Partnerships in mental healthcare service delivery in low-resource settings: developing an innovative network in rural Nepal

Mental health services implementation in Colombia-A systematic review

Colombia's mental health services have a complex history shaped by 60 years of armed conflict, a predominantly clinical approach to mental health, and social factors such as inequities and stigma. The 1990 Caracas declaration proposed a shift towards decentralised community mental health services and interventions based on the recovery approach and emphasis on social determinants of mental health in the Americas. Colombia has adopted these approaches in its legal and practical framework in recent years, but implementation has been uneven. This systematic review aims to contribute to mental health services understanding in Colombia by examining the barriers and facilitators to the implementation of mental health services in Colombia. A search was conducted to explore available peer-reviewed studies on Colombian mental health services across five databases (Medline, PubMed, Scopus, Scielo and BVS) on quantitative and qualitative research papers published in the last ten years and without language restrictions. The Consolidated Framework for Implementation Research (CFIR) was used to structure the analysis and identify barriers and facilitators during the implementation of mental health services. We adapted the CFIR to attend to gender, race and age informed by the Socio-Political Economy of Global Mental Health framework, given the importance of these factors to the Colombian health landscape. Finally, narrative synthesis was used to summarise the data. 1 530 records were identified, and 12 articles met all inclusion criteria and were included in the analysis. 8 papers described substance use disorders services, 11 involved multidisciplinary healthcare professionals, and 7 were implemented at a local scale. The primary barriers to implementation were the lack of coordination, high workloads, and low funding. Facilitators included the use of protocols, and the involvement of communities, stakeholders, users, and external champions. Findings suggest the continued importance of community and recovery approaches and efforts to improve coordination between multi-sector actors involved in the mental health spaces (e.g., public, and private organisations, users and their families).

Cluster randomised controlled trial of a problem-solving, Story-bridge mental health literacy programme for improving Ghanaian community leaders' knowledge of depression

BACKGROUND

Low levels of mental health literacy about depression in the community impact negatively on attitudes towards people with the disorder and their help-seeking.

AIMS

The aim of this study was to assess the effectiveness of a problem-solving, Story-bridge mental health literacy programme, in improving community leaders' knowledge about helpful interventions for, and recognition of, depression.

METHODS

A cluster randomised controlled trial involving 140 assembly members, intervention (n = 70) and control (n = 70) groups. The intervention group received a three-hour mental health literacy programme. The control group received a plain language basic brochure about mental health issues. Data were collected at baseline and 12-week follow-up.

RESULTS

The intervention group demonstrated greater improvement in knowledge about helpful interventions for, and recognition of, depression compared to the control group at follow-up; however, the differences in both measures were small and not statistically significant.

CONCLUSION

The programme has the potential to improve participants' knowledge about helpful interventions for, and recognition of, depression. Positive outcomes have public mental health implications as they might enhance early help-seeking and contribute to better outcomes for individuals with mental health problems.

TRIAL REGISTRATION

ACTRN12617000033347. Date of registration - 9 January 2017.

Feasibility and acceptability of a multicomponent, group psychological intervention for adolescents with psychosocial distress in public schools of Pakistan: a feasibility cluster randomized controlled trial (cRCT)

BACKGROUND

Child and adolescent mental health problems are a global public mental health priority. However, there is a lack of evidence-based scalable psychological interventions for adolescents living in low resource settings. This trial was designed to evaluate the feasibility and acceptability of delivering the World Health Organization's Early Adolescent Skills for Emotions (EASE) intervention at public schools in a rural sub-district in Rawalpindi, Pakistan.

METHODS

A two arm, single blinded, feasibility cluster randomized controlled trial with mixed-methods evaluation was conducted with 59 adolescents and their caregivers from 8 public schools. In the 4 intervention arm schools, 6 non-specialist facilitators delivered the culturally-adapted EASE group sessions to the adolescents (n = 29) and their caregivers with desired fidelity under the supervision of in-country supervisors.

RESULTS

The participation rate of adolescents in the intervention sessions was 83%. The intervention strategies were implemented by the adolescents. However, attending biweekly sessions at schools was challenging for caregivers with only 50% caregivers attending the sessions.

CONCLUSIONS

The results of this study support the feasibility and acceptability of delivering this culturally adapted intervention through non-specialist facilitators in school settings in Pakistan and pave the way to conduct a fully powered cluster randomized controlled trial to test the effectiveness of intervention to improve psychological outcomes in adolescents. Trial registration Trial registered with Clinicaltrials.gov prospectively; NCT04254393.

The Effect of a Spirituality-Based Program on Stress, Anxiety, and Depression of Caregivers of Patients with Mental Disorders in Iran

One of the important issues regarding caring for patients with mental disorders is the high prevalence of stress, anxiety, and depression in their caregivers. This study aimed to investigate the effect of a spirituality-based program on stress, anxiety, and depression of caregivers of patients with mental disorders. This clinical-trial study involved 60 family caregivers of patients with mental disorders who were referred to the clinic of Shahid Ayatollah Modarres Psychiatric Hospital in Isfahan, Iran, during 2019-2020. Accordingly, the samples were selected using convenient sampling method and then divided into two groups of experimental and control by simple random allocation. Next, the spirituality-based intervention was performed for the intervention group, and the needed data were collected in both intervention and control groups before, immediately after, and one month after the intervention. The data collection tool used in this study was DASS-21 questionnaire. No significant differences were observed between the two groups in terms of the mean scores of stress, anxiety, and depression (p > 0.05) before the intervention. However, some significant differences were found in terms of the stress, anxiety, and depression scores between the two groups immediately (p < 0.001) and one month after the intervention (p < 0.001). The spirituality-based program seemed to affect stress, anxiety, and depression of caregivers of patients with mental disorders positively. So, it is suggested to perform this intervention as an inexpensive and available supportive method for family caregivers of patients with mental disorders.

Diaspora engagement: a scoping review of diaspora involvement with strengthening health systems of their origin country

BACKGROUND

Diaspora communities are a growing source of external aid and resources to address unmet needs of health systems of their homelands. Although numerous articles have been published, these endeavors as a whole have not been systematically assessed.

OBJECTIVE

Examine the available literature to assess activities through which diasporas engage with the health system in their origin country and what barriers they face in their interventions.

METHODS

This is a scoping review from 1990-2018 using the PRISMA-Scr framework to examine both peer-reviewed and gray literature on (1) specific activities through which diasporas contribute to the health system in their origin country; (2) major health needs diasporas have tried to address; and (3) barriers faced by diaspora healthcare efforts.

RESULTS

The initial search identified 119 articles, of which 45 were eligible after excluding non-relevant studies. These were case studies of diaspora contributions to health systems in their origin country (13), interviews (13), literature reviews (9), general articles on the topic (4), and correspondences or presentations (6). The healthcare needs diasporas have sought to address include health workforce emigration ('brain drain') (10), capacity building for research and training (10), inadequate infrastructure (5), and finances (4). Specific activities included short-term missions (11), establishing partnerships (9), emigration back to country of origin (8), specific research and training programs (8), and financial remittances (5). Specific barriers identified were most commonly financial need within the origin country (8), lack of sustainability (6), communication issues (6), lack of intention to return to the origin country (5), infrastructure (4), and political concerns (3).

CONCLUSION

Further research on how to expand the scope of and reduce barriers to diaspora engagement is needed to optimize the effectiveness of diaspora contributions to their origin countries. Metrics and standards should be developed for assessing impact of diaspora engagement and interventions.

WhatsApp and Health Communication

Little is known about the use of WhatsApp in promoting oral health among parents or caregivers. Therefore, the survey examined the impact of social media in disseminating health infographic messages in supporting children's oral health from the parent's perspective. The group of respondents read or saw posts or messages related to health education through Facebook (n=85, 31.9%), WhatsApp (n=68, 25.2%), and YouTube (n=61, 22.6%). There was a significant difference before and after the infographics were sent to the respondent, and it was found to be statistically significant (P-value &lt;0.001). As a social media platform for oral health education purposes, WhatsApp appeared to improve parents' knowledge and behaviors towards their children's oral health. Most respondents perceived WhatsApp to be beneficial. Knowing how people use social media now could help health communication efforts be more effective and equitable.

Twelve tips for point-of-care ultrasound teaching in low-resource settings

Point-of-care ultrasound (POCUS) has become the standard of care for many emergency department evaluations. Low-resource settings are ideal for POCUS to help improve access to imaging for a number of indications that are obstetric, disease or trauma related. The following twelve specific tips are aimed toward organizations and individuals who aspire to initiate POCUS training in a low-resource setting.

Collaborative care model for depression in rural Nepal: a mixed-methods implementation research study

INTRODUCTION

Despite carrying a disproportionately high burden of depression, patients in low-income countries lack access to effective care. The collaborative care model (CoCM) has robust evidence for clinical effectiveness in improving mental health outcomes. However, evidence from real-world implementation of CoCM is necessary to inform its expansion in low-resource settings.

METHODS

We conducted a 2-year mixed-methods study to assess the implementation and clinical impact of CoCM using the WHO Mental Health Gap Action Programme protocols in a primary care clinic in rural Nepal. We used the Capability Opportunity Motivation-Behaviour (COM-B) implementation research framework to adapt and study the intervention. To assess implementation factors, we qualitatively studied the impact on providers' behaviour to screen, diagnose and treat mental illness. To assess clinical impact, we followed a cohort of 201 patients with moderate to severe depression and determined the proportion of patients who had a substantial clinical response (defined as ≥50% decrease from baseline scores of Patient Health Questionnaire (PHQ) to measure depression) by the end of the study period.

RESULTS

Providers experienced improved capability (enhanced self-efficacy and knowledge), greater opportunity (via access to counsellors, psychiatrist, medications and diagnostic tests) and increased motivation (developing positive attitudes towards people with mental illness and seeing patients improve) to provide mental healthcare. We observed substantial clinical response in 99 (49%; 95% CI: 42% to 56%) of the 201 cohort patients, with a median seven point (Q1:-9, Q3:-2) decrease in PHQ-9 scores (p<0.0001).

CONCLUSION

Using the COM-B framework, we successfully adapted and implemented CoCM in rural Nepal, and found that it enhanced providers' positive perceptions of and engagement in delivering mental healthcare. We observed clinical improvement of depression comparable to controlled trials in high-resource settings. We recommend using implementation research to adapt and evaluate CoCM in other resource-constrained settings to help expand access to high-quality mental healthcare.

Task Sharing or Task Dumping: Counsellors Experiences of Delivering a Psychosocial Intervention for Mental Health Problems in South Africa

Given task-sharing mental health counselling to non-specialist providers is a recognised strategy to increase service capacity, ensuring that their training, supervision, and support needs are met is necessary to facilitate the sustainable delivery of a high-quality service. Using in-depth interviews, we qualitatively explored the experiences of 18 facility-based counsellors (FBCs) tasked with delivering a counselling intervention within chronic disease services offered within primary care facilities participating in the project MIND cluster randomised controlled trial. Findings show that project MIND training with a strong emphasis on role playing and skills rehearsal improved FBCs' confidence and competence, complemented by highly structured supervision and debriefing provided by a registered counsellor, were key strategies for supporting the implementation of task-shared mental health counselling. FBCs perceived many benefits to providing mental health counselling in primary healthcare but systemic interventions are needed for sustained implementation.

Accountability in medical education from theory to practice Tabriz 2018 statement: A step towards the implementation of this social necessity

Background: To implement the education reform package on accountability in medical education, the Education Development Center (EDC) of Tabriz University of Medical Sciences has held the first national conference on accountability in medical education, and the present statement is the result of scientific interactions and exchanges in the conference.

Methods: For implementation of the accountability in medical education, there was a need to inform faculty members and other stakeholders about their responsibility in education and health care needs. The provision of such platform was provided by holding a specialized conference on accountability in medical education by Tabriz University of Medical Sciences. Steps of preparing the draft version of the Tabriz 2018 Statement were as follow: Formation the scientific committee; Division of the responsibility for drafting the statement between various workgroups; and Preparation and primary approval of the draft of Tabriz 2018 Statement.

Results: Steps of preparing the draft version of the Tabriz 2018 Statement were: Formation of the scientific committee, Division of the responsibility for drafting the statement between the various workgroups and Preparation and primary approval of the draft of Tabriz 2018 Statement.

Conclusion: Establishing an educational accreditation model and reviewing accreditation standards based on social accountability can be an effective step to strengthen accountability towards community needs.

The Impact of Diaspora-Based Psychiatrists' Participation in Clinical Teaching in a Lower Middle-Income Country on Interest in Psychiatry Among Medical Students and the Choice of Psychiatry as a Career

OBJECTIVE

The authors assess the impact of Ghanaian diaspora-based psychiatrists' participation in clinical teaching in Ghana on the attitudes of medical students toward careers in psychiatry.

METHODS

This quantitative cross-sectional study involved fifth- and sixth-year medical students of the four public medical schools in Ghana. Data were analyzed with descriptive and inferential statistics.

RESULTS

About half (49.7%) of clinical year medical students in Ghana reported that diaspora-based Ghanaian psychiatrists participated in their teaching during their clinical psychiatry rotation. A significantly higher proportion of medical students who had diaspora-based psychiatrists participate in their clinical training expressed that the depth of clinical teaching (54.4% vs. 45.6%, p = 0.003) and the extent of experience gained during their psychiatric rotations (54.7% vs. 45.3%, p = 0.001) were adequate or somewhat adequate when compared with medical students who did not have diaspora psychiatrists participate in their clinical training. Medical students who had diaspora-based Ghanaian psychiatrists participate in their teaching were significantly more likely to consider careers in psychiatry after their clinical rotation (42.2% versus 25.6%, χ² = 16.2, p = 0.00).

CONCLUSIONS

In a low-resource country with few psychiatrists, the involvement of diaspora-based psychiatrists in the teaching of clinical year medical students has the potential to improve the global experience and attitude of the medical students toward psychiatry.

Building capacity in mental health care in low- and middle-income countries by training primary care physicians using the mhGAP: a randomized controlled trial

To address the rise in mental health conditions in Tunisia, a training based on the Mental Health Gap Action Programme (mhGAP) Intervention Guide (IG) was offered to primary care physicians (PCPs) working in the Greater Tunis area. Non-specialists (such as PCPs)' training is an internationally supported way to target untreated mental health symptoms. We aimed to evaluate the programme's impact on PCPs' mental health knowledge, attitudes, self-efficacy and self-reported practice, immediately following and 18 months after training. We conducted an exploratory trial with a combination of designs: a pretest-posttest control group design and a one-group pretest-posttest design were used to assess the training's short-term impact; and a repeated measures design was used to assess the training's long-term impact. The former relied on a delayed-intervention strategy: participants assigned to the control group (Group 2) received the training after the intervention group (Group 1). The intervention consisted of a weekly mhGAP-based training session (totalling 6 weeks), comprising lectures, discussions, role plays and a support session offered by trainers. Data were collected at baseline, following Group 1's training, following Group 2's training and 18 months after training. Descriptive, bivariate and ANOVA analyses were conducted. Overall, 112 PCPs were randomized to either Group 1 (n = 52) or Group 2 (n = 60). The training had a statistically significant short-term impact on mental health knowledge, attitudes and self-efficacy scores but not on self-reported practice. When comparing pre-training results and results 18 months after training, these changes were maintained. PCPs reported a decrease in referral rates to specialized services 18 months after training in comparison to pre-training. The mhGAP-based training might be useful to increase mental health knowledge and self-efficacy, and decrease reported referral rates and negative mental health attitudes among PCPs in Tunisia and other low- and middle-income countries. Future studies should examine relationships among these outcome variables.

Barriers and facilitators of child and guardian attendance in task-shifted mental health services in schools in western Kenya

BACKGROUND

Globally, nearly 140 million children have experienced the death of one or both parents, and as a result many experience higher rates of mental health problems. Trauma-focused cognitive behavioral therapy (TF-CBT) delivered by lay counselors has been shown to improve mental health outcomes for children experiencing traumatic grief due to parental loss; however, challenges with treatment attendance limit the public health impact of mental health services. This study used qualitative methods to assess barriers and facilitators of child and guardian attendance of school-based lay counselor delivered TF-CBT.

METHODS

Semi-structured interviews were conducted with 36 lay counselors (18 teachers; 18 community health volunteers) who delivered TF-CBT to explore their perceptions of barriers of facilitators of child and guardian attendance of group-based sessions delivered in schools.

RESULTS

Counselors identified attendance barriers and facilitators related to the delivery setting, resources, participant characteristics, intervention characteristics and counselor behaviors. The findings revealed a greater number of facilitators than barriers. Common facilitators included participant and counselor resources, counselor commitment behaviors and communication efforts to encourage attendance. Barriers were less frequently endorsed, with participant resources, child or guardian illness and communication challenges most commonly mentioned.

CONCLUSIONS

Attention to barriers and facilitators of attendance in the context in which mental health interventions are delivered allows for identification of ways to improve attendance and treatment engagement and achieve the potential promise of providing accessible mental health services.

Prevalence of mental disorders in South Asia: An umbrella review of systematic reviews and meta-analyses

Mental disorders are highly prevalent in eight South Asian countries, yet there is a gap of a synthesized overview of the prevalence of mental disorders in this region. This umbrella review aims to summarize the prevalence of mental disorders from systematic reviews and meta-analyses of South Asian studies. A systematic search of 11 major databases and additional sources was conducted until December 11, 2019. Articles were included if they were systematic reviews or meta-analyses, reported the prevalence of mental disorders, and reported primary studies conducted in South Asian countries only. Among 2591 citations, a total of 23 reviews met all the criteria of this umbrella review. The synthesized findings from those reviews suggest high prevalence rates for mental disorders, including depressive disorders, anxiety disorders, mood disorders, suicidal behavior and self-harm, schizophrenia, substance use disorders, neurodevelopmental disorders, dementia, and other mental health problems. Also, findings suggest a high burden of maternal depression, psychiatric comorbidities in chronic physical illnesses, and various mental disorders among children, elderly adults, refugees, and other vulnerable populations. Most studies were from India whereas evidence from Afghanistan, Bhutan, and Maldives was limited. The findings of this review are constrained with heterogeneity in prevalence estimations, methodologies, sampling issues, and limitations in the existing literature, which should be addressed in future research. The evidence synthesized in this review provides national and regional overview of the prevalence of mental disorders, which may inform better policymaking and practice advancing mental health in South Asia.

Receipt of Emotional Support among Rural South African Adults

As the world undergoes rapid ageing, informal support from friends and relatives is becoming especially important among older adults in middle and low income countries, where formalized social protections may be limited. We use new data from a cohort of adults ages 40 and older in rural South Africa to explore how receipt of emotional support differs by gender and marital status. Our findings suggest that women are more likely to get emotional support than men and have more sources of support. Moreover, women are more likely to get emotional support from relatives, whereas men are more likely to get support from friends. In regard to marital status, married people are more likely to get emotional support and have more sources of support than people who are not married. However, separated/divorced and widowed people are more likely to get emotional support from relatives and have more sources of non-spousal support than married people. These findings point toward gaps in informal systems of support, and the particular importance of considering men and unmarried (especially never married) people when designing policies to offer social protections to older populations.

Supported Housing as a recovery option for long-stay patients with severe mental illness in a psychiatric hospital in South India: Learning from an innovative de-hospitalization process

Individuals with severe mental illness have long been segregated from living in communities and participating in socio- cultural life. In recent years, owing to progressive legislations and declarations (in India and globally), there has been a growing movement towards promoting social inclusion and community participation, with emphasis on the need to develop alternative and inclusive care paradigms for persons with severe mental illness. However, transitions from inpatient care to community settings is a complex process involving implications at multiple levels involving diverse stakeholders such as mental health service users, care providers, local communities and policy makers. This article studies how the transition from a hospital setting to a community-based recovery model for personals with severe mental illness can be facilitated. It reflects on the innovative process of creating a Supported Housing model in South India, where 11 MH Service users transitioned from a psychiatric ECRC to independent living facilities. Experiences in various phases of the project development, including care provider- and community level responses and feedback were scrutinised to understand the strategies that were employed in enabling the transition. Qualitative methods (including in-depth interviews and naturalistic observations) were used with residents and staff members to explore the challenges they encountered in stabilizing the model, as well as the psychosocial benefits experienced by residents in the last phase. These were complemented with a Brief Psychiatric Rating Scale (BPRS) and WHO Quality of Life scale to compare baseline and post-assessment results and an increase of quality of life. Results display a significant reduction of psychiatric symptoms in patients (p< 0.5). It also describes the challenges encountered in the current context, and strategies that were used to respond and adapt the model to address these concerns effectively. Positive behavioural and psycho-emotional changes were observed amongst the residents, significant amongst those being enhanced in their mobility and participation. The article concludes by discussing the implications of this study for the development of innovative community-based models in wider contexts.

Pharmacotherapeutic interventions for bipolar disorder type II: addressing multiple symptoms and approaches with a particular emphasis on strategies in lower and middle-income countries

Introduction: Appropriately managing mental disorders is a growing priority across countries in view of the impact on morbidity and mortality. This includes patients with bipolar disorders (BD). Management of BD is a concern as this is a complex disease with often misdiagnosis, which is a major issue in lower and middle-income countries (LMICs) with typically a limited number of trained personnel and resources. This needs to be addressed.Areas covered: Medicines are the cornerstone of managing patients with Bipolar II across countries including LMICs. The choice of medicines, especially antipsychotics, is important in LMICs with high rates of diabetes and HIV. However, care is currently compromised in LMICs by issues such as the stigma, cultural beliefs, a limited number of trained professionals and high patient co-payments.Expert opinion: Encouragingly, some LMICs have introduced guidelines for patients with BD; however, this is very variable. Strategies for the future include addressing the lack of national guidelines for patients with BD, improving resources for mental disorders including personnel, improving medicine availability and patients' rights, and monitoring prescribing against agreed guidelines. A number of strategies have been identified to improve the treatment of patients with Bipolar II in LMICs, and will be followed up.

Efforts and Challenges to Ensure Continuity of Mental Healthcare Service Delivery in a Low Resource Settings During COVID-19 Pandemic-A Case of a Kenyan Referral Hospital

The rising number of patients with Covid-19 as well as the infection control measures have affected healthcare service delivery, including mental healthcare. Mental healthcare delivery in low and middle income countries where resources were already limited are likely to be affected more during this pandemic. This paper describes the efforts of ensuring mental healthcare delivery is continued in a referral hospital in Kenya, Moi Teaching and Referral hospital, as well as the challenges faced. These efforts are guided by the interim guidelines developed by the Kenyan ministry of health. Some of the adjustments described includes reducing number of patients admitted, shortening the stay in the inpatient setting, using outdoors for therapy to promote physical distancing, utilization of electronic platforms for family therapy sessions, strengthening outpatient services, and supporting primary care workers to deliver mental health care services. Some of the challenges include limited ability to move about, declining ability for patients to pay out of pocket due to the economic challenges brought about by measures to control Covid-19, limited drug supplies in primary care facilities, inability to fully implement telehealth due to connectivity issues and stigma for mental health which results in poor social support for the mentally ill patients. It is clear that current pandemic has jeopardized the continuity of usual mental healthcare in many settings. This has brought to sharp focus the need to decentralize mental health care and promote community based services. Meanwhile, there is need to explore feasible alternatives to ensure continuity of care.

A Customized Social Network Platform (Kids Helpline Circles) for Delivering Group Counseling to Young People Experiencing Family Discord That Impacts Their Well-Being: Exploratory Study

BACKGROUND

It has often been reported that young people are at high risk of mental health concerns, more so than at any other time in development over their life span. The situational factors that young people report as impacting their well-being are not addressed as often: specifically, family discord. Kids Helpline, a national service in Australia that provides free counseling online and by telephone to young people in distress, report that family discord and well-being issues are one of the major concerns reported by clients. In order to meet the preferences that young people seek when accessing counseling support, Kids Helpline has designed and trialed a custom-built social network platform for group counseling of young people experiencing family discord that impacts their well-being.

OBJECTIVE

In this exploratory study, we communicate the findings of Phase 1 of an innovative study in user and online counselor experience. This will lead to an iterative design for a world-first, purpose-built social network that will do the following: (1) increase reach and quality of service by utilizing a digital tool of preference for youth to receive peer-to-peer and counselor-to-peer support in a safe online environment and (2) provide the evidence base to document the best practice for online group counseling in a social network environment.

METHODS

The study utilized a participatory action research design. Young people aged 13-25 years (N=105) with mild-to-moderate depression or anxiety (not high risk) who contacted Kids Helpline were asked if they would like to trial the social networking site (SNS) for peer-to-peer and counselor-to-peer group support. Subjects were grouped into age cohorts of no more than one year above or below their reported age and assigned to groups of no more than 36 participants, in order to create a community of familiarity around age and problems experienced. Each group entered into an 8-week group counseling support program guided by counselors making regular posts and providing topic-specific content for psychoeducation and discussion. Counselors provided a weekly log of events to researchers; at 2-week intervals, subjects provided qualitative and quantitative feedback through open-ended questions and specific psychometric measures.

RESULTS

Qualitative results provided evidence of user support and benefits of the online group counseling environment. Counselors also reported benefits of the modality of therapy delivery. Psychometric scales did not report significance in changes of mood or affect. Counselors and users suggested improvements to the platform to increase user engagement.

CONCLUSIONS

Phase 1 provided proof of concept for this mode of online counseling delivery. Users and counselors saw value in the model and innovation of the service. Phase 2 will address platform issues with changes to a new social network platform. Phase 2 will focus more broadly on mental health concerns raised by users and permit inclusion of a clinical population of young people experiencing depression and anxiety.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12616000518460; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=370381.

Health research in humanitarian crises: an urgent global imperative

Globally, humanitarian crises-such as armed conflict, forced displacement, natural disasters and major disease outbreaks-affect more people today than at any point in recorded history. These crises have immense acute and long-term health impacts on hundreds of millions of people, predominantly in low and middle-income countries (LMIC), yet the evidence base that informs how humanitarian organisations respond to them is weak. Humanitarian crises are often treated as an outlier in global health. However, they are an increasingly common and widespread driver of health that should be integrated into comprehensive approaches and strategies, especially if we hope to achieve ambitious global health targets such as the Sustainable Development Goals. The academic research community can play an important role in addressing the evidence gap in humanitarian health. There are important scientific questions of high public health relevance that can only be addressed by conducting research in humanitarian settings. While working in these settings is uniquely challenging, there are effective strategies that can be employed, such as using flexible and adaptive research methodologies, partnering with non-governmental organisations and other humanitarian actors, and devoting greater attention to issues of research ethics, community engagement, local LMIC-based partners, building humanitarian research capacity and collaborating across disciplines.

Forming and implementing community advisory boards in low- and middle-income countries: a scoping review

BACKGROUND

Community advisory boards (CABs) have expanded beyond high-income countries (HICs) and play an increasing role in low- and middle-income country (LMIC) research. Much research has examined CABs in HICs, but less is known about CABs in LMICs. The purposes of this scoping review are to examine the creation and implementation of CABs in LMICs, including identifying frequently reported challenges, and to discuss implications for research ethics.

METHODS

We searched five databases (PubMed, Embase, Global Health, Scopus, and Google Scholar) for publications describing or evaluating CABs in LMICs. Two researchers independently reviewed articles for inclusion. Data related to the following aspects of CABs were extracted from included publications: time, country, financial support, research focus, responsibilities, and challenges. Thematic analyses were used to summarize textual data describing challenges.

RESULTS

Our search yielded 2005 citations, 83 of which were deemed eligible for inclusion. Most studies (65) were published between 2010 and 2017. Upper-middle-income countries were more likely to have studies describing CABs, with South Africa (17), China (8), and Thailand (7) having the greatest numbers. The United States National Institutes of Health was the main source of financial support for CABs. Many CABs (53/88, 60%) focused on HIV research. Thirty-four studies reported how CABs influenced the informed consent process for clinical trials or other aspects of research ethics. CAB responsibilities were related to clinical trials, including reviewing study protocols, educating local communities about research activities, and promoting the ethical conduct of research. Challenges faced by CABs included the following: incomplete ethical regulations and guidance; limited knowledge of science among members of communities and CABs; unstable and unbalanced power relationships between researchers and local communities; poor CAB management, including lack of formal participation structures and absence of CAB leadership; competing demands for time that limited participation in CAB activities; and language barriers between research staff and community members. Several challenges reflected shortcomings within the research team.

CONCLUSIONS

Our findings examine the formation and implementation of CABs in LMICs and identify several ethical challenges. These findings suggest the need for further ethics training among CAB members and researchers in LMICs.

Service gaps related to culturally appropriate mental health care for African immigrants

The population of overseas-born Australians continues to grow including the recent increase of immigrants and refugees from African countries. Due to this increase, healthcare services need to assess if current available services are culturally appropriate for African immigrant inpatients. This qualitative study, with a quality improvement focus, examined current services to identify key service gaps and consider recommendation to improve care of African immigrant mental health inpatients in the hospital from the point of view of staff working within the organisation. What was revealed is that services currently offered to African mental health inpatients were culturally inappropriate. Emerging themes included inadequate interpreter services, lack of cultural awareness staff training, lack of organisation link with other services, unmet spiritual needs, use of staff/families as interpreters, culturally inappropriate information, and lack of or inadequate culturally appropriate policies and framework. Changes to current practices are recommended to provide culturally appropriate mental health care to African inpatients.

Community-Based Mental Health Care: Stigma and Coping Strategies Among Professionals and Family Caregivers in the Eastern Region of Ghana

To a large extent caregivers perceive stigma through their social and community interactions by virtue of their association with persons with mental health problems. Meanwhile, evidence on their strategies for coping with potentially undesirable experiences linked with stigma is limited. Using a descriptive qualitative approach, the present study explored affiliate stigma among mental health professionals and family caregivers of persons with mental illness. Data, collected through one-on-one interviews with 10 mental health professionals and 10 family caregivers, were examined with content analysis. Findings revealed that, although stigma attached to mental illness was largely directed at sufferers and family caregivers, professionals sometimes had their fair share. To manage the negative impact of stigma, caregivers adopted various strategies including the use of realisation, tactical or planned ignoring, self-motivation, acceptance and religion. Implications of the findings necessitate the intensification of mental health education among the general populace, which must be targeted at demystifying mental illness.

A conceptual model for establishing collaborative partnerships between universities and Native American communities

BACKGROUND

Collaborative partnerships are increasingly recognised as valuable and essential tools for improving community health.

AIM

To present the process used to establish a collaboration between a university and a community, including a description of the conceptual model that provided guidance for one such project.

DISCUSSION

While numerous studies explore the potential benefits of such efforts, few have addressed how to initiate partnerships. The initiation phase and formative work required are arguably the most crucial step, as they become the foundation on which all future efforts are built and through which sustainability is achieved.

CONCLUSION

These formative steps are essential when working with Native American communities, which experience severe health disparities, but for which limited initiatives are available for community health interventions.

IMPLICATIONS FOR PRACTICE

The approach used in this project can guide the establishment of a university-community collaboration, from initiation to evaluation.

An Embedded Systems Perspective in Conceptualizing Canada’s Healthcare Sustainability

Healthcare sustainability has been dominated by a strong fiscal orientation. In an era of budget cuts and staff reductions, the financial challenges in Canadian healthcare are immediate and must be addressed. However, an independent focus on financial viability is too narrow a framing; too limited to allow for the kind of creative, novel, and even radical thinking that is required to fundamentally alter the current course of healthcare in Canada and internationally. Prospects for solving the current financial challenges are likely to be greatly enhanced if we simultaneously account for the broad and interrelated dimensions of sustainability. What would a healthcare system look like if sustainability were adopted as the focal and principal goal? And what might a “deep” sustainability orientation imply for how we think about and manage healthcare systems? This analysis is informed by the notion that healthcare systems are fully contained within the societal system, which is itself fully contained within the broader ecological system. This model, which foregrounds nature as the most fundamental and important system, has both greater ecological validity and particular relevance to the healthcare context given the interdependence between the health of natural systems and the health of humans. Our understanding of nature in relation to health may be key to solving or at least reducing the economic burden of healthcare. A multidimensional systems orientation thus has the potential to unveil new modes of thinking that highlight intersectoral relations, communications, collaboration, and cross-boundary learning for improved health and wellbeing, healthcare performance, and sustainability.

Power, potential, and pitfalls in global health academic partnerships: review and reflections on an approach in Nepal

Background: Global health academic partnerships are centered around a core tension: they often mirror or reproduce the very cross-national inequities they seek to alleviate. On the one hand, they risk worsening power dynamics that perpetuate health disparities; on the other, they form an essential response to the need for healthcare resources to reach marginalized populations across the globe.

Objectives: This study characterizes the broader landscape of global health academic partnerships, including challenges to developing ethical, equitable, and sustainable models. It then lays out guiding principles of the specific partnership approach, and considers how lessons learned might be applied in other resource-limited settings.

Methods: The experience of a partnership between the Ministry of Health in Nepal, the non-profit healthcare provider Possible, and the Health Equity Action and Leadership Initiative at the University of California, San Francisco School of Medicine was reviewed. The quality and effectiveness of the partnership was assessed using the Tropical Health and Education Trust Principles of Partnership framework.

Results: Various strategies can be taken by partnerships to better align the perspectives of patients and public sector providers with those of expatriate physicians. Actions can also be taken to bring greater equity to the wealth and power gaps inherent within global health academic partnerships.

Conclusions: This study provides recommendations gleaned from the analysis, with an aim towards both future refinement of the partnership and broader applications of its lessons and principles. It specifically highlights the importance of targeted engagements with academic medical centers and the need for efficient organizational work-flow practices. It considers how to both prioritize national and host institution goals, and meet the career development needs of global health clinicians.

The development of a training course for clubfoot treatment in Africa: learning points for course development

BACKGROUND

Clubfoot is a common congenital musculoskeletal disorder that causes mobility impairment. There is a lack of trained mid-level personnel to provide clubfoot treatment in Africa and there is no standard training course. This prospective study describes the collaborative and participatory approach to the development of a training course for the treatment of clubfoot in children in resource constrained settings.

METHODS

We used a systems approach to evaluate the development of the training course. Inputs: The research strategy included a review of context and available training materials, and the collection of data on current training practices. Semi-structured interviews were conducted with seven expert clubfoot trainers. A survey of 32 international and regional trainers was undertaken to inform practical issues. The data were used to develop a framework for training with advice from two technical groups, consisting of regional and international stakeholders and experts.

PROCESS

A consensus approach was undertaken during workshops, meetings and the sharing of documents. The design process for the training materials took twenty-four months and was iterative. The training materials were piloted nine times between September 2015 and February 2017. Processes and materials were reviewed and adapted according to feedback after each pilot.

RESULTS

Fifty-one regional trainers from Africa (18 countries), 21 international experts (11 countries), 113 local providers of clubfoot treatment (Ethiopia, Rwanda and Kenya) and local organising teams were involved in developing the curriculum and pilot testing. The diversity of the two technical advisory groups allowed a wide range of contributions to the collaboration. Output: The resulting curriculum and content comprised a two day basic training and a two day advanced course. The basic course utilised adult learning techniques for training novice providers in the treatment of idiopathic clubfoot in children under two years old. The advanced course builds on these principles.

CONCLUSION

Formative research that included mixed methods (both qualitative and quantitative) was important in the development of an appropriate training course. The process documentation from this study provides useful information to assist planning of medical training programmes and may serve as a model for the development of other courses.

Translating mental health diagnostic and symptom terminology to train health workers and engage patients in cross-cultural, non-English speaking populations

Although there are guidelines for transcultural adaptation and validation of psychometric tools, similar resources do not exist for translation of diagnostic and symptom terminology used by health professionals to communicate with one another, their patients, and the public. The issue of translation is particularly salient when working with underserved, non-English speaking populations in high-income countries and low- and middle-income countries. As clinicians, researchers, and educators working in cross-cultural settings, we present four recommendations to avoid common pitfalls in these settings. We demonstrate the need for: (1) harmonization of terminology among clinicians, educators of health professionals, and health policymakers; (2) distinction in terminology used among health professionals and that used for communication with patients, families, and the lay public; (3) linkage of symptom assessment with functional assessment; and (4) establishment of a culture of evaluating communication and terminology for continued improvement.