Task sharing of a psychological intervention for maternal depression in Khayelitsha, South Africa: study protocol for a randomized controlled trial

Protocol of a cost-effectiveness analysis of a combined intervention for depression and parenting compared with enhanced standard of care for perinatally depressed, HIV-positive women and their infants in rural South Africa

INTRODUCTION

Poverty, HIV and perinatal depression represent a triple threat to public health in sub-Saharan Africa because of their combined negative effects on parenting and child development. In the resource-constrained context of low-income and middle-income countries, a lay-counsellor-delivered intervention that combines a psychological and parenting intervention could offer the potential to mitigate the consequences of perinatal depression while also optimising scarce resources for healthcare.Measuring the cost-effectiveness of such a novel intervention will help decision-makers to better understand the relative costs and effects associated with replicating the intervention, thereby supporting evidence-based decision-making. This protocol sets out the methodological framework for analysing the cost-effectiveness of a cluster randomised controlled trial (RCT) that compares a combined intervention to enhanced standard of care when treating depressed, HIV-positive pregnant women and their infants in rural South Africa.

METHODS AND ANALYSIS

This cost-effectiveness analysis (CEA) protocol complies with the Consolidated Health Economic Evaluation Reporting Standards 2022 checklist. A societal perspective will be chosen.The proposed methods will determine the cost and efficiency of implementing the intervention as per the randomised control trial protocol, as well as the cost of replicating the intervention in a non-research setting. The costs will be calculated using an appropriately adjusted version of the Standardised Early Childhood Development Costing Tool.Primary health outcomes will be used in combination with costs to determine the cost per improvement in maternal perinatal depression at 12 months postnatal and the cost per improvement in child cognitive development at 24 months of age. To facilitate priority setting, the incremental cost-effectiveness ratios for improvements in child cognitive development will be ranked against six other child cognitive-development interventions according to Verguet et al's methodology (2022).A combination of activity-based and ingredient-based costing approaches will be used to identify, measure and value activities and inputs for all alternatives. Outcomes data will be sourced from the RCT team.

ETHICS AND DISSEMINATION

The University of Oxford is the sponsor of the CEA. Ethics approval has been obtained from the Human Sciences Research Council (HSRC, #REC 5/23/08/17), South Africa and the Oxford Tropical Research Ethics Committee (OxTREC #31-17), UK.Consent for publication is not applicable since no participant data are used in this protocol.We plan to disseminate the CEA results to key policymakers and researchers in the form of a policy brief, meetings and academic papers.

TRIAL REGISTRATION DETAILS

ISRCTN registry #11 284 870 (14/11/2017) and SANCTR DOH-27-102020-9097 (17/11/2017).

Effectiveness of interpersonal psychotherapy in comparison to other psychological and pharmacological interventions for reducing depressive symptoms in women diagnosed with postpartum depression in low- and middle-income countries: A systematic review

Background

Postpartum depression (PPD) is a condition that can affect any woman regardless of ethnicity, age, party, marital status, income, and type of delivery. This condition is highly prevalent worldwide. PPD, if not treated timely, can affect the maternal-child bond and can have a detrimental impact on the future cognitive, emotional, and behavioral development of the child. Interpersonal psychotherapy (IPT) has been reported as an effective treatment of PPD in previous studies as this focuses on relationship and social support issues. Previous reviews conducted in developed nations have reported the superior efficacy of IPT in comparison to other treatment options. There is no systematic review conducted in low to middle-income countries on the efficacy of IPT on PPD. Therefore it was necessary to undertake a systematic review to assess the effectiveness of IPT in reducing the depression among postpartum women in low and middle-income countries (LMICs).

Objectives

The main aim of this systematic review was to assess the effectiveness of IPT alone or in conjunction with pharmacological therapy and/or other psychological and psychosocial interventions, in reducing depressive symptoms among women diagnosed with PPD residing in LMICs.

Search Methods

The systematic search encompassed several prominent databases and grey literature. Furthermore, experts specializing in the field of IPT were consulted to identify any relevant studies conducted in LMICs that fulfilled the predetermined eligibility criteria. The most recent search update was performed in July 2022.

Selection Criteria

The PICOS criteria were meticulously defined for this review as described. Participants: Postpartum women diagnosed with PPD in LMICs were included. Intervention: IPT either as a standalone treatment or in conjunction with pharmacological therapy was included. Comparison: any form of psychological therapy or pharmacological therapy, whether administered individually or in combination, was considered for comparison. Study designs: experimental and quasi-experimental, factorial designs, and quantitative components (experimental, quasi-experimental, factorial designs) of mixed methods designs were eligible to be included. Studies with single-group study designs and qualitative studies were excluded from the review.

Data Collection and Analysis

Two reviewers from our team conducted a rigorous screening process to determine the eligibility of articles for inclusion. This involved an initial evaluation of titles and abstracts, followed by a comprehensive assessment of the full text of selected articles. In instances where discrepancies arose between the two reviewers, resolution was achieved through discussion or consultation with a third author to establish a consensus. Following the screening process, two team members independently extracted pertinent information and data from the studies that met the inclusion criteria. The treatment effect of the intervention, in comparison to the control group, was subsequently analyzed utilizing the fixed effects model taking into account the small number of studies.

Main Results

A total of 17,588 studies were identified from various databases, and 6493 duplicate studies were removed. Subsequently, 9380 studies underwent independent title and abstract screening resulting in the exclusion of 9040 studies. 345 full texts were thoroughly assessed leading to the exclusion of 341 studies, finally including 4 studies for review. The four included trials were randomized trials and comprised a total sample size of 188 women diagnosed with PPD residing in LMICs. Among these studies, three compared IPT with usual treatment, while one study compared IPT with antidepressant medications (ADMs). In terms of the providers of IPT, in one study, IPT was administered by nurses, while psychologists delivered IPT in another study. In one study, community health workers were responsible for providing IPT. However, in one study, information regarding the specific providers of IPT was not available or reported. The primary outcome measure reported in all four studies was depression, assessed using the Edinburgh Postnatal Depression Scale (EPDS). The geographical distribution of the studies included; one conducted in Zambia, one in Kenya, one in Pakistan, and one in Iran. Out of the four studies, three were included in the meta-analysis, as missing data from one study could not be obtained. Based on the overall treatment effect, it was found that depression scores decreased significantly more in the IPT group compared to other interventions (usual treatment or ADMs) (standardized mean difference [SMD] -0.62, 95% confidence interval [CI] (-1.01, -0.23), Z = 3.13 (p = 0.002), χ 2 = 49.49; df = 2; p < 0.00001; I 2 = 96%; 3 studies, n = 136). Out of the three studies, two studies compared the effectiveness of IPT in reducing depression scores specifically when compared to the usual treatment, and in both studies, depression scores were reduced significantly in the IPT group as compared to the usual treatment group. Only one study directly compared the effectiveness of IPT with ADM, reporting that IPT was more effective than ADM in reducing depression scores among postpartum women. Regarding adverse outcomes, only one study reported suicidal ideation with one participant in the IPT group and two in the ADM group (RR 0.50, 95% CI (0.05, 5.30), p = 0.56, n = 78). The same study reported seven participants in the ADM group had adverse drug reactions as compared to none in the IPT group (RR 15.0, 95% CI (0.89, 254), p = 0.06, n = 78).

Authors' Conclusions

Our comprehensive search yielded a limited number of four studies conducted in such settings. Despite the scarcity of available evidence, the findings collectively suggest that IPT is indeed an effective treatment for reducing PPD when compared to usual treatment and pharmacological therapy. However given the low certainty of evidence, there is a need for further research in the form of well-designed randomized controlled trials with larger sample sizes and a reduced risk of bias. Such studies would greatly contribute to enhancing the strength and reliability of the evidence base regarding the effectiveness of IPT in the context of PPD in LMICs. The knowledge generated from future research endeavors would be highly valuable in guiding the development of more affordable and cost-effective treatment approaches for PPD in resource-limited settings.

Postpartum depressive symptoms in women with female genital mutilation in Somalia

OBJECTIVES

This study aimed to identify associated factors for postpartum depression (PPD) among women with female genital mutilation (FGM) in Somalia.

METHODS

This was a cross-sectional study conducted between February and May 2021 in Somalia Mogadishu-Turkey Recep Tayyip Erdogan Training and Research Hospital, Mogadishu, Somalia. Mothers with any known chronic disease, or psychiatric disorders and who refused to participate were excluded from the study. The cutoff point for depression was defined as ≥13 points according to the Edinburgh Postnatal Depression Scale.

RESULTS

Out of 446 postpartum mothers, 267 (59.9%) had increased depressive symptoms in the early postpartum period. PPD scale scores of mothers who were very poor were significantly higher depression scores than their counterparts (p = .002). Education level, place of residence, occupational status, number of children, type of FGM, and the presence of perineal tear did not differ significantly between depressed and non-depressed groups.

CONCLUSIONS

Women with FGM had increased depressive symptoms in the early postpartum period in Somalia. In addition, women who had lower income had higher PPD scores than their counterparts. Further studies are needed to develop a deeper understanding of the relationships between FGM and PPD and its causes.

Garlic essential oil ameliorates depression-like behaviors in unpredictable chronic mild stress by modulating the brain NLRP3 inflammasome pathway and influencing the gut barrier and microbiota

Depression is a severe mental disorder, with approximately 300 million people suffering from it. Recent studies have demonstrated that chronic neuroinflammation is significantly associated with intestinal flora and barrier function in depression. As a therapeutic herb, garlic (Allium sativum L.) has detoxification, antibacterial activity, and antiinflammatory functions; however, its antidepressant effect through gut microbiota and barrier function has not been reported yet. The present study investigated the effect of garlic essential oil (GEO) and its active constituent diallyl disulfide (DADS) on depressive behavior by attenuating the NLRP3 inflammasome, alternating intestinal barrier function and gut microbiota in an unpredictable chronic mild stress (US) model in rats. This study found that dopamine and serotonin turnover rates were reduced significantly with a low dose of GEO (25 mg per kg bw). The GEO groups effectively reversed sucrose preference and increased the total distance traveled in the behavioral test. Moreover, 25 mg per kg bw GEO inhibited the UCMS-induced activated inflammatory response, reflected by reduced expression in the frontal cortex of NLRP3, ASC, caspase-1, and its downstream IL-1β proteins, as well as the concentration of IL-1β and TNF-α in the serum. Supplementation with GEO increased the expression of occludin and ZO-1 and the concentration of short-chain fatty acids to influence the impact of intestinal permeability in depressive conditions. The results revealed that GEO administration caused significant changes in the α and β diversity and abundance of certain bacteria. At the genus level, GEO administration significantly increased the relative abundance, particularly beneficial SCFA-producing bacteria, and may improve depression-like behavior. In conclusion, these results indicated the antidepressant effects of GEO involved in the inflammatory pathway, short-chain fatty acids, intestinal integrity, and intestinal composition.

Understanding integrated service delivery: a scoping review of models for noncommunicable disease and mental health interventions in low-and-middle income countries

BACKGROUND

Noncommunicable diseases (NCDs) and mental health conditions represent a growing proportion of disease burden in low- and middle-income countries (LMICs). While past efforts have identified interventions to be delivered across health system levels to address this burden, the challenge remains of how to deliver heterogenous interventions in resource-constrained settings. One possible solution is the Integration of interventions within existing care delivery models. This study reviews and summarizes published literature on models of integrated NCD and mental health care in LMICs.

METHODS

We searched Pubmed, African Index Medicus and reference lists to conduct a scoping review of studies describing an integrated model of NCD or neuropsychiatric conditions (NPs) implemented in a LMIC. Conditions of interest were grouped into common and severe NCDs and NPs. We identified domains of interest and types of service integration, conducting a narrative synthesis of study types. Studies were screened and characteristics were extracted for all relevant studies. Results are reported using PRISMA-ScR.

RESULTS

Our search yielded 5004 studies, we included 219 models of integration from 188 studies. Most studies were conducted in middle-income countries, with the majority in sub-Saharan Africa. Health services were offered across all health system levels, with most models implemented at health centers. Common NCDs (including type 2 diabetes and hypertension) were most frequently addressed by these models, followed by common NPs (including depression and anxiety). Conditions and/or services were often integrated into existing primary healthcare, HIV, maternal and child health programs. Services provided for conditions of interest varied and frequency of these services differed across health system levels. Many models demonstrated decentralization of services to lower health system levels, and task shifting to lower cadre providers.

CONCLUSIONS

While integrated service design is a promising method to achieve ambitious global goals, little is known about what works, when, and why. This review characterizing care integration programs is an initial step toward developing a structured study of care integration.

Implementation of a task-shared psychosocial intervention for perinatal depression in South Africa: A grounded theory process evaluation

Perinatal depression carries significant levels of disability for both women and their infants, but there is a large treatment gap for this condition in low and middle-income countries (LMICs). To address this gap, task-sharing using community health workers (CHWs) to provide psychosocial interventions for perinatal depression is increasingly common. Many of these interventions have shown significant positive effects on maternal mood, however not all have done so. This study used data from a task-shared psychosocial intervention for perinatal depression in Cape Town, South Africa, the 'Africa Focus on Intervention Research for Mental Health' (AFFIRM-SA) randomised controlled trial (RCT). It aimed to examine the processes that occurred within the delivery of the counselling intervention, and to use these findings to provide recommendations for psychosocial task sharing in LMICs. A grounded theory analysis was conducted of 234 counselling session transcripts from 39 randomly selected participants from the RCT. This revealed that the effectiveness of the intervention was compromised by the negative influence of participants' socio-economic context, and by counselling strategies that did not align with what was intended in the counselling manual. Despite this, participants provided spontaneous accounts of improvement in mood and cognition, and reasons for these improvements, interpreted as elements that were therapeutically effective for them. Most of these elements aligned with previously identified 'common elements' of therapy. Recommendations for future research and practice include conducting participatory formative research, using an iterative and responsive research design informed by implementation science, incorporating contextually appropriate strategies in interventions such as addressing social determinants of mental health, conducting intensive training and supervision, adopting a staged approach to managing depression, and using common elements of therapy as the basis for psychosocial interventions.

Integrating HIV-Associated Neurocognitive Impairment Screening within Primary Healthcare Facilities: A Pilot Training Intervention

HIV-associated neurocognitive impairment (H-NCI) remains a common comorbidity, which may affect several key health outcomes among people with HIV. However, there are shortages of appropriately skilled healthcare workers able to identify and manage H-NCI in low- and middle-income countries. We conducted an exploratory, quasi-experimental, pre- and post-cohort training intervention in KwaZulu-Natal, South Africa. Thirty-four healthcare workers (two general medical doctors, twenty-two nurses, and ten adherence counsellors) from six facilities and a mobile clinic unit attended two, two-hour face-to-face, training sessions. The training included knowledge and skill transfer components. Pre- and post-knowledge questionaries demonstrated an improvement among 82% (n = 28) of the attendees from all three cadres. Knowledge was retained by 88% (n = 30) of the attendees after eight weeks. The H-NCI screening tools were administered with 78% accuracy. After eight weeks, two general medical doctors and eight senior nurses were able to accurately administer the tool. The Primary Healthcare H-NCI training was successful in improving knowledge among primary healthcare workers; however, several healthcare workers experienced challenges with administering such tools.

Health systems strengthening interventions for perinatal common mental disorders and experiences of domestic violence in Cape Town, South Africa: protocol for a pilot implementation study

BACKGROUND

During the perinatal period, common mental disorders (CMDs) such as depression and anxiety are highly prevalent, especially in low-resource settings, and are associated with domestic violence, poverty, and food insecurity. Perinatal CMDs have been associated with several adverse maternal and child outcomes. While the Department of Health in South Africa provides healthcare workers with the tools to detect psychological distress and experiences of domestic violence, few healthcare workers routinely screen pregnant women at clinic visits, citing discomfort with mental health issues and the lack of standardised referral pathways as the key barriers. The aim of this study is to select and evaluate a set of health systems strengthening (HSS) interventions aimed at improving the care and outcomes for perinatal women with CMDs and experiences of domestic violence, attending public healthcare facilities in Cape Town.

METHODS

This study consists of a pre-implementation, development, and implementation phase. Contextual barriers identified during the pre-implementation phase included poor patient knowledge and health-seeking behaviour, high levels of stigma, and poor detection, referral, and treatment rates. Implementation science determinant frameworks were applied to findings from the pre-implementation phase to identify determinants and gaps in delivering high-quality evidence-informed care. A participatory Theory of Change workshop was used to design a HSS programme, consisting of awareness raising, detection, referral, and treatment. HSS interventions selected to support the delivery of the HSS programme includes training, health promotion, change to the healthcare environment, task-sharing, audit and feedback, and performance monitoring. The implementation phase will be used to assess several implementation and clinical outcomes associated with the delivery of the HSS programme, which will be piloted at three healthcare facilities. Qualitative and quantitative methods will be used to evaluate the implementation and clinical outcomes.

DISCUSSION

This pilot implementation study will inform us about a range of implementation and clinical outcome measures that are relevant for assessing HSS interventions for perinatal women with depression, anxiety, or experiences of domestic violence in low-resource settings. Lessons learnt from the pilot study will be incorporated into the design of a cluster randomised control trial for which further funding will be sought.

Costs of common perinatal mental health problems in South Africa

BACKGROUND

Perinatal mental health problems, defined as mental health problems occurring from the start of pregnancy to one year after birth, substantially affect women's and children's quality of life in low- and middle-income countries. In South Africa, despite high prevalence and documented negative impacts, most women do not receive any care.

METHODS

A modelling study examined the costs of perinatal mental health problems, namely depression and anxiety, for a hypothetical cohort of women and their children in South Africa over part of their life course (10 years for women, 40 years for children). In sensitivity analysis, additional impacts of post-traumatic stress disorder (PTSD) and completed suicide were included. Data sources were published findings from cohort studies, as well as epidemiological and economic data from South Africa. Data from international studies were considered where no data from South Africa were available.

RESULTS

Lifetime costs of perinatal depression and anxiety in South Africa amount to USD 2.8 billion per annual cohort of births. If the impacts of PTSD and suicide are included, costs increase to USD 2.9 billion. This includes costs linked to losses in quality of life (USD 1.8 billion), losses in income (USD 1.1 billion) and public sector costs (USD 3.5 million).

CONCLUSIONS

Whilst important progress has been made in South Africa with regards to mental health policies and interventions that include assessment and management of perinatal mental health problems, substantial underinvestment prevents progress. Findings from this study strengthen the economic case for investing in perinatal mental health care.

An evaluation of a combined psychological and parenting intervention for HIV-positive women depressed in the perinatal period, to enhance child development and reduce maternal depression: study protocol for the Insika Yomama cluster randomised controlled trial

BACKGROUND

The combination of poverty, HIV and depression in the perinatal period represents a major public health challenge in many Southern African countries. In some areas, up to a third of HIV-positive women experience perinatal depression. Perinatal depression is associated with negative effects on parenting and key domains of child development including cognitive, behavioural and growth, especially in socio-economically disadvantaged communities. Several studies have documented the benefits of psychological interventions for perinatal depression in low- and middle-income countries, but none have evaluated an integrated psychological and parenting intervention for HIV-positive women using task-sharing. This randomised controlled trial aims to evaluate the effect of a home-based intervention, combining a psychological treatment for depression and a parenting programme for perinatally depressed HIV-positive women.

METHODS

This study is a cluster randomised controlled trial, consisting of 48-60 geospatial clusters. A total of 528 pregnant HIV-positive women aged ≥ 16 years who meet the criteria for depression on the Edinburgh Postnatal Depression Scale (EPDS, score ≥ 9)) are recruited from antenatal clinics in rural KwaZulu-Natal, South Africa. The geospatial clusters are randomised on an allocation ratio of 1:1 to either the intervention or Enhanced Standard of Care (ESoC). The intervention group receives 10 home-based counselling sessions by a lay counsellor (4 antenatal and 6 postnatal sessions) and a booster session at 16 months. The intervention combines behavioural activation for depression with a parenting programme, adapted from the UNICEF/WHO Care for Child Development programme. The ESoC group receives two antenatal and two postnatal counselling support and advice telephone calls. In addition, measures have been taken to enhance the routine standard of care. The co-primary outcomes are child cognitive development at 24 months assessed on the cognitive subscale of the Bayley Scales of Infant Development-Third Edition and maternal depression at 12 months measured by the EPDS.

ANALYSIS

The primary analysis will be a modified intention-to-treat analysis. The primary outcomes will be analysed using mixed-effects linear regression.

DISCUSSION

If this treatment is successful, policymakers could use this model of mental healthcare delivered by lay counsellors within HIV treatment programmes to provide more comprehensive services for families affected by HIV.

TRIAL REGISTRATION

ISRCTN registry # 11284870 (14/11/2017) and SANCTR DOH-27-102020-9097 (17/11/2017).

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.

Adaptation and validation of a structured version of the Hamilton Depression Rating Scale for use by non-clinicians in South Africa (AFFIRM-HDRS)

RATIONALE, AIMS AND OBJECTIVES

The Hamilton depression rating scale (HDRS) is seen as an international gold standard for the measurement of depression. High rates of untreated depression, including perinatal depression, support the rationale to adapt and validate a structured version of the HDRS to be used by non-clinicians in low-income settings.

METHODS

Using previous structured versions of the HDRS as a foundation, the tool was adapted, translated, and then validated with an isiXhosa speaking perinatal population in South Africa (n = 187), using cognitive testing, test-retest reliability, and inter-rater assessments. The AFFIRM-HDRS was compared with the Edinburgh postnatal depression scale (EPDS) using the non-parametric Spearman Rho test to assess concurrent validity. Internal consistency was examined using Cronbach's Alpha, and inter-rater and test-retest reliability were assessed with the intra-class coefficient (ICC). Cohen's Kappa was used to assess the overall percentage agreement for each individual item of the AFFIRM-HDRS.

RESULTS

The AFFIRM-HDRS showed good construct and content validity had significant associations with the EPDS (Rho = 0.60 and 0.43, P < .001), and acceptable internal consistency (Cronbach's alpha = 0.74.). Inter-rater reliability and test-retest scores were excellent, with intraclass correlations ranging from 0.97 (0.94-0.99) to 0.98 (0.97-0.99) between raters, and test-retest reliability being 0.90 (95% CI: 0.86-0.93). The tool performed similarly to previous structured versions. Individual item-rest correlations suggest that the items "Weight loss or gain," "Insight," and "Libido" did not fit well with the overall instrument, but that the rest of the items performed well.

CONCLUSION

The AFFIRM-HDRS is adequately structured to be used by non-clinicians in an isiXhosa speaking perinatal population. It is hoped that this structured tool can be used to assist with identification and referral of these at-risk populations by non-clinicians in resource-constrained environments, thereby playing a role in addressing the treatment gap for perinatal depression in LMICs.

Barriers to addressing mental health issues in childbearing women in Ghana

Aim

The aim of the study is to investigate factors hampering the provision of mental health services by nurses and midwives to childbearing women to assist in the prioritization and distribution of limited mental health resources.

Design

This is a cross‐sectional self‐report study.

Methods

Data collected from 309 nurses and midwives were analysed using descriptive and inferential statistic, namely chi‐square and analysis of variance (ANOVA).

Results

The barriers reported by the participants include unavailability of mental health services (77%), lack of knowledge of mental health in women from different tribes (75.7%), lack of a clear mental healthcare pathway (75.1%), heavy workload (74.1%) and lack of knowledge of mental health issue (74.1%). These barriers are less likely to be reported by participants who are males, old and who have practiced for a long time.

Conclusions

Systematic effort to restructure the healthcare delivery system, including equipping healthcare professionals with requisite knowledge, skills and competencies in maternal mental health, is highly recommended.

Task-sharing of psychological treatment for antenatal depression in Khayelitsha, South Africa: Effects on antenatal and postnatal outcomes in an individual randomised controlled trial

The study's objective was to determine the effectiveness of a task-sharing psychological treatment for perinatal depression using non-specialist community health workers. A double-blind individual randomised controlled trial was conducted in two antenatal clinics in the peri-urban settlement of Khayelitsha, Cape Town. Adult pregnant women who scored 13 or above on the Edinburgh Postnatal Depression rating Scale (EPDS) were randomised into the intervention arm (structured six-session psychological treatment) or the control arm (routine antenatal health care and three monthly phone calls). The primary outcome was response on the Hamilton Depression Rating Scale (HDRS) at three months postpartum (minimum 40% score reduction from baseline) among participants who did not experience pregnancy or infant loss (modified intention-to-treat population) (registered on Clinical Trials: NCT01977326). Of 2187 eligible women approached, 425 (19.4%) screened positive on the EPDS and were randomised; 384 were included in the modified intention-to-treat analysis (control: n = 200; intervention: n = 184). There were no significant differences in response on the HDRS at three months postpartum between the intervention and control arm. A task-sharing psychological treatment was not effective in treating depression among women living in Khayelitsha, South Africa. The findings give cause for reflection on the strategy of task-sharing in low-resource settings.

Economic burden of maternal depression among women with a low income in Cape Town, South Africa

BACKGROUND

Maternal depression is a notable concern, yet little evidence exists on its economic burden in low- and middle-income countries.

AIMS

This study assessed societal costs and economic outcomes across pregnancy to 12 months postpartum comparing women with depression with those without depression. Trial registration: ClinicalTrials.gov: NCT01977326 (registered on 24 October 2013); Pan African Clinical Trials Registry (www.pactr.org): PACTR201403000676264 (registered on 11 October 2013).

METHOD

Participants were recruited during the first antenatal visit to primary care clinics in Khayelitsha, Cape Town. In total, 2187 women were screened, and 419 women who were psychologically distressed were retained in the study. Women were interviewed at baseline, 8 months gestation and at 3 and 12 months postpartum; the Hamilton Rating Scale for Depression was used to categorise women as having depression or not having depression at each interview. Collected data included sociodemographics; health service costs; user fees; opportunity costs of accessing care; and travelling expenses for the women and their child(ren). Using Markov modelling, the incremental economic burden of maternal depression was estimated across the period.

RESULTS

At 12 months postpartum, women with depression were significantly more likely to be unemployed, to have lower per capita household income, to incur catastrophic costs and to be in a poorer socioeconomic group than those women without depression. Costs were higher for women with depression and their child(ren) at all time points. Modelled provider costs were US$805 among women without depression versus US$1303 in women with depression.

CONCLUSIONS

Economic costs and outcomes were worse in perinatal women with depression. The development of interventions to reduce this burden is therefore of significant policy importance.

Association between perinatal depressive symptoms and suicidal risk among low-income South African women: a longitudinal study

PURPOSE

The aim of this study was to assess the association between depressive symptoms and suicidal risk over time among perinatal women at risk for depression antenatally, and assess modifying effects of age, perinatal stage and depressive symptom trajectory.

METHODS

A total of 384 adult pregnant women were recruited from two antenatal clinics in an informal settlement near Cape Town, South Africa, and followed up at eight months gestation, and at 3- and 12-month postpartum. The MINI 6.0 Suicidality module and the Hamilton Depression Rating Scale (HDRS) were used to measure suicidal risk and depression, respectively. Generalised Estimating Equations were used to assess the association between change in depressive symptoms from one assessment to the next (predictor) and change in suicide score or change in suicidal risk (score ≥ 9) (outcomes).

RESULTS

HDRS scores were positively correlated with suicide score (95% CI 0.35, 0.78; p < 0.001), and with odds of being at moderate risk for suicide, after controlling for risk of suicide at the previous assessment (adjusted odds ratio = 1.15; 95% CI 1.09, 1.22; p < 0.001). Age was a significant effect modifier: change in HDRS scores was not associated with change in suicide scores among participants aged 35-45 years. Secondary analyses indicated that a decrease in HDRS score was associated with a decrease in suicide scores, but an increase in HDRS score was not associated with change in suicide score.

CONCLUSIONS

Depression and suicide are overlapping but relatively independent phenomena, especially among older or more chronically depressed perinatal women.

Promoting maternal mental health in Ghana: An examination of the involvement and professional development needs of nurses and midwives

Insight into the involvement and professional development needs (PDNs) of non-mental health nurses and midwives with respect to promoting maternal mental health is necessary to integrate mental health services into primary healthcare delivery. Using a cross-sectional survey and self-report methodology, the study investigates the involvement, PDNs, knowledge and attitudes of 309 nurses and midwives in promoting maternal mental health in Ghana. Data were analyzed using descriptive and inferential statistics, namely Analysis of Variance, bivariate and logistic regression, and cluster analysis. The results showed that the majority of the participants (94%) indicated they were involved in promoting maternal mental health. Knowledge about maternal mental health correlated significantly with involvement in promoting maternal mental health (p < .05), whereas attitude towards maternal mental health did not. An overwhelming proportion of the participants (83%-94%) expressed profound interest in professional development education across a range of maternal mental health areas. Enhancing the mental health knowledge-base of nurses and midwives could contribute significantly to promoting maternal mental health.

Perinatal depressive symptoms among low-income South African women at risk of depression: trajectories and predictors

BACKGROUND

The aim of the study was to identify trajectories of perinatal depressive symptoms and their predictors among women living in a low-resource setting in South Africa, and who present with a risk of depression during pregnancy.

METHODS

This is a secondary analysis of a randomised controlled trial among 384 women living in Khayelitsha, a low income setting in South Africa, recruited at their first antenatal visit if they scored 13 or above on the Edinburgh Postnatal Depression Scale, were at least 18 years of age, less than 29 weeks pregnant and spoke isiXhosa. Participants were followed up at 8 months gestation, 3 and 12 months postpartum. Latent trajectories of depressive symptoms were identified using growth mixture modelling, based on the Hamilton Depression Rating Scale (HDRS). There were no differences in HDRS scores between the control and intervention arms, so all participants were assessed together. Health, social and economic predictors of trajectories were investigated to identify high-risk groups with greater or more chronic depressive symptoms, using univariate logistic regression.

RESULTS

Two trajectories were identified: antenatal only (91.4%), with moderate to severe symptoms at baseline which later subside; and antenatal and postnatal (8.6%), with severe depressive symptoms during pregnancy and later in the postpartum period, which subside temporarily to moderate levels at 3 months postpartum. Predictors for the antenatal and postnatal trajectory include severe food insecurity, intimate partner violence, lower social support, greater functional impairment, problematic drinking and suicide risk.

CONCLUSIONS

A small proportion of women who are at risk for depression antenatally remain at risk throughout the perinatal period, and can be differentiated from those who show a natural remission. Identification and referral strategies should be developed with these findings in mind, especially given the limited mental health resources in low-income settings.

Intervention for alcohol use disorders at an HIV care clinic in Harare: a pilot and feasibility study

BACKGROUND

Alcohol use in HIV infected patients is associated with risky sexual behaviour, poor adherence to Highly Active Antiretroviral Therapy, treatment failure and increased physiologic harm. The objectives of the study were to pilot the outcome assessments to be used in the trial proper, assess the feasibility of delivery of a brief MI/CBT intervention compared to an WHO mhGAP intervention for problematic alcohol use in PLWH in Zimbabwe, and pilot the effectiveness (on alcohol use, functionality and CD4 count) of these interventions at 3 months in a randomised controlled trial design.

METHODS

An intervention for HIV infected patients with problematic alcohol use, developed through adaptation of existing evidence based psychological treatments, was assessed for its feasibility at a tertiary HIV care clinic in Zimbabwe. Registered general nurses, using a manualised protocol, delivered the intervention. Forty patients were recruited and randomised to receive either an MI/CBT intervention or the WHO mhGAP Intervention Guide for AUDs (n = 20 patients per group).

RESULTS

Out of 40 participants enrolled, 31 were successfully followed up for 3 months with a loss to follow-up rate of 23%. There was a statistically significant decrease in AUDIT score over time in both groups (p < 0.001), however no statistically significant group difference with a mean difference of 0.80, standard error of 2.07 and p = 0.70. For the CD4 count, the median and interquartile ranges at baseline for MI/CBT and WHO mhGAP IG groups were 218 (274) and 484 (211.50), respectively. At follow-up, median and interquartile ranges for the CD4 count for MI/CBT and WHO mhGAP IG groups were 390 (280) and 567 (378), respectively, indicative of improvement in immunological parameters in both arms.

CONCLUSION

The findings from this pilot study suggests that a brief MI/CBT delivered by Registered General Nurses for problematic alcohol use is feasible in this population but will require the implementation of additional measures to improve retention. However, mechanisms to improve retention need special attention. Trial registration Pan African Clinical Trial Registry, current PACTR201509001211149.

Improving psychotherapies offered in public hospitals in Nairobi, Kenya: extending practice-based research model for LMICs

BACKGROUND

Psychotherapy and mental health services in Nairobi's public hospitals are increasing. Rather than prematurely imposing psychotherapy protocols developed in Western countries to Kenya, we argue that first studying psychological interventions as they are practiced may generate understanding of which psychological problems are common, what interventions therapists use, and what seems to be effective in reducing psychiatric problems in a lower and middle income country like Kenya.

METHOD

We present preliminary findings from a process-outcome study involving 345 patients from two public institutions, Kenyatta National and Mathare National Hospitals. We asked our patients to fill out a brief personal information questionnaire, Clinical Outcomes in Routine Evaluation-Outcome Measure (Evans et al. in Br J Psychiatry 180:51-60, 2002, and the Session Alliance Inventory (Falkenström et al. in Psychol Assess 27:169-183, 2015) after each session. We present descriptives for CORE-OM, patient-therapist concordance on the SAI, and using longitudinal mixed-effects model, test change in CORE-OM over time with various therapy and patient factors as predictors in regression analyses.

RESULTS

The majority of patients who attended the outpatient care clinics were young males. Our regression analysis suggested that patients with depression reported higher initial distress levels (2.75 CORE-OM scores, se = 1.11, z = 2.48, p = 0.013, 95% CI 0.57-4.93) than patients with addictions, anxiety, or psychosis. Older clients improved slower (0.08 CORE-OM scores slower improvement per session per year older age; se = 0.03, z = 3.02 p = 0.003, 95% CI 0.03, 0.14). Female patients reported higher initial distress than men (2.62 CORE-OM scores, se = 1.00, z = 2.61, p = 0.009, 95% CI 0.65, 4.58). However, interns had patients who reported significantly higher initial distress (3.24 CORE-OM points, se = 0.90, z = 3.60, p < 0.001, 95% CI 1.48, 5.00), and improved more over time (- 1.20 CORE-OM scores per session, se = 0.51, z = - 2.35, p = 0.019, 95% CI - 2.20, - 0.20) than patients seeing mental health practitioners. The results showed that at average alliance, CORE-OM decreased by 1.74 points per session (se = 0.21, p < 0.001). For each point higher on the SAI at session 2, the CORE-OM decreased by an additional 0.58 points per session (se = 0.25, p = 0.02).

DISCUSSION

Our objective was to study psychotherapies as they are practiced in naturalistic settings. The overall significant finding is that our participants report improvement in their functioning mental health condition and distress reduced as psychotherapy progressed. There were many more male than female participants in our sample; younger patients improved more than older ones; and while interns had patients with higher distress, their patients improved better than those patients attended by professionals.

CONCLUSIONS

These are preliminary observations to consider for a larger sample follow-up study. Before changing practices, evaluating the existing practices by mapping clinical outcomes is a helpful route.

Positive adjustment to first grade despite divorce: Lessons for school psychologists

Positive adjustment to first grade is an important milestone in children’s lives. Yet, it is sometimes further complicated by additional challenges such as parental divorce. Drawing on a social ecological perspective we explored how the systems rooted in social ecologies enable children’s resilience when their parents are divorced so as to result in their coping well with adjusting to first grade. We used a single instrumental case study that involved visual methodologies to uncover lessons from the story of a first grader whose parents divorced but who continued to adjust well to first grade. Our findings suggest leverage points for school psychologists (SPs) who wish to champion the resilience of first graders who are adjusting to formal school as well as their parents’ divorce. SPs can intervene by supporting the first grader’s processes of agency and meaning making; by working systemically to engage systems of support; and by mobilizing systems with task-sharing.

The Effect of a Community Health Worker Utilized Mobile Health Application on Maternal Health Knowledge and Behavior: A Quasi-Experimental Study

Background

Mobile technology (mHealth) is increasingly being used to achieve improved access and quality of maternal care, particularly in rural areas of low- and middle-income countries. In 2011, a mobile application—Mobile for Mothers (MfM)—was implemented in Jharkhand, India to support home visits by community health workers. The objective of this study is to assess the impact of the mHealth intervention on maternal health.

Methods

Households from three subdistricts in the Deoghar district of Jharkhand were selected using a multistage cluster sampling approach. Households from the Sarwan subdistrict received the MfM intervention, those from Devipur subdistrict received other interventions asides MfM from the implementing non-governmental organization (NGO), while households from Mohanpur subdistrict received the current standard of care. Women (n = 2,200) between the ages of 18 and 45 who had delivered a baby in the past 1 year were enrolled into the study. The primary outcomes of interest were maternal health knowledge, antenatal care (ANC) attendance, and delivery in a health facility.

Results

Post-intervention, women in the MfM group had higher maternal health knowledge, were more likely to attend four or more ANC visits, and deliver at the health facility when compared with the NGO and standard care group. After controlling for predictors, women in the intervention group significantly performed better than both the NGO and standard care groups on all three-outcome variables (all P > 0.05).

Conclusion

The results indicate that although the MfM mHealth intervention could influence adherence and practice of recommended maternal health behaviors, it could not overcome key sociocultural determinants of maternal health such as caste and educational status, which are specific to the Indian context. mHealth holds continued promise for maternal health but implementers and policy makers must additionally address health system and sociocultural factors that play a significant role in the uptake of recommended maternal health practices.

Patterns of intimate partner violence among perinatal women with depression symptoms in Khayelitsha, South Africa: a longitudinal analysis

BACKGROUND

A combination of intimate partner violence (IPV) and depression is a common feature of the perinatal period globally. Understanding this association can provide indications of how IPV can be addressed or prevented during pregnancy. This paper aims to determine the prevalence and correlates of IPV among pregnant low-income women with depressive symptoms in Khayelitsha, South Africa, and changes in IPV reports during the course of the perinatal period.

METHODS

This study is a secondary analysis of data collected as part of a randomised controlled trial testing a psychosocial intervention for antenatal depression. IPV, socio-demographic measures, depression and other mental health measures were collected at recruitment (first antenatal visit), 8 months gestation, and 3 and 12 months postpartum. IPV was defined as a sexual or physical violence perpetrated by the participant's partner in the past 3 months. Descriptive statistics are reported.

RESULTS

Of 425 recruited depressed participants, 59 (13.9%) reported IPV at baseline, with physical IPV being the most frequently reported (69.5%). Reported IPV was associated with greater emotional distress, potentially higher food insecurity and higher rates of alcohol abuse. There were clear longitudinal trends in reported IPV with the majority of women no longer reporting IPV postpartum. However, some women reported IPV at later assessment points after not reporting IPV at baseline.

CONCLUSIONS

There is a strong association between IPV and depression in pregnancy. IPV reports remit over time for the women in this study, although the reason for this reduction is not clear and requires further investigation.

Impediments and catalysts to task-shifting psychotherapeutic interventions for adolescents with PTSD: perspectives of multi-stakeholders

BACKGROUND

This qualitative study was nested within a randomized controlled trial (RCT) where two psychotherapeutic interventions (supportive counselling and prolonged exposure for adolescents) were provided by supervised nurses (who served as 'nurse counsellors') to adolescents with PTSD in school settings. This paper describes the perspectives of nurse counsellors (NCs) and school liaisons (SLs). SLs were teachers or administrative personnel at the schools who coordinated the study visits of participants with the NCs. We focus on the impediments and catalysts to and recommendations for treatment implementation.

METHODS

NCs (n = 3) and SLs (n = 3) who participated in the RCT during 2014 were purposively recruited by telephone and participated in face-to-face semi-structured in-depth interviews that were recorded and doubly transcribed. Thematic content analysis was applied using Atlas.ti software to identify emerging themes. This paper describes the impediments and catalysts to provide psychotherapy by task-shifting in a community setting across three sub-themes: personal, community, and collaborative care.

RESULTS

Although nurses were initially resistant to supervision it was central to personally coping with complex interventions, managing traumatic content, and working apart from a multi-disciplinary team. Delivering the interventions in the community presented multiple logistical impediments (e.g. transport, communication, venue suitability) which required creative solutions. In light of resource shortages, networking is central to effective delivery and uptake of the interventions. Collaboration between government departments of health and education may have a major impact on providing school-based psychotherapy through task-shifting.

CONCLUSIONS

Impediments to implementation are not insurmountable. This article provides recommendations to maximize the success of task-shifting interventions should they be rolled out.

A process evaluation exploring the lay counsellor experience of delivering a task shared psycho-social intervention for perinatal depression in Khayelitsha, South Africa

BACKGROUND

Task sharing of psycho-social interventions for perinatal depression has been shown to be feasible, acceptable and effective in low and middle-income countries. This study conducted a process evaluation exploring the perceptions of counsellors who delivered a task shared psycho-social counselling intervention for perinatal depression in Khayelitsha, Cape Town together with independent fidelity ratings.

METHODS

Post intervention qualitative semi-structured interviews were conducted with six counsellors from the AFrica Focus on Intervention Research for Mental health (AFFIRM-SA) randomised controlled trial on their perceptions of delivering a task shared psycho-social intervention for perinatal depression. Themes were identified using the framework approach and were coded and analysed using Nvivo v11. These interviews were supplemented with fidelity ratings for each counsellor and supervision notes.

RESULTS

Facilitating factors in the delivery of the intervention included intervention related factors such as: the content of the intervention, ongoing training and supervision, using a counselling manual, conducting counselling sessions in the local language (isiXhosa) and fidelity to the manual; counsellor factors included counsellors' confidence and motivation to conduct the sessions; participant factors included older age, commitment and a desire to be helped. Barriers included contextual factors such as poverty, crime and lack of space to conduct counselling sessions and participant factors such as the nature of the participant's problem, young age, and avoidance of contact with counsellors. Fidelity ratings and dropout rates varied substantially between counsellors.

CONCLUSION

These findings show that a variety of intervention, counsellor, participant and contextual factors need to be considered in the delivery of task sharing counselling interventions. Careful attention needs to be paid to ongoing supervision and quality of care if lay counsellors are to deliver good quality task shared counselling interventions in under-resourced communities.

TRIAL REGISTRATION

Clinical Trials: NCT01977326 , registered on 24/10/2013; Pan African Clinical Trials Registry: PACTR201403000676264 , registered on 11/10/2013.

Identifying inequities in maternal and child health through risk stratification to inform health systems strengthening in Northern Togo

OBJECTIVE

In Togo, substantial progress in maternal and child health is needed to reach global development goals. To better inform clinic and community-based health services, this study identifies factors associated with maternal and child health care utilization in the Kara region of Northern Togo.

METHODS

We conducted a population-representative household survey of four health clinic catchment areas of 1,075 women of reproductive age in 2015. Multivariable logistic regression was used to model individual and structural factors associated with utilization of four maternal and child health services. Key outcomes were: facility-based delivery, maternal postnatal health check by a health professional within the first six weeks of birth, childhood vaccination, and receipt of malaria medication for febrile children under age five within 72 hours of symptom onset.

RESULTS

83 percent of women who gave birth in the last 2 years delivered at a health facility. In adjusted models, the strongest predictor of facility delivery in the rural catchment areas was proximity to a health center, with women living under three kilometers having 3.7 (95% CI 1.7, 7.9) times the odds of a facility birth. Only 11 percent of women received a health check by a health provider at any time in the postnatal period. Postnatal health checks were less likely for women in the poorest households and for women who resided in rural areas. Children of polygamous mothers had half the odds of receiving malaria medication for fever within 72 hours of symptom onset, while children with increased household wealth status had increased odds of childhood vaccination and receiving treatment for malaria.

CONCLUSION

Our analysis highlights the importance of risk stratification analysis to inform the delivery and scope of maternal and child health programs needed to reach those with the least access to care.

Developing mental health research in sub-Saharan Africa: capacity building in the AFFIRM project

BACKGROUND

There remains a large disparity in the quantity, quality and impact of mental health research carried out in sub-Saharan Africa, relative to both the burden and the amount of research carried out in other regions. We lack evidence on the capacity-building activities that are effective in achieving desired aims and appropriate methodologies for evaluating success.

METHODS

AFFIRM was an NIMH-funded hub project including a capacity-building program with three components open to participants across six countries: (a) fellowships for an M.Phil. program; (b) funding for Ph.D. students conducting research nested within AFFIRM trials; (c) short courses in specialist research skills. We present findings on progression and outputs from the M.Phil. and Ph.D. programs, self-perceived impact of short courses, qualitative data on student experience, and reflections on experiences and lessons learnt from AFFIRM consortium members.

RESULTS

AFFIRM delivered funded research training opportunities to 25 mental health professionals, 90 researchers and five Ph.D. students across 6 countries over a period of 5 years. A number of challenges were identified and suggestions for improving the capacity-building activities explored.

CONCLUSIONS

Having protected time for research is a barrier to carrying out research activities for busy clinicians. Funders could support sustainability of capacity-building initiatives through funds for travel and study leave. Adoption of a train-the-trainers model for specialist skills training and strategies for improving the rigor of evaluation of capacity-building activities should be considered.

"The sun has set even though it is morning": Experiences and explanations of perinatal depression in an urban township, Cape Town

This study examined experiences and explanations of depression amongst Xhosa-speaking pregnant women, mothers, and health workers in an urban township in Cape Town, South Africa. The study was conducted as part of formative research for a randomised controlled trial to develop and evaluate a task-sharing counselling intervention for maternal depression in this setting. We conducted qualitative semi-structured interviews with 12 depressed and 9 nondepressed pregnant women and mothers of young babies, and 13 health care providers. We employed an in-depth framework analysis approach to explore the idioms, descriptions, and perceived causes of depression particular to these women, and compared these with the ICD-10 and DSM-5 criteria for major depression. We found that symptoms of major depression are similar in this township to those described in international criteria (withdrawal, sadness, and poor concentration), but that local descriptions of these symptoms vary. In addition, all the symptoms described by participants were directly related to stressors occurring in the women's lives. These stressors included poverty, unemployment, lack of support from partners, abuse, and death of loved ones, and were exacerbated by unwanted or unplanned pregnancies and the discovery of HIV positive status at antenatal appointments. The study calls attention to the need for specifically designed counselling interventions for perinatal depression that are responsive to the lived experiences of these women and grounded in the broader context of poor socioeconomic conditions and living environments in South Africa, all of which have a direct impact on mental health.

Filling the treatment gap: developing a task sharing counselling intervention for perinatal depression in Khayelitsha, South Africa

BACKGROUND

Perinatal depression is a major public health issue especially in low income settings in South Africa, where there is a shortage of mental health professionals. New psychological interventions delivered by non-specialists are needed to fill the treatment gap. This paper describes the process of developing a manual based task sharing counselling intervention for perinatal depression in Khayelitsha, Cape Town.

METHODS

Qualitative semi-structured interviews were conducted with 26 participants, including service providers and service users at a clinic in Khayelitsha in order to explore the feasibility, acceptability and content of a task sharing counselling intervention. The interviews were recorded, translated and transcribed. Themes were identified using the framework analysis approach and were coded and analysed using NVivo v10. After the semi-structured interviews, a workshop was conducted with mental health experts on evidence-based psychological interventions for depression, together with a document review of counselling manuals for community health workers in South Africa.

RESULTS

The findings indicate that a task sharing counselling intervention was acceptable and feasible for depressed women in Khayelitsha, under the following conditions: (1) respondents preferred a female counsellor and felt that clinic based individual sessions should be provided at least once a month by an experienced Xhosa speaking counsellor from the community; and (2) the content of a counselling intervention should include psycho-education on cognitive and behavioural effects of depression, how to cope with interpersonal problems, and financial stressors. Based on these conditions, the review of manuals and expert consultation, key components of the counselling intervention were identified as: psycho-education, problem solving, healthy thinking and behaviour activation. These were included in the final counselling manual.

CONCLUSION

The development of task sharing counselling interventions for perinatal depression should be informed by the views and needs of local service users and service providers. The study illustrates the manner in which these views can be incorporated for the development of evidence-based psychological interventions, within a task sharing framework in low and middle-income countries.

Task sharing for the care of severe mental disorders in a low-income country (TaSCS): study protocol for a randomised, controlled, non-inferiority trial

BACKGROUND

Task sharing mental health care through integration into primary health care (PHC) is advocated as a means of narrowing the treatment gap for mental disorders in low-income countries. However, the effectiveness, acceptability, feasibility and sustainability of this service model for people with a severe mental disorder (SMD) have not been evaluated in a low-income country.

METHODS/DESIGN

A randomised, controlled, non-inferiority trial will be carried out in a predominantly rural area of Ethiopia. A sample of 324 people with SMD (diagnoses of schizophrenia, schizoaffective disorder, bipolar disorder or major depressive disorder) with an ongoing need for mental health care will be recruited from 1) participants in a population-based cohort study and 2) people attending a psychiatric nurse-led out-patient clinic. The intervention is a task-sharing model of locally delivered mental health care for people with SMD integrated into PHC delivered over 18 months. Participants in the active control arm will receive the established and effective model of specialist mental health care delivered by psychiatric nurses at an out-patient clinic within a centrally located general hospital. The hypothesis is that people with SMD who receive mental health care integrated into PHC will have a non-inferior clinical outcome, defined as a mean symptom score on the Brief Psychiatric Rating Scale, expanded version, of no more than six points higher, compared to participants who receive the psychiatric nurse-led service, after 12 months. The primary outcome is change in symptom severity. Secondary outcomes are functional status, relapse, service use costs, service satisfaction, drop-out and medication adherence, nutritional status, physical health care, quality of care, medication side effects, stigma, adverse events and cost-effectiveness. Sustainability and cost-effectiveness will be further evaluated at 18 months. Randomisation will be stratified by health centre catchment area using random permuted blocks. The outcome assessors and investigators will be masked to allocation status.

DISCUSSION

Evidence about the effectiveness of task sharing mental health care for people with SMD in a rural, low-income African country will inform the World Health Organisation's mental health Gap Action Programme to scale-up mental health care globally.

TRIAL REGISTRATION

NCT02308956 (ClinicalTrials.gov). Date of registration: 3 December 2014.

Generating evidence to narrow the treatment gap for mental disorders in sub-Saharan Africa: rationale, overview and methods of AFFIRM

There is limited evidence on the acceptability, feasibility and cost-effectiveness of task-sharing interventions to narrow the treatment gap for mental disorders in sub-Saharan Africa. The purpose of this article is to describe the rationale, aims and methods of the Africa Focus on Intervention Research for Mental health (AFFIRM) collaborative research hub. AFFIRM is investigating strategies for narrowing the treatment gap for mental disorders in sub-Saharan Africa in four areas. First, it is assessing the feasibility, acceptability and cost-effectiveness of task-sharing interventions by conducting randomised controlled trials in Ethiopia and South Africa. The AFFIRM Task-sharing for the Care of Severe mental disorders (TaSCS) trial in Ethiopia aims to determine the acceptability, affordability, effectiveness and sustainability of mental health care for people with severe mental disorder delivered by trained and supervised non-specialist, primary health care workers compared with an existing psychiatric nurse-led service. The AFFIRM trial in South Africa aims to determine the cost-effectiveness of a task-sharing counselling intervention for maternal depression, delivered by non-specialist community health workers, and to examine factors influencing the implementation of the intervention and future scale up. Second, AFFIRM is building individual and institutional capacity for intervention research in sub-Saharan Africa by providing fellowship and mentorship programmes for candidates in Ethiopia, Ghana, Malawi, Uganda and Zimbabwe. Each year five Fellowships are awarded (one to each country) to attend the MPhil in Public Mental Health, a joint postgraduate programme at the University of Cape Town and Stellenbosch University. AFFIRM also offers short courses in intervention research, and supports PhD students attached to the trials in Ethiopia and South Africa. Third, AFFIRM is collaborating with other regional National Institute of Mental Health funded hubs in Latin America, sub-Saharan Africa and south Asia, by designing and executing shared research projects related to task-sharing and narrowing the treatment gap. Finally, it is establishing a network of collaboration between researchers, non-governmental organisations and government agencies that facilitates the translation of research knowledge into policy and practice. This article describes the developmental process of this multi-site approach, and provides a narrative of challenges and opportunities that have arisen during the early phases. Crucial to the long-term sustainability of this work is the nurturing and sustaining of partnerships between African mental health researchers, policy makers, practitioners and international collaborators.