Trained lay health workers reduce common mental disorder symptoms of adults with suicidal ideation in Zimbabwe: a cohort study

Interventions for Self-Harm and Suicidal Ideation in Africa: A Systematic Review

BACKGROUND

Self-harm and suicidal ideation are increasing public health concerns globally and are paramount in Africa. Therefore, a review of suicidal ideation and self-harm interventions would be beneficial in identifying culturally appropriate interventions for the African context.

METHOD

The Population, phenomenon of Interest and Context (PICo) model was adopted to formulate the review strategy. Thus, the Population (Africans), phenomenon of Interest (intervention) and Context (self-harm and suicidal ideation). We used this PICo strategy which is a modified version of PICO for qualitative studies. Framework with Boolean operators (AND/OR/NOT) was further used to ensure rigor through search terms such as ("Suicide" OR "suicidal ideation") AND ("Intervention" OR "Treatment" OR "Therapy" OR "Psychological" OR "Psychosocial" OR "Culturally adapted") AND "Africa" OR "African countries." Six databases were searched (Embase, PsycINFO, ProQuest Central, Cochrane Controlled Trials Register, Medline, and Web of Science) for published articles between 2000 and March 2023. N = 12 studies met the inclusion criteria, and the relevant data extracted were synthesized and thematically analyzed. The review protocol was pre-registered on the PROSPERO Registry (no. CRD42021283795).

RESULTS

N = 12 studies met the inclusion criteria, and the following themes emerged from the synthesized literature and analyses of current African approaches to curbing self-harm and suicidal ideation: (a) Western medical and compassion-focused intervention (b) the helpful role of traditional healing and healers (c) psychoeducation and self-help techniques (d) use of technology and a nation-wide approach.

CONCLUSION

Self-harm and suicidal ideation are global health concerns. To address this health concern in Africa, the authors recommend culturally adapted psychological interventions to be tested via randomized control trials.

Integrating Depression and Alcohol Use Care Into Primary Care in Low- and Middle-Income Countries: A Meta-Analysis

OBJECTIVE

Evaluation of the effectiveness of integration of depression and alcohol use disorder care into primary health care in low- and middle-income countries (LMICs) is limited. The authors aimed to quantify the effectiveness of integrating mental health care into primary care by examining depression and alcohol use disorder outcomes. The study updates a previous systematic review summarizing research on care integration in LMICs.

METHODS

Following PRISMA guidelines, the authors included studies from the previous review and studies published from 2017 to 2020 that included adults with alcohol use disorder or depression. Studies were evaluated for type of integration model with the typology developed previously. A meta-analysis using a random-effects model to assess effectiveness of integrated interventions was conducted. Meta-regression analyses to examine the impact of study characteristics on depression and alcohol use disorder outcomes were conducted.

RESULTS

In total, 49 new articles were identified, and 74 articles from the previous and current studies met inclusion criteria for the meta-analysis. Overall random effect sizes were 0.28 (95% CI=0.22-0.35) and 0.17 (95% CI=0.11-0.24) for studies targeting care integration for depression or for alcohol use disorder, respectively, into primary care in LMICs. High heterogeneity within and among studies was observed. No significant association was found between country income level and depression and alcohol use outcomes. However, differences in effect sizes between types of integration model were statistically significant (p<0.001).

CONCLUSIONS

Integration of mental health care into primary health care in LMICs was found to improve depression and alcohol use disorder outcomes. This evidence should be considered when designing interventions to improve mental health screening and treatment in LMICs.

Mental health task-sharing in South Africa - a role for clinical associates?

BACKGROUND

South Africa (SA) lacks the specialised workforce needed to provide mental health services particularly in the public sector and in rural areas. Mid-level medical workers offer a potential option for mental health task-sharing in countries where they exist, including SA. The objectives of the study were to explore the roles that SA's mid-level medical worker cadre (clinical associates) could play in mental health service delivery, and to explore views on advanced training in mental health for this cadre.

METHODS

This was an explorative, qualitative study involving key informants linked to the three clinical associate training programmes in SA. A total of 19 in-depth interviews were conducted with university-based academic staff, facility-based trainers, and student representatives. The interviews were audio-recorded and professionally transcribed. Thematic analysis was conducted with the aid of Atlas.ti software. Themes and subthemes were identified.

RESULTS

The first theme identified was 'there is a place for them at the table'. Participants felt that there was a definite role for clinical associates in mental health service provision. The levels of care thought most appropriate were primary health care facilities and district hospitals. The most frequently identified role for clinical associates was in providing immediate care and stabilising mental health patients presenting in emergency settings. Other potential settings included inpatient wards, outpatients' departments, and in communities (e.g. home visits). The second theme identified was 'earning a seat at the table'. There was virtually unanimous support for additional training and in particular a postgraduate clinical specialisation in mental health. Participants felt a clinical specialisation in mental health would strengthen the health system by addressing workforce shortages as well as access and equity issues. They also held the view it would strengthen the profession by creating a career path and providing more employment opportunities for clinical associates.

CONCLUSIONS

There was broad support for a role for clinical associates in mental health service delivery in SA as well as for the establishing a clinical specialisation in mental health for clinical associates. Clinical associates with advanced training in mental health could potentially play an important role in rural settings to alleviate the shortage of specialist mental health practitioners.

Lay HIV counselors' knowledge and attitudes toward depression: A mixed-methods cross-sectional study at primary healthcare centers in Mozambique

Introduction

Depression is the most common mental disorder among people living with HIV/AIDS and has a negative impact on HIV treatment outcomes. Training lay HIV counselors to identify and manage depression may contribute to improved patient access and adherence to treatment, and reduce stigma and discrimination among lay health workers toward both HIV and depression. The purpose of this study was to assess the current knowledge and attitudes of lay HIV counselors toward managing depression in primary care in Mozambique.

Methods

We conducted a mixed-methods cross-sectional study to assess depression-related knowledge and attitudes among lay HIV counselors in 13 primary healthcare facilities in Mozambique. We used the quantitative Depression Attitude Questionnaire (DAQ) scale, followed by open-ended questions to further explore three key DAQ domains: the nature of depression, treatment preferences, and professional attitudes or reactions.

Results

The sample included 107 participants (77.6% female, mean age: 32.3 years, sd = 7.4). Most (82.2%) had less than a high/technical school education. Findings suggested that some HIV counselors had knowledge of depression and described it as a cluster of psychological symptoms (e.g., deep sadness, anguish, apathy, isolation, and low self-esteem) sometimes leading to suicidal thoughts, or as a consequence of life stressors such as loss of a loved one, abuse, unemployment or physical illness, including being diagnosed with HIV infection. HIV counselors identified talking to trusted people about their problems, including family and/or counseling with a psychotherapist, as the best way for patients to deal with depression. While acknowledging challenges, counselors found working with patients with depression to be rewarding.

Conclusion

Lay health counselors identified HIV and psychosocial issues as key risk factors for depression. They believed that the treatment approach should focus on social support and psychotherapy.

Feasibility and acceptability of a mental health stigma intervention for low-income South African caregivers: A qualitative investigation

Background

Common mental health illnesses such as depression and anxiety disorders are increasing globally. There remain significant gaps in health services provision and support for mental illness linked to stigma in developing countries.

Aim

Our study aimed to assess the feasibility and acceptability of a mental health intervention for caregivers of mental health service users.

Setting

Low-income South African communities.

Method

Our study qualitatively assessed the feasibility of an anti-stigma mental health intervention for family caregivers in low-income settings. The intervention was structured into five sessions delivered over three days. Caregivers attended all the sessions at a centralised community venue. Semi-structured qualitative interviews were held separately with caregivers (n = 10) and their service users (n = 9) eight weeks post-intervention. Interviews were translated verbatim from local languages to English prior to framework analysis.

Results

Post-intervention, service users reported improved family relations and understanding of mental illness among family members. The intervention was reported as acceptable and helpful by caregivers as it increased knowledge, fostering better relationships with service users. Group discussions were noted as a critical driver of intervention success. Widespread mental health stigma within communities remained a key concern for caregivers and service users.

Conclusion

With the government’s drive for deinstitutionalisation, the need to integrate anti-stigma interventions within community mental health services is vital, as is the need for population-wide anti-stigma interventions to support the integration of mental health service users within communities.

Lay Health Workers in Community-Based Care and Management of Dementia: A Qualitative ‘Pre’ and ‘Post’ Intervention Study in Southwestern Uganda

Background

The global need for efficient and cost-effective use of healthcare resources in low-income countries has led to the introduction of lay health workers (LHWs) as a link of the community to healthcare services. As such, the LHWs perform a variety of tasks such as education, support for care delivery, and social support across all disease types. However, little is known about their ability to support dementia care and management in the community.

Purpose

The goal of the pilot intervention was to evaluate the 5-day training intervention for LHWs in rural southwestern Uganda in community-based care and management of people with dementia, and implementation of the knowledge and skills gained.

Methods

This was a “pre” and “post” pilot intervention study which involved a qualitative assessment of LHWs' knowledge on community-based management and care for people with dementia. We focused on four core competency domains in the WHO dementia toolkit. The intervention included a five-day training of the LHWs on dementia care, eight weeks of implementation, and an evaluation of the experiences. Analysis focused on the needs assessment, early detection and management, community engagement, support for people with dementia; and evaluation of the eight weeks implementation.

Results

Before the training, the LHWs did not know much about what dementia-related support to provide in the community. Activities were limited to general support, including nutrition, and health education. After the training, LHWs had a basic understanding of dementia and began sensitizing the communities. They felt more comfortable working with people with dementia and reported a notable change in the attitude of family members. However, they reported challenges in differentiating the signs of early dementia from superstitious beliefs.

Conclusion

With enhanced capacity, LHWs may be able to support community-based management for people with dementia. A larger study is needed to explore potential roles for LHWs and further assess effectiveness of the LHWs' skills.

Barriers to the provision of non-communicable disease care in Zimbabwe: a qualitative study of primary health care nurses

BACKGROUND

Non-communicable diseases (NCDs) contribute significantly to the global disease burden, with low-and middle-income (LMICs) countries disproportionately affected. A significant knowledge gap in NCDs exacerbates the high burden, worsened by perennial health system challenges, including human and financial resources constraints. Primary health care workers play a crucial role in offering health care to most people in LMICs, and their views on the barriers to the provision of quality care for NCDs are critical. This study explored perceived barriers to providing NCDs care in primary health care facilities in Zimbabwe.

METHODS

In-depth, individual semi-structured interviews were conducted with general nurses in primary care facilities until data saturation was reached. We focused on diabetes, hypertension, and depression, the three most common conditions in primary care in Zimbabwe. We used thematic content analysis based on an interview guide developed following a situational analysis of NCDs care in Zimbabwe and views from patients with lived experiences.

RESULTS

Saturation was reached after interviewing 10 participants from five busy urban clinics. For all three NCDs, we identified four cross-cutting barriers, a) poor access to medication and functional equipment such as blood pressure machines, urinalysis strips; b) high cost of private care; c)poor working conditions; and d) poor awareness from both patients and the community which often resulted in the use of alternative potentially harmful remedies. Participants indicated that empowering communities could be an effective and low-cost approach to positive lifestyle changes and health-seeking behaviours. Participants indicated that the Friendship bench, a task-shifting programme working with trained community grandmothers, could provide a platform to introduce NCDs care at the community level. Also, creating community awareness and initiating screening at a community level through community health workers (CHWs) could reduce the workload on the clinic nursing staff.

CONCLUSION

Our findings reflect those from other LMICs, with poor work conditions and resources shortages being salient barriers to optimal NCDs care at the facility level. Zimbabwe's primary health care system faces several challenges that call for exploring ways to alleviate worker fatigue through strengthened community-led care for NCDs. Empowering communities could improve awareness and positive lifestyle changes, thus optimising NCD care. Further, there is a need to optimise NCD care in urban Zimbabwe through a holistic and multisectoral approach to improve working conditions, basic clinical supplies and essential drugs, which are the significant challenges facing the country's health care sector. The Friendship Bench could be an ideal entry point for providing an integrated NCD care package for diabetes, hypertension and depression.

Cultural adaptation of psychological interventions for people with mental disorders delivered by lay health workers in Africa: scoping review and expert consultation

BACKGROUND

Lay Health Workers (LHW) are important providers of community mental health services and help mitigate access and treatment gaps in Africa. However, there is a paucity of knowledge about the role and performance of these workers, as well as about the extent to which the interventions delivered are culturally adapted to the African context.

AIMS

This scoping review aimed to explore the content and aspects concerning the cultural adaptation and sustainability of psychological interventions delivered by LHW to people with mental disorders in Africa.

METHODS

We conducted a scoping review of the peer-reviewed literature published from January 2000 to December 2018 to identify psychological interventions delivered by LHW for people with mental disorders in Africa. We systematically searched PubMed, Google scholar and Hinari to select relevant publications. The articles were evaluated for risk of bias according to study design with the National Heart, Lung, and Blood Institute's (NHLBI) Quality Assessment Tools. Expert consultation was performed according to Arksey & O'Malley framework and cultural adaptation analysis was performed according to Bernal framework.

RESULTS

Out of 14,549 retrieved records, we identified ten peer-reviewed articles conducted in Zimbabwe, Uganda, South Africa and Zambia describing four distinct interventions. Six were randomized controlled trials; none addressed implementation outcomes. Group-based interpersonal therapy (n = 5), trauma-focused cognitive behaviour therapy (n = 1), problem solving therapy (n = 3) and narrative exposure therapy (n = 1) emerged as psychological interventions delivered by LHW for people with depression, anxiety, trauma and suicidal behavior. Psychological interventions delivered by LHW in Africa were all culturally adapted to meet the competence of LHW. All the interventions were associated with symptom improvement, but the quality of this evidence varied widely with study design.

CONCLUSION

Task-shifting psychological interventions delivered by LHW after appropriate cultural adaptation show promise for addressing unmet mental health care needs in Africa. More effectiveness and implementation evidence is needed, especially with regard to psychological interventions delivered by LHW for adolescence, older people and those with severe mental disorders and suicidal behaviors.

"Seeing a Brighter Future" - Experiences of Adolescents with Common Mental Disorders Receiving the Problem-Solving Therapy "Youth Friendship Bench" in Zimbabwe

In Zimbabwe common mental disorders are prevalent among adolescents and the treatment gap is large. The recently introduced Youth Friendship Bench intervention (YouFB) addresses this gap by task-shifting youth lay health workers to offer a culturally contextualised, manual-based, six-session problem-solving therapy to adolescents, 16-19 years of age. The aim of this study was to explore participants´ experiences of YouFB to attain a first insight into this novel intervention. Interviews with nine adolescents were analysed using qualitative content analysis on a latent level. The experience of YouFB was positive, perceived to offer hope and relief from feelings of isolation and uncertainty, increase manageability of problems, and contribute to feelings of autonomy, resulting in a feeling of optimism about the future. The notion among participants that this brief intervention had such a positive influence on their lives, sparks interest because of its applicability in low-resource settings.

A descriptive mapping review of suicide in vulnerable populations in low and middle countries

INTRODUCTION

In 2016, low-and-middle income countries (LMICs) accounted for 79% of the global suicide deaths. In LMICs, vulnerable groups-women, sexual minorities and refugees, and internally displaced persons (IDPs)-are at high risk of suicidal ideation, attempts and deaths by suicide, but information for designing targeted interventions for them is fragmented and missing, making it difficult to address gaps in the existing system. This review highlights these gaps by mapping: (a) risk factors associated with suicides and suicidal behavior including challenges in implementing targeted programmes for vulnerable groups; and (b) recommendations for effective suicide prevention interventions and strategies in LMICs as documented in the literature.

METHODS

A descriptive mapping review of literature was conducted. Three electronic databases-PubMed, Google Scholar, and Refworld-were searched for specific keywords. The researchers mapped and reviewed 34 studies on suicide and suicide prevention across three main vulnerable groups.

RESULTS

This review highlighted the need for gender-specific interventions for women and sexual minorities, addressing gender-based discrimination, access to healthcare, abuse and violence, while for refugees and IDPs, critical concerns are monitoring and understanding suicidal behaviors and to address psychological and emotional responses to resettlement.

CONCLUSION

In LMICs, specific and unique socio-cultural and environmental factors may increase the risk of vulnerable groups to suicidal behaviors. In order to develop effective and comprehensive suicide prevention strategies, it is crucial to evaluate these differential risk factors and develop culturally appropriate and sensitive interventions and strategies.

Lay-delivered talk therapies for adults affected by humanitarian crises in low- and middle-income countries

BACKGROUND

Published by the World Health Organization (WHO) and United Nations High Commissioner for Refugees (UNHCR) in 2015, the mental health Gap Action Programme Humanitarian Intervention Guide (mhGAP-HIG) recommends brief versions of structured psychological interventions for people experiencing symptoms of common mental disorders (CMDs). mhGAP-HIG acknowledges a growing body of evidence suggesting these interventions can be delivered by lay workers to people affected by humanitarian crises in low- and middle-income countries (LMICs). However, there has not yet been a systematic review and synthesis of this evidence. This paper reports the results of a systematic review of qualitative, quantitative, and mixed-methods studies assessing the implementation and/or effectiveness of talk therapies for CMDs when provided by lay workers in LMICs to adults who have survived or are currently living in humanitarian situations.

METHODS

Seven electronic databases were searched: MEDLINE, Embase, PsycINFO, PsycEXTRA, Global Health, Cochrane Library, and ClinicalTrials.gov . We also hand-searched the contents pages of three academic journals, reference lists of 30 systematic reviews, and online resource directories of two mental health networks. A preliminary list of included studies was circulated to topical experts for review, and all included studies were backward and forward searched. All titles, abstracts, and full-texts were independently double-screened. Quality appraisal and data extraction were carried out by a single reviewer and checked by a second reviewer, using standardised tools. Any disagreements were discussed and referred to a third reviewer as needed.

RESULTS

We identified 23 unique studies and carried out a narrative synthesis of patient and implementation outcome data. Every evaluation of the effectiveness of lay-delivered talk therapies for adults affected by humanitarian crises in LMICs showed some treatment effect for at least one CMD, and often multiple CMDs. Implementation research generally found these interventions to be acceptable, appropriate and feasible to implement, with good fidelity to manualised therapies.

CONCLUSION

Although results are promising, particularly for individually-delivered talk therapies based on cognitive behavioural therapy techniques, there is a high degree of heterogeneity in this literature. We make several recommendations on how to improve the quality and generalisability of research on this topic, to facilitate further evidence synthesis.

TRIAL REGISTRATION

PROSPERO registration number: CRD42017058287 .

Current strategies in the reduction of stigma among caregivers of patients with mental illness: a scoping review

Mental healthcare and wellness are a global concern and have increasingly become an essential service and priority from a human rights perspective. However, negative attitudes towards mental health, such as stigmatisation and discrimination from communities and family members, continue to pose challenges for deinstitutionalisation and home care of mentally ill persons. This study aimed to review the literature on the content and implementation methods of stigma reduction interventions for family/community caregivers of patients with mental illness to inform the development of an anti-stigma intervention for such caregivers in low- and middle-income countries like South Africa. A scoping literature review was conducted of English language studies published from 2008 to 2019 in peer-reviewed journals, using established guidelines for the study objectives. Primary interventions targeting caregivers of mental health patients were searched from PsycINFO, ScienceDirect, CINAHL, and Medline. In total, nine full-text articles were extracted for inclusion in the review, indicating a scarcity of literature on anti-stigma interventions aimed at primary caregivers of mental health patients. Interventions varied in terms of educational content, duration, delivery methods, and sample sizes. Intervention delivery was primarily through face-to-face, telephone, and online methods. Anti-stigma interventions for caregivers of patients with mental illness are varied and show positive short-term impacts on mental health stigma reduction among family caregivers. The evolution of health systems is a feasible approach towards integrating learning and trials that are needed to assess long-term impacts.

Common mental disorders and HIV status in the context of DREAMS among adolescent girls and young women in rural KwaZulu-Natal, South Africa

BACKGROUND

HIV affects many adolescent girls and young women (AGYW) in South Africa. Given the bi-directional HIV and mental health relationship, mental health services may help prevent and treat HIV in this population. We therefore examined the association between common mental disorders (CMD) and HIV-related behaviours and service utilisation, in the context of implementation of the combination DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored and Safe) HIV prevention programme in rural uMkhanyakude district, KwaZulu-Natal. DREAMS involved delivering a package of multiple interventions in a single area to address multiple sources of HIV risk for AGYW.

METHODS

We analysed baseline data from an age-stratified, representative cohort of 13-22 year-old AGYW. We measured DREAMS uptake as a count of the number of individual-level or community-based interventions each participant received in the last 12 months. CMD was measured using the validated Shona Symptom Questionnaire, with a cut off score ≥ 9 indicating probable CMD. HIV status was ascertained through home-based serotesting. We used logistic regression to estimate the association between CMD and HIV status adjusting for socio-demographics and behaviours.

RESULTS

Probable CMD prevalence among the 2184 respondents was 22.2%, increasing steadily from 10.1% among 13 year-old girls to 33.1% among 22 year-old women. AGYW were more likely to report probable CMD if they tested positive for HIV (odds ratio vs. test negative: 1.88, 95% confidence interval: 1.40-2.53). After adjusting for socio-demographics and behaviours, there was evidence that probable CMD was more prevalent among respondents who reported using multiple healthcare-related DREAMS interventions.

CONCLUSION

We found high prevalence of probable CMD among AGYW in rural South Africa, but it was only associated with HIV serostatus when not controlling for HIV acquisition risk factors. Our findings highlight that improving mental health service access for AGYW at high risk for HIV acquisition might protect them. Interventions already reaching AGYW with CMD, such as DREAMS, can be used to deliver mental health services to reduce both CMD and HIV risks. There is a need to integrate mental health education into existing HIV prevention programmes in school and communities.

The Friendship Bench as a brief psychological intervention with peer support in rural Zimbabwean women: a mixed methods pilot evaluation

BACKGROUND

There is a large treatment gap for common mental disorders in rural areas of low-income countries. We tested the Friendship Bench as a brief psychological intervention delivered by village health workers (VHWs) in rural Zimbabwe.

METHODS

Rural women identified with depression in a previous trial received weekly home-based problem-solving therapy from VHWs for 6 weeks, and joined a peer-support group. Depression was assessed using the Edinburgh Postnatal Depression Scale (EPDS) and Shona Symptom Questionnaire (SSQ). Acceptability was explored through in-depth interviews and focus group discussions. The proportion of women with depression pre- and post-intervention was compared using McNemar's test.

RESULTS

Ten VHWs delivered problem-solving therapy to 27 women of mean age 33 years; 25 completed six sessions. Women valued an established and trustful relationship with their VHW, which ensured confidentiality and prevented gossip, and reported finding individual problem-solving therapy beneficial. Peer-support meetings provided space to share problems, solutions and skills. The proportion of women with depression or suicidal ideation on the EPDS declined from 68% to 12% [difference 56% (95% confidence interval (CI) 27.0-85.0); p = 0.001], and the proportion scoring high (>7) on the SSQ declined from 52% to 4% [difference 48% (95% CI 24.4-71.6); p < 0.001] after the 6-week intervention.

CONCLUSION

VHW-delivered problem-solving therapy and peer-support was acceptable and showed promising results in this pilot evaluation, leading to quantitative and qualitative improvements in mental health among rural Zimbabwean women. Scale-up of the Friendship Bench in rural areas would help close the treatment gap for common mental disorders.

Applying the Exploration Preparation Implementation Sustainment (EPIS) Framework to the Kigali Imbereheza Project for Rwandan Adolescents Living With HIV

BACKGROUND

Sub-Saharan African adolescents living with HIV face challenges to antiretroviral therapy (ART) adherence. Poor mental health drives nonadherence but can be improved with cognitive behavioral therapy (CBT). CBT delivered by peers may strengthen effects while building capacity for sustainment in low-income countries. This case study retrospectively applied the Exploration Preparation Implementation Sustainment framework to characterize the execution of the Kigali Imbereheza Project, a 2-arm individually randomized group controlled trial of Trauma-Informed Adherence-Enhanced CBT (TI-CBTe) delivered by Rwandan youth leaders (YLs) to adolescents living with HIV.

METHODS

YL (n = 14, 43% female, M = 22.71 years) had confirmed HIV and self-reported ART adherence >95%. Participants (n = 356, 51% female, M = 16.78 years) living with HIV were randomized to TI-CBTe or usual care. Two YLs co-led TI-CBTe sessions over 2 months for a total of 12 hours, while other YL observed and rated fidelity. Participants reported on YL competence. Additional data evaluated feasibility, acceptability, uptake, and fidelity.

RESULTS

In the Exploration phase, focus groups, stakeholder meetings, and individual interviews revealed strong consensus for delivering TI-CBT to reduce adolescent depression and trauma and improve ART adherence. In the Preparation phase, curriculum revisions were made, YLs were successfully trained, and a cascading supervision model was established. In the Implementation phase, YL delivered TI-CBTe with close monitoring and supervision. Findings revealed strong feasibility, acceptability, uptake, and fidelity, increasing the likelihood of Sustainment.

CONCLUSIONS

Exploration Preparation Implementation Sustainment can guide implementation planning and delivery and evaluate implementation outcomes.

Community Interventions to Promote Mental Health and Social Equity

(Reprinted with permission from Current Psychiatry Reports (2020) 21: 35).

Mental health in elite athletes: International Olympic Committee consensus statement (2019)

Mental health symptoms and disorders are common among elite athletes, may have sport related manifestations within this population and impair performance. Mental health cannot be separated from physical health, as evidenced by mental health symptoms and disorders increasing the risk of physical injury and delaying subsequent recovery. There are no evidence or consensus based guidelines for diagnosis and management of mental health symptoms and disorders in elite athletes. Diagnosis must differentiate character traits particular to elite athletes from psychosocial maladaptations.

Management strategies should address all contributors to mental health symptoms and consider biopsychosocial factors relevant to athletes to maximise benefit and minimise harm. Management must involve both treatment of affected individual athletes and optimising environments in which all elite athletes train and compete. To advance a more standardised, evidence based approach to mental health symptoms and disorders in elite athletes, an International Olympic Committee Consensus Work Group critically evaluated the current state of science and provided recommendations.

Community Interventions to Promote Mental Health and Social Equity

PURPOSE OF REVIEW

We review recent community interventions to promote mental health and social equity. We define community interventions as those that involve multi-sector partnerships, emphasize community members as integral to the intervention, and/or deliver services in community settings. We examine literature in seven topic areas: collaborative care, early psychosis, school-based interventions, homelessness, criminal justice, global mental health, and mental health promotion/prevention. We adapt the social-ecological model for health promotion and provide a framework for understanding the actions of community interventions.

RECENT FINDINGS

There are recent examples of effective interventions in each topic area. The majority of interventions focus on individual, family/interpersonal, and program/institutional social-ecological levels, with few intervening on whole communities or involving multiple non-healthcare sectors. Findings from many studies reinforce the interplay among mental health, interpersonal relationships, and social determinants of health. There is evidence for the effectiveness of community interventions for improving mental health and some social outcomes across social-ecological levels. Studies indicate the importance of ongoing resources and training to maintain long-term outcomes, explicit attention to ethics and processes to foster equitable partnerships, and policy reform to support sustainable healthcare-community collaborations.

Where there is no evidence: implementing family interventions from recommendations in the NICE guideline 11 on challenging behaviour in a South African health service for adults with intellectual disability

BACKGROUND

Low- and middle-income countries often lack the fiscal, infrastructural and human resources to conduct evidence-based research; similar constraints may also hinder the application of good clinical practice guidelines based on research findings from high-income countries. While the context of health organizations is increasingly recognized as an important consideration when such guidelines are implemented, there is a paucity of studies that have considered local contexts of resource-scarcity against recommended clinical guidelines.

METHODS

This paper sets out to explore the implementation of the NICE Guideline 11 on family interventions when working with persons with intellectual disability and challenging behavior by a group of psychologists employed in a government health facility in Cape Town, South Africa.

RESULTS

In the absence of evidence-based South African research, we argue that aspects of the guidelines, in particular those that informed our ethos and conceptual thinking, could be applied by clinical psychologists in a meaningful manner notwithstanding the relative scarcity of resources.

CONCLUSION

We have argued that where guidelines such as the NICE Guidelines do not apply contextually throughout, it remains important to retain the principles behind these guidelines in local contexts. Limitations of this study exist in that the data were drawn only from the clinical experience of authors. Some of the implications for future research in resource-constrained contexts such as ours are discussed. Smaller descriptive, qualitative studies are necessary to explore the contextual limitations and resource strengths that exist in low- and middle-income settings, and these studies should be more systematic than drawing only on the clinical experience of authors, as has been done in this study.

A structural equation modelling of the buffering effect of social support on the report of common mental disorders in Zimbabwean women in the postnatal period

OBJECTIVE

Globally, 13-20% of women experience a common mental disorder (CMD) postnatally. Unfortunately, the burden of CMDs is disproportionally substantial in women from low-income countries. Nevertheless, there is a growing recognition of the buffering effect of social support (SS) on psychiatric morbidity and the need for mental well-being support services/interventions. This study evaluated the relationship between psychiatric morbidity and SS levels, and factors influencing the mental health functioning of Zimbabwean women postnatally. Data were collected from 340 mothers and were analysed through structural equation modelling.

RESULTS

The mothers' mean age was 26.6 (SD 5.6) years. The mean Multidimensional Scale of Perceived Social Support score was 42.7 (SD 10.8), denoting high levels of SS. Additionally, 29.1% of the population reported excessive psychiatric morbidity, the median Shona Symptoms Questionnaire score was 5 (IQR: 2-8). The structural equation model demonstrated the buffering effects of SS on psychiatric morbidity (r = - 0.585, p = 0.01), and accounted for 70% of the variance. Being unmarried, increased maternal age, lower educational and income levels were associated with poorer maternal mental health. There is a need for routine; surveillance and treatment of CMDs in women in the postnatal period, including integration of low-cost, evidenced-based and task-shifting SS interventions.