The feasibility of a role for community health workers in integrated mental health care for perinatal depression: a qualitative study from Surabaya, Indonesia

Rural Friendship Bench: A qualitative study in Zaka district, Zimbabwe

BACKGROUND

We piloted the Friendship Bench-an evidence-based, urban-area task sharing intervention for common mental disorders-in rural Zimbabwe. The intervention combines problem solving therapy with income generating activities. This study sought to understand the intervention's implementation in terms of acceptability, feasibility, and sustainability as well as local attitudes towards mental wellbeing in rural Zimbabwe.

METHODS

Using four separate semi-structured interview guides, we conducted in-depth interviews (N = 32) with patients (n = 9), village health workers (n = 12), nurses (n = 6), and community leaders (n = 5). We analyzed our data using thematic analysis with a diverse coding team using an integrative deductive-inductive approach.

RESULTS

Five themes emerged: 1) explanatory models for mental illness, 2) clinical workflow and emphasis on documentation, 3) positive feedback about the Friendship Bench, 4) accessibility, and 5) feasibility.

CONCLUSION

In its current format, our intervention was acceptable but neither feasible nor sustainable. Sociocultural context is critical in the development of rural task sharing interventions for mental health. We thus recommend a robust pilot and adaptation phase when scaling task sharing interventions in rural sub-Saharan Africa to elevate community voices, leverage existing social structures, and embed interventions as deeply into communities as possible.

An exploration of the Indonesian lay mental health workers' (cadres) experiences in performing their roles in community mental health services: a qualitative study

BACKGROUND

Volunteers trained to support community mental health programs in Indonesia are known as 'mental health cadres.' These are lay people trained to provide basic support for people with mental illness in their local communities. The role of cadres in community mental health services is to provide health promotion activities and support for people with mental illness, such as home visits and family assistance. Their contribution can potentially address the challenges health services currently face in remote and resource-limited settings. However, little is currently known about implementing this form of the lay workforce and the experiences of mental health cadres in Indonesia in particular. This study aimed to explore the experience of cadres when performing their roles in community mental health services in Indonesia from the cadres' perspective.

METHODS

The study employed a descriptive qualitative design. Purposive sampling was employed to recruit cadres with at least one year of experience handling those diagnosed with schizophrenia across four geographical areas in Java and Sumatra, Indonesia. Data were collected utilising focus groups undertaken between July and November 2020. Due to COVID-19 restrictions, eight focus group sessions for mental health cadres were carried out virtually via Zoom and non-virtual, facilitated by local moderators. Data were analysed using thematic analysis.

RESULTS

The study involved 71 cadres in four regions: Aceh, Jakarta, West Java and East Java. The majority of participants were looking after their families with a minimum of high school-level qualifications. Four themes were interpreted from the data: (1) Motivation for volunteering, (2) The role of cadres in supporting mental health services, (3) Training and support needs in carrying out cadre roles, and (4) Barriers and facilitators to the implementation of cadre roles in local communities.

CONCLUSIONS

Cadres reported a motivation to help people improve their mental health and reduce the stigma associated with mental illness. Cadres also contributed to secondary and primary prevention of mental illness with some limitations. This study's results are relevant to those wishing to understand and optimise the implementation of lay workforces in resource-limited settings.

Healthcare workers' perceptions and experiences of primary healthcare integration: a scoping review of qualitative evidence

BACKGROUND

Primary healthcare (PHC) integration has been promoted globally as a tool for health sector reform and universal health coverage (UHC), especially in low-resource settings. However, for a range of reasons, implementation and impact remain variable. PHC integration, at its simplest, can be considered a way of delivering PHC services together that sometimes have been delivered as a series of separate or 'vertical' health programmes. Healthcare workers are known to shape the success of implementing reform interventions. Understanding healthcare worker perceptions and experiences of PHC integration can therefore provide insights into the role healthcare workers play in shaping implementation efforts and the impact of PHC integration. However, the heterogeneity of the evidence base complicates our understanding of their role in shaping the implementation, delivery, and impact of PHC integration, and the role of contextual factors influencing their responses.

OBJECTIVES

To map the qualitative literature on healthcare workers' perceptions and experiences of PHC integration to characterise the evidence base, with a view to better inform future syntheses on the topic.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 28 July 2020. We did not search for grey literature due to the many published records identified.

SELECTION CRITERIA

We included studies with qualitative and mixed methods designs that reported on healthcare worker perceptions and experiences of PHC integration from any country. We excluded settings other than PHC and community-based health care, participants other than healthcare workers, and interventions broader than healthcare services. We used translation support from colleagues and Google Translate software to screen non-English records. Where translation was not feasible we categorised these records as studies awaiting classification.

DATA COLLECTION AND ANALYSIS

For data extraction, we used a customised data extraction form containing items developed using inductive and deductive approaches. We performed independent extraction in duplicate for a sample on 10% of studies allowed for sufficient agreement to be reached between review authors. We analysed extracted data quantitatively by counting the number of studies per indicator and converting these into proportions with additional qualitative descriptive information. Indicators included descriptions of study methods, country setting, intervention type, scope and strategies, implementing healthcare workers, and client target population.

MAIN RESULTS

The review included 184 studies for analysis based on 191 included papers. Most studies were published in the last 12 years, with a sharp increase in the last five years. Studies mostly employed methods with cross-sectional qualitative design (mainly interviews and focus group discussions), and few used longitudinal or ethnographic (or both) designs. Studies covered 37 countries, with close to an even split in the proportions of high-income countries (HICs) and low- and middle-income countries (LMICs). There were gaps in the geographical spread for both HICs and LMICs and some countries were more dominant, such as the USA for HICs, South Africa for middle-income countries, and Uganda for low-income countries. Methods were mainly cross-sectional observational studies with few longitudinal studies. A minority of studies used an analytical conceptual model to guide the design, implementation, and evaluation of the integration study. The main finding was the various levels of diversity found in the evidence base on PHC integration studies that examined healthcare workers' perceptions and experiences. The review identified six different configurations of health service streams that were being integrated and these were categorised as: mental and behavioural health; HIV, tuberculosis (TB) and sexual reproductive health; maternal, women, and child health; non-communicable diseases; and two broader categories, namely general PHC services, and allied and specialised services. Within the health streams, the review mapped the scope of the interventions as full or partial integration. The review mapped the use of three different integration strategies and categorised these as horizontal integration, service expansion, and service linkage strategies. The wide range of healthcare workers who participated in the implementation of integration interventions was mapped and these included policymakers, senior managers, middle and frontline managers, clinicians, allied healthcare professionals, lay healthcare workers, and health system support staff. We mapped the range of client target populations.

AUTHORS' CONCLUSIONS

This scoping review provides a systematic, descriptive overview of the heterogeneity in qualitative literature on healthcare workers' perceptions and experience of PHC integration, pointing to diversity with regard to country settings; study types; client populations; healthcare worker populations; and intervention focus, scope, and strategies. It would be important for researchers and decision-makers to understand how the diversity in PHC integration intervention design, implementation, and context may influence how healthcare workers shape PHC integration impact. The classification of studies on the various dimensions (e.g. integration focus, scope, strategy, and type of healthcare workers and client populations) can help researchers to navigate the way the literature varies and for specifying potential questions for future qualitative evidence syntheses.

Healthcare workers' perceptions and experiences of primary healthcare integration: a scoping review of qualitative evidence

BACKGROUND

Primary healthcare (PHC) integration has been promoted globally as a tool for health sector reform and universal health coverage (UHC), especially in low-resource settings. However, for a range of reasons, implementation and impact remain variable. PHC integration, at its simplest, can be considered a way of delivering PHC services together that sometimes have been delivered as a series of separate or 'vertical' health programmes. Healthcare workers are known to shape the success of implementing reform interventions. Understanding healthcare worker perceptions and experiences of PHC integration can therefore provide insights into the role healthcare workers play in shaping implementation efforts and the impact of PHC integration. However, the heterogeneity of the evidence base complicates our understanding of their role in shaping the implementation, delivery, and impact of PHC integration, and the role of contextual factors influencing their responses.

OBJECTIVES

To map the qualitative literature on healthcare workers' perceptions and experiences of PHC integration to characterise the evidence base, with a view to better inform future syntheses on the topic.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 28 July 2020. We did not search for grey literature due to the many published records identified.

SELECTION CRITERIA

We included studies with qualitative and mixed methods designs that reported on healthcare worker perceptions and experiences of PHC integration from any country. We excluded settings other than PHC and community-based health care, participants other than healthcare workers, and interventions broader than healthcare services. We used translation support from colleagues and Google Translate software to screen non-English records. Where translation was not feasible we categorised these records as studies awaiting classification.

DATA COLLECTION AND ANALYSIS

For data extraction, we used a customised data extraction form containing items developed using inductive and deductive approaches. We performed independent extraction in duplicate for a sample on 10% of studies allowed for sufficient agreement to be reached between review authors. We analysed extracted data quantitatively by counting the number of studies per indicator and converting these into proportions with additional qualitative descriptive information. Indicators included descriptions of study methods, country setting, intervention type, scope and strategies, implementing healthcare workers, and client target population.

MAIN RESULTS

The review included 184 studies for analysis based on 191 included papers. Most studies were published in the last 12 years, with a sharp increase in the last five years. Studies mostly employed methods with cross-sectional qualitative design (mainly interviews and focus group discussions), and few used longitudinal or ethnographic (or both) designs. Studies covered 37 countries, with close to an even split in the proportions of high-income countries (HICs) and low- and middle-income countries (LMICs). There were gaps in the geographical spread for both HICs and LMICs and some countries were more dominant, such as the USA for HICs, South Africa for middle-income countries, and Uganda for low-income countries. Methods were mainly cross-sectional observational studies with few longitudinal studies. A minority of studies used an analytical conceptual model to guide the design, implementation, and evaluation of the integration study. The main finding was the various levels of diversity found in the evidence base on PHC integration studies that examined healthcare workers' perceptions and experiences. The review identified six different configurations of health service streams that were being integrated and these were categorised as: mental and behavioural health; HIV, tuberculosis (TB) and sexual reproductive health; maternal, women, and child health; non-communicable diseases; and two broader categories, namely general PHC services, and allied and specialised services. Within the health streams, the review mapped the scope of the interventions as full or partial integration. The review mapped the use of three different integration strategies and categorised these as horizontal integration, service expansion, and service linkage strategies. The wide range of healthcare workers who participated in the implementation of integration interventions was mapped and these included policymakers, senior managers, middle and frontline managers, clinicians, allied healthcare professionals, lay healthcare workers, and health system support staff. We mapped the range of client target populations.

AUTHORS' CONCLUSIONS

This scoping review provides a systematic, descriptive overview of the heterogeneity in qualitative literature on healthcare workers' perceptions and experience of PHC integration, pointing to diversity with regard to country settings; study types; client populations; healthcare worker populations; and intervention focus, scope, and strategies. It would be important for researchers and decision-makers to understand how the diversity in PHC integration intervention design, implementation, and context may influence how healthcare workers shape PHC integration impact. The classification of studies on the various dimensions (e.g. integration focus, scope, strategy, and type of healthcare workers and client populations) can help researchers to navigate the way the literature varies and for specifying potential questions for future qualitative evidence syntheses.

Need Asseesment on Maternal Mental Health Care for Perinatal Mothers during COVID-19: A Qualitative Study

Background

During COVID-19 pandemic, the isolation, socialization, and extreme changes in daily life have some potential mental health consequences which should be recognized as a critical public health concern, especially for perinatal mothers. Therefore, it is very important to assess the needs for maternal mental health care in perinatal mothers during COVID-19 pandemic. This study aimed to explore mothers' needs for maternal mental health care in the perinatal period during COVID-19 pandemic.

Material and Methods

Realistic phenomenological approach was carried out in this qualitative study. The study was conducted at five community health centers in the city of Tangerang, Indonesia. In-depth interviews were conducted to 11 mothers who were pregnant, in labor, during puerperium and two months after giving birth with purposive sampling. Data were collected from May to August 2021. Interviews were conducted face to face, audio recorded, and transcribed verbatim. Data were analyzed by using Van Manen's phenomenological method.

Result

Initial finding revealed 254 codes, which were then reduced to 122 codes, 98 sub-categories, 22 categories, and 5 themes. There were five themes related to mothers' needs for mental health care during COVID-19, i.e., health protocol during pandemic, psychological support, health education, simple coping mechanism, and support system.

Conclusions

The needs can be fulfilled by the closest people the mothers have and healthcare system for perinatal mental health. Vaccination, health protocol, and psychological resilience should be delivered to mothers during COVID-19.

Community health centers response to the need of dementia care

Background:

Dementia prevalence among Indonesian older people is increasing. Community health centers (CHCs) as primary care providers have a responsibility to meet the need of their community. This study aims to measure the response of CHCs to the growing of dementia cases and to investigate factors associated with the knowledge of CHC staff on dementia symptoms in Special Region of Yogyakarta (DI Yogyakarta), Indonesia.

Design and methods:

This study used a cross-sectional design to obtain census data from 121 CHCs in DI Yogyakarta by interviewing 121 older person program managers of the CHCs via telephone between January and February 2021. Data on knowledge of 10 dementia symptoms, participation in dementia prevention and treatment with dementia, dementia/cognitive screening and coverage as well as factors associated with memory loss and change in mood and behavior were assessed. Data were analyzed using descriptive, bivariate, and multiple logistic regression.

Results:

The knowledge of dementia symptoms among health workers was low (15%–37%). CHCs had not yet received training on dementia prevention and treatment (58%). Only a few of CHCs treated patient with dementia (36%). Dementia screening and coverage were also low. Engaged in dementia training were more likely to have higher knowledge of dementia symptoms, particularly memory loss and changes in mood and behavior.

Conclusions:

Dementia training and education are needed to increase knowledge among care providers which would eventually improve CHC response to dementia. Priority should also be in place to support dementia care management.

Factors affecting the implementation of task-sharing interventions for perinatal depression in low- and middle-income countries: A systematic review and qualitative metasynthesis

Background The vast majority of women with perinatal depression (PND) live in low- and middle-income countries (LMICs). Task sharing is an alternative delivery strategy to implement PND services. However, the exploration of influencing factors for task sharing in PND services is poor. Therefore, this study aimed to identify factors affecting LMICs to implement PND task-sharing interventions from the perspective of stakeholders and weigh their levels of evidence. Methods A comprehensive literature search was carried out through six English and Chinese databases on qualitative data. We used Critical Appraisal Skills Programme (CASP)/Meta Quality Appraisal Tool (MetaQAT) to appraise included studies, extracted data according to the Consolidated Framework for Implementation Research (CFIR), and assigned levels of confidence in the factors through Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual). Results 17 studies met the eligibility criteria, factors identified with high levels of evidence were coded to the CFIR constructs, including "Knowledge and Attitudes of Those Served by the Organization", "Available Resources", "Compatibility", "Access to knowledge and information", "Resources of Those Served by the Organization" and "Alignment". Conclusion This metasynthesis highlights task sharing in PND interventions is influenced by multiple factors. We synthesized and developed implementation recommendations for practice. Strategies must be actively developed to enable women and their families to enjoy the benefits of good perinatal mental health.

Primary Health Care Workforce in Southeast Asia Region, Existing Status and Strategies for Non-Communicable Diseases and Oral Health Alliance: A Scoping Review

Oral diseases and non-communicable diseases (NCD) share modifiable risk factors and common social determinants, thus creating new opportunities for improving oral health. The existing primary health care workers can play an integral role in NCD and oral health care integration by creating awareness, promoting oral health, controlling risk factors, and referring for timely dental care. This study aimed to identify and understand the roles of the existed human health resources working at primary health care and develop strategies to build on a unified NCD and oral health alliance human resources at this level.

A scoping review was conducted to identify the primary health workforce in the Southeast Asia region, their roles and responsibility, and integration in oral health care. Various databases like NCBI (PubMed), Google Scholar, World Health Organisation (WHO)-Southeast Asia region (SEAR), Ministry of Health and Family Welfare websites in SEAR were comprehensively searched from January 1980 to December 2020 for reports, reviews, and original research. The keywords used were “primary health care workers,” “community health care workers,” “primary oral health care in SEAR,” etc. Only full-text articles in English language and reports available in Ministry of Health and Family Welfare (MOHFW) sites of SEAR were included in the study.

Information was taken from 39 full-text articles, six WHO reports, and two reports from Ministry of Health sites of SEAR. Primary health workers (PHW) are known by multiple names in different countries of Southeast Asia. They share various common roles and responsibilities. There are many opportunities for the prevention and control of oral diseases in the SEAR. Basic systems and human resources for the control of NCD are in place in many countries. Oral health can be integrated with NCD programs and policies to reduce the burden of diseases.

Adaptation of the Edinburgh Postnatal Depression Scale in the Indonesian Version: Self-reported Anxiety and Depression Symptoms in Pregnant WomenAdaptation of the Edinburgh Postnatal Depression Scale in the Indonesian Version: Self-reported Anxiety and Depression Symptoms in Pregnant Women

BACKGROUND: Anxiety and depression disorders in pregnant women are often not identified so that early treatment is not optimal. Indonesia already has comprehensive integrated antenatal care, including services for pregnant women with mental disorders, but until now Indonesia does not yet have a standardized instrument that is valid and suitable as a screening tool to assess symptoms of anxiety and depression in pregnant women. The Edinburgh Postnatal Depression Scale (EPDS) is a screening instrument with high sensitivity and specificity, has been translated into Indonesian, but until now, the Indonesian version of the EPDS instrument has not been evaluated for validity and reliability in the population of pregnant women. AIM: this study aimed to adapt the Indonesian version of the EPDS instrument, including testing the validity and reliability of the instrument when used on pregnant women in Indonesia. METHODS: This research is a cross sectional study. The number of pregnant women who participated were 125 samples. Data were collected randomly, and the assessment of symptoms of anxiety and depression was self-reported via online. Content validity was assessed with a content validity index from 5 experts, construct validation was analyzed by Explanatory Factor Analysis and Confirmatory Factor Analysis and Convergent Validity. The reliability of the EPDS instrument was assessed by construct reliability and Cronbach's Alpha. RESULTS: Content validity index shows expert agreement with a value of .98. The Indonesian version of the EPDS shows assessing three factors, namely: Depression (5 items), Anxiety (3 items), and Anhedonia (2 items). The reliability of the Indonesian version of the EPDS instrument is good with Cronbach's Alpha .80 and the internal reliability of the 10 items (Cronbach's Alpha .767-.812). CONCLUSION: The Indonesian version of the EPDS instrument is valid and reliable to be used to assess symptoms of anxiety and depression in pregnant women in antenatal care in Indonesia.   Keywords: pregnant women, EPDS, validity, reliability

Contemporary management of unipolar depression in the perinatal period

Introduction: There is increasing recognition that antenatal depression and postpartum depression are highly prevalent and have significant impact on maternal and child health.Areas Covered: In the initial part of the manuscript, the authors review the epidemiology of antenatal and postpartum depression and its impact on maternal and child health. The later part of the manuscript reviews the current status of the medical management and psychosocial interventions targeting perinatal depression.Expert Opinion: Perinatal depression is the focus of several studies with increasing interest in developing effective interventions. While several psychosocial interventions targeting maternal depressive symptoms during pregnancy and postpartum are available, more studies are needed to address the need for safe and efficacious strategies for the use of antidepressant medication during pregnancy and in the postpartum period.

Incidence of concomitant illnesses in pregnancy in Indonesia: Estimates from 1990-2019, with projections to 2030

Background

‘Indirect’ causes of maternal death including concomitant illnesses such as infectious and non-communicable diseases (NCDs), accounted for 23% of maternal deaths in Indonesia in 2010. Reproductive-age women in Indonesia face a “double burden” of disease with increasing rates of NCDs and persisting rates of infectious disease. However, there is a lack of data on the burden of these diseases in pregnancy. The aim of this study was to estimate incidence of concomitant illnesses among pregnant women in Indonesia from 1990–2030.

Methods

Publicly available data was accessed including incidence of concomitant illnesses in Indonesian reproductive-age women, population data and crude birth rate data from 1990–2019, and formed basis for projections to 2030. A dataset of estimates for all variables was generated for each year and sampled from a binomial distribution. Using these estimates, pregnancy estimates and incidence in pregnant women were calculated. A cubic splines model was fitted to generate estimates of incidence of concomitant illnesses in pregnancy.

Findings

Past trends to 2019 show a decline in incident cases of infectious diseases except for HIV/AIDs, and an increase in most NCDs. In 2019, the most common disease was sexually transmitted infections. From 2020–2030, incidences of diabetes and lower respiratory infections are estimated to continue to increase.

Interpretation

With an increasing incidence of NCDs and high-incidence of infectious diseases in pregnancy, Indonesian policymakers and stakeholders should consider what evidence-based strategies and interventions are best to reduce potential impacts of concomitant illnesses on pregnancy outcomes.

Funding

Australian Government Research Training Program Scholarship.

Cultural Adaptation of Community Informant Tool for Detection of Maternal Depression in Rural Pakistan

Background: Evidence indicates that mental health issues like depression, epilepsy, and substance misuse can be detected with reasonable accuracy in resource-poor settings. The Community Informant Detection Tool (CIDT) is one such approach used for detecting mental health problems, including depression. We adapted this community informant approach for detecting maternal depression in Pakistan. Methods: Adaptation of Community Informant Detection Tool for Maternal Depression (CIDT-MD) involved five steps. First, a scoping review of the literature was conducted to select an appropriate tool for adaptation. Second, in-depth interviews were conducted to explore the idioms of depression and distress, perceived causes, and the effects of maternal depression among currently depressed and recovered mothers (n = 11), mothers in law (n = 6), and Primary Care Providers (Primary Care Physicians and Lady Health Supervisors) (n = 6). Third, case vignettes and illustrations were created with input from a panel of mental health experts, incorporating the idioms of depression and distress used, causes, and effects for each symptom described. Fourth, to assess the comprehensibility of the illustrations and level of understanding, Focus Group Discussions (n = 4) were done with purposely selected community health workers (Lady Health Workers and Lay Peers, n = 28) trained in delivering maternal depression intervention. The final step was reflection and inputs by a panel of mental health experts on all steps to finalize the content of the tool. Results: Context-specific cultural adaptation in the presentation and format of CIDT-MD was conducted successfully. Lady Health Workers (LHW) and Lay Peers (LP) were found to be the most appropriate persons to use the tool and function as the informants. The adapted tool with all its vignettes and illustrations was found to be easily understandable, comprehensible, and culturally appropriate, meaningful, and contextually relevant by the community health workers and peers working in the relevant settings. They easily relate to and identify potentially depressed such women lining up with the tool. Lastly, the coding of the tool was found easy to follow as well. Conclusion: The Community Informant Detection Tool for Maternal Depression (CIDT-MD) is a culturally acceptable, easy to use, and comprehensible tool for detecting maternal depression in community settings of Pakistan. The community informants found the content and approach highly relevant to the local needs.

How to Screen Suitable Service Improve Community Health Care Services by University Students in Taiwan

Engaging in social contributions to enhance social participation and attending community experiential service learning or internship courses have become an essential learning experience for university students. On the basis of postmodern education theories, this study adopted images and oral accounts involving personal experiences to construct a postmodern education research scheme by using the method of collaborative ethnography. This study selected and performed the following services: filming a community documentary, administering community health dance classes, and archiving community cultural artifacts in databases. Interviews were also administered to facilitate implementation of the actual services. Community health services commonly seen in Taiwan and abroad were compiled, and the resources required for each service were examined. Subsequently, factor analysis was performed to explore the characteristic of these services in order to recommend feasible services for university students to undertake. The results indicated that the eight resources required for the 59 common community health services were (1) a designated space or venue, (2) materials, (3) monetary resources, (4) human resources, (5) expertise, (6) professional equipment, (7) patience, and (8) empathy. The results revealed three principal components, namely labor services, high-resource services, and professional services, for a total explanatory power of 67.99%; the individual explanatory power of these components accounted for 25.04%, 21.81%, and 21.15%, respectively. Next, community health care services suitable for university students to perform were selected and implemented, and these services were well received. The study results indicated that community and environmental justice can be realized by identifying with the value of community health services and promoting postmodern education theories and social norms. The research results are suitable for implementation after the COVID-19 pandemic.

The impact of an integrated depression and HIV treatment program on mental health and HIV care outcomes among people newly initiating antiretroviral therapy in Malawi

BACKGROUND

Depression is highly prevalent among patients newly starting antiretroviral treatment (ART) in Malawi and many other countries. Untreated depression at ART initiation can disrupt the HIV care continuum. Effective approaches for depression screening and treatment exist for low-resource settings, but they are rarely applied. Identifying effective implementation strategies are critical.

METHODS

A pilot program integrated depression screening and treatment into routine HIV care using existing staff at two public health clinics in Malawi in two phases; a screening-only "control" phase and an active "intervention" phase. During the intervention phase, providers prescribed antidepressants or referred patients for Friendship Bench problem-solving therapy. We evaluated the program's impact on retention in HIV care, viral suppression, and depression remission at 6 months using tabular comparisons and log-binomial models to estimate adjusted risk ratios and mean differences among the intervention group relative to the control group.

RESULTS

Nearly all consenting participants were screened for depression appropriately and 25% had mild to severe depressive symptoms. During the intervention phase, 86% of participants with mild depressive symptoms started Friendship Bench therapy and 96% of participants with moderate to severe depressive symptoms started antidepressants. Few participants in the intervention group received consistent depression treatment over their first 6 months in care. In the adjusted main analysis, program exposure did not demonstrably affect most HIV or mental health outcomes, though the probability of currently being on ART at 6 months was significantly lower among the intervention group than the control group [RR 0.6(95%CI: 0.4-0.9)].

CONCLUSIONS

While it is feasible to integrate depression screening and treatment initiation into ART initiation, providing ongoing depression treatment over time is challenging. Similar implementation science studies focused on maintaining depression management will be increasingly important as we strive to understand and test the best ways to implement evidence-based depression treatment within HIV care.

Civic engagement and mental health system strengthening in Indonesia: a qualitative examination of the views of health professionals and national key stakeholders

BACKGROUND

Mental health services in Indonesia are developing rapidly in response to national and global health policy to support people living with psychosis. This presents a unique opportunity for civic engagement, the active involvement of patients, carers and communities in mental health care, to shape emergent services. In-depth explorations of the views of professionals and other key stakeholders in mental health care on the use of civic engagement in Indonesia are lacking which contributes to a limited understanding of its potential in this regard. The study aimed to explore contemporary professionals' and other key stakeholders' perspectives on the current use of and potential for civic engagement to strengthen mental health systems in Indonesia.

METHODS

Qualitative interviews were undertaken and analysed using thematic analysis underpinned by a critical realist approach. Eighteen multi-disciplinary professionals and lay health workers involved in mental health care in Jakarta and Bogor and 10 national key stakeholders were recruited.

RESULTS

Despite high levels of awareness of and support for civic engagement amongst mental health professionals and policy makers combined with a nascent grass roots movement, analysis revealed unstructured and insufficient mechanisms for civic engagement which resulted in ad-hoc and mostly superficial levels of involvement activity. Civic engagement was thought to require a marked shift in existing practices as well as organisational and societal cultures. Challenging stigma is a key feature of civic engagement and our analysis highlights the relevance of social contact methods which are locally and culturally contextualised in this regard. Our findings point to a need to expand current definitions of civic engagement which focus on indivdiual enablement to ones that also encompass environmental and organisational enablement to optimise the future use of civic engagement in mental health settings.

CONCLUSIONS

Key mental health stakeholders have identified that central aspects of Indonesian culture are well aligned to the ethos of civic engagement which has the potential to facilitate the enactment of recent global health policy. However, full realisation is likely to be impeded by prevailing paternalistic cultures in mental health services and high levels of stigma and discrimination towards those with mental illness in Indonesia without intervention.

Exploring the potential use of patient and public involvement to strengthen Indonesian mental health care for people with psychosis: A qualitative exploration of the views of service users and carers

BACKGROUND

Patient and public involvement (PPI) has the potential to strengthen mental health systems in Indonesia and improve care for people living with psychosis. Current evidence from other parts of the world demonstrates the need to understand the contexts in which PPI is to be enacted to ensure optimal implementation.

OBJECTIVE

To understand service users' and carers' views on the current use and potential applicability of PPI within Indonesian mental health services.

DESIGN

Qualitative study incorporating focus groups analysed using thematic analysis.

SETTING AND PARTICIPANTS

Participants included 22 service users and 21 carers recruited from two study sites in Indonesia (Jakarta and Bogor). All participants had experience of psychosis either as a service user or carer.

RESULTS

Despite the value attributed to PPI in relation to improving services and promoting recovery, current use of such activities in Indonesian mental health services was limited. Participants expressed a desire for greater levels of involvement and more holistic care but felt community organizations were best placed to deliver this because PPI was considered more congruent with the ethos of third-sector organizations. Additional barriers to PPI included stigma and low levels of mental health literacy in both health services and communities.

DISCUSSION AND CONCLUSION

Participants felt that there was potential value in the use of PPI within Indonesian mental health services with careful consideration of individual contexts. Future aspirations of involvement enactment should ensure a central design and delivery role for third-sector organizations. Facilitators to global collaborative research in the context of the current study are also discussed.

Implementation process and outcomes of a mental health programme integrated in primary care clinics in rural Mexico: a mixed-methods study

Background

Policies and programmes in Mexico promote the integration of mental health services into primary health care (PHC), however these services remain largely unavailable in the country. Since 2014 a non-governmental organisation has delivered a mental health programme at PHC clinics in the state of Chiapas, in partnership with the local Ministry of Health (MoH). The programme provides mental health services based on the mhGAP guidelines through multiple implementation strategies, including programme financing, infrastructure strengthening, high-intensity training, and supervision. This study aimed to examine the implementation process and outcomes of this mental health programme to understand the extent to which mental health care integration has been achieved and to identify the successes and remaining challenges in order to inform the development and implementation of similar programmes.

Methods

We used a mixed-methods convergent design. Quantitative data for the period between December 2016 and December 2017 were extracted from the organisation’s health information system to capture process indicators, including the amount (dose) and quality (fidelity) of services delivered. We conducted two focus groups and 24 semi-structured interviews with health providers and managers to ascertain implementation outcome data: penetration, fidelity, acceptability, appropriateness and feasibility. Quantitative and qualitative data were analysed using descriptive and framework analyses, respectively.

Results

During the study period, health providers delivered mental health consultations to 486 adults diagnosed with a mood or anxiety disorder. Programme fidelity was limited given that talk-based interventions, which are required in all consultations according to programme guidelines, were only provided in 24% of consultations. Only 42% of service users attended more than 50% of scheduled mental health follow-up consultations, which also hindered fidelity. Low attendance is partially attributed to limited programme appropriateness, given that interventions to address social risk factors are not available. High levels of acceptability and feasibility enabled through strong support from the organisation were key programme strengths.

Conclusions

Mental health programmes at PHC can be implemented when adequate support and supervision structures are in place, and key resources are available. There is an urgent need for health systems strengthening to support efforts to provide mental health care, and to link PHC with locally-relevant social interventions.

Implementation outcomes and strategies for depression interventions in low- and middle-income countries: a systematic review

BACKGROUND

We systematically reviewed implementation research targeting depression interventions in low- and middle-income countries (LMICs) to assess gaps in methodological coverage.

METHODS

PubMed, CINAHL, PsycINFO, and EMBASE were searched for evaluations of depression interventions in LMICs reporting at least one implementation outcome published through March 2019.

RESULTS

A total of 8714 studies were screened, 759 were assessed for eligibility, and 79 studies met inclusion criteria. Common implementation outcomes reported were acceptability (n = 50; 63.3%), feasibility (n = 28; 35.4%), and fidelity (n = 18; 22.8%). Only four studies (5.1%) reported adoption or penetration, and three (3.8%) reported sustainability. The Sub-Saharan Africa region (n = 29; 36.7%) had the most studies. The majority of studies (n = 59; 74.7%) reported outcomes for a depression intervention implemented in pilot researcher-controlled settings. Studies commonly focused on Hybrid Type-1 effectiveness-implementation designs (n = 53; 67.1), followed by Hybrid Type-3 (n = 16; 20.3%). Only 21 studies (26.6%) tested an implementation strategy, with the most common being revising professional roles (n = 10; 47.6%). The most common intervention modality was individual psychotherapy (n = 30; 38.0%). Common study designs were mixed methods (n = 27; 34.2%), quasi-experimental uncontrolled pre-post (n = 17; 21.5%), and individual randomized trials (n = 16; 20.3).

CONCLUSIONS

Existing research has focused on early-stage implementation outcomes. Most studies have utilized Hybrid Type-1 designs, with the primary aim to test intervention effectiveness delivered in researcher-controlled settings. Future research should focus on testing and optimizing implementation strategies to promote scale-up of evidence-based depression interventions in routine care. These studies should use high-quality pragmatic designs and focus on later-stage implementation outcomes such as cost, penetration, and sustainability.

Helping or Heightening Vulnerability? Midwives as Arbiters of Risk for Women Experiencing Self-Directed Violence in Urban Sri Lanka

The response of midwives to women engaging in self-directed violence (SDV) may affect women's care and outcomes. The author explored midwives' understanding of SDV through semi-structured focus groups and in-depth interviews with 11 Public Health Midwives in urban Sri Lanka. Thematic analysis identified four key themes: (a) perceived dimensions of women's risk and vulnerability to SDV, (b) midwives as arbiters of risk, (c) representations of women engaging in SDV, and (d) midwives' perceived capacity to respond. Given their proximity to communities, trustworthiness as sites of disclosure, and respectability as women and guardians of ideal womanhood in Sri Lankan society, midwives occupy a powerful position in the health system through which to alleviate or reinforce women's risk to SDV. Yet, investment in developing their skills and role to respond to the growing phenomenon of SDV among women in Sri Lanka must consider the context within which midwives assess and select their responses.

Integrated health care systems in Asia: an urgent necessity

A rapidly aging population along with the increasing burden of patients with chronic conditions in Asia requires efficient health systems with integrated care. Although some efforts to integrate primary care and hospital care in Asia are underway, overall care delivery remains fragmented and diverse, eg, in terms of medical electronic record sharing and availability, patient registries, and empowerment of primary health care providers to handle chronic illnesses. The primary care sector requires more robust and effective initiatives targeted at specific diseases, particularly chronic conditions such as diabetes, hypertension, depression, and dementia. This can be achieved through integrated care - a health care model of collaborative care provision. For successful implementation of integrated care policy, key stakeholders need a thorough understanding of the high-risk patient population and relevant resources to tackle the imminent population demographic shift due to the extremely rapid rate of increase in the aging population in Asia.

Personal attributes and competencies required by community health workers for a role in integrated mental health care for perinatal depression: voices of primary health care stakeholders from Surabaya, Indonesia

Background

Non-professional community health workers have been widely reported as possibly having a role in mental health. In Indonesia, their role is currently being introduced in the national health system for perinatal depression. Prior publications have shown that it is generally considered feasible and acceptable by key stakeholders for community health workers to identify and refer women experiencing mental health issues during their perinatal phase to primary care. However, characteristics and competencies required for these workers have not yet been identified.

Methods

62 participants from four groups of stakeholders in primary health care in Surabaya were interviewed, including program managers, health workers, community health workers (CHWs), mental health specialists, and pregnant and postpartum women. Semi-structured questions were used to explore participants’ views about characteristics and competencies required by CHWs to identify and refer perinatal depression.

Results

Literacy and social skills were seen as basic characteristics required for CHWs to contribute to perinatal identification, together with willingness to volunteer and time availability. Participants identified females in the age range 30–50 years who have experienced pregnancy as being preferable. To ensure competency, training addressing knowledge about maternal life and depression, and communication skills are regarded as prerequisites for the role.

Conclusions

The results are consistent with WHO guidelines for informal workers working with people with mental disorders in non-specialised settings. The results provide a rationale for the criteria to be met when informal workers are to be involved in primary care mental health area and provide information for the development of training in the identification of perinatal depression.