistic, rural, or less-developed contexts such as low- and middle-income countries (LMICs). This position paper aims to present an initial review of the existing literature on self-regulation in LMICs, with a focus on parenting, and to describe challenges in terms of measurement and implementation of self-regulation components into existing interventions for parents, children and adolescents in these settings. We conclude by establishing steps or recommendations for conducting basic research to understand how self-regulation expresses itself in vulnerable and low-resource settings and for incorporating components of self-regulation into services in LMICs.
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Affiliation(s)
- Divna Haslam
- Parenting & Family Support Centre, The University of Queensland, Brisbane, Australia.
| | | | - Dana Thomson
- Boston College School of Social Work, Chestnut Hill, MA, USA
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Merrill KG, Knight L, Glynn JR, Allen E, Naker D, Devries KM. School staff perpetration of physical violence against students in Uganda: a multilevel analysis of risk factors. BMJ Open 2017; 7:e015567. [PMID: 28821514 PMCID: PMC5724111 DOI: 10.1136/bmjopen-2016-015567] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To conduct a multilevel analysis of risk factors for physical violence perpetration by school staff against Ugandan students. DESIGN Multilevel logistic regression analysis of cross-sectional survey data from 499 staff and 828 caregivers of students at 38 primary schools, collected in 2012 and 2014 during the Good Schools Study. SETTING Luwero District, Uganda. MAIN OUTCOME MEASURE Past-week use of physical violence by school staff against students was measured using the International Society for the Prevention of Child Abuse and Neglect 'Child Abuse Screening Tool- Child International' and the WHO Multi-Country Study on Women's Health and Domestic Violence against Women. RESULTS Of 499 staff, 215 (43%) reported perpetration of physical violence against students in the past week. Individual risk factors associated with physical violence perpetration included being a teacher versus another type of staff member (p<0.001), approving of physical discipline practices (p<0.001), having children (p<0.01), being age 30-39 years (p<0.05), using physical violence against non-students (p<0.05) and being a victim of intimate partner violence (IPV) (p<0.05). We observed weak evidence (p=0.06) that male staff members who had been a victim of IPV showed higher odds of violence perpetration compared with male staff who had not been a victim of IPV. No evidence was observed for school- or community-level risk factors. CONCLUSIONS Physical violence perpetration from school staff is widespread, and interventions are needed to address this issue. Staff who have been victims of violence and who use violence against people other than students may benefit from additional interventions. Researchers should further investigate how school and community contexts influence staff's physical violence usage, given a lack of associations observed in this study.
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Affiliation(s)
- Katherine G Merrill
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Louise Knight
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Judith R Glynn
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Elizabeth Allen
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Karen M Devries
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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