A qualitative study assessing the feasibility of implementing a group cognitive-behavioural therapy-based intervention in Sierra Leone

Cultural challenges for adapting behavioral intervention frameworks: A critical examination from a cultural psychology perspective

We introduce the bias and equivalence framework to highlight how concepts, methods, and tools from cultural psychology can contribute to successful cultural adaptation and implementation of behavioral interventions. To situate our contribution, we provide a review of recent cultural adaptation research and existing frameworks. We identified 68 different frameworks that have been cited when reporting cultural adaptations and highlight three major adaptation dimensions that can be used to differentiate adaptations. Regarding effectiveness, we found an average effect size of zr = 0.24 (95%CI 0.20, 0.29) in 24 meta-analyses published since 2014, but also substantive differences across domains and unclear effects of the extent of cultural adaptations. To advance cultural adaptation efforts, we outline a framework that integrates key steps from previous cultural adaptation frameworks and highlight how cultural bias and equivalence considerations in conjunction with community engagement help a) in the diagnosis of behavioral or psychological problems, b) identification of possible interventions, c) the selection of specific mechanisms of behavior change, d) the specification and documentation of dose effects and thresholds for diagnosis, e) entry and exit points within intervention programs, and f) cost-benefit-sustainability discussions. We provide guiding questions that may help researchers when adapting interventions to novel cultural contexts.

What are effective strategies to respond to the psychological impacts of working on the frontlines of a public health emergency?

Background

The COVID-19 pandemic has disrupted the healthcare and public health sectors. The impact of working on the frontlines as a healthcare or public health professional has been well documented. Healthcare organizations must support the psychological and mental health of those responding to future public health emergencies.

Objective

This systematic review aims to identify effective interventions to support healthcare workers' mental health and wellbeing during and following a public health emergency.

Methods

Eight scientific databases were searched from inception to 1 November 2022. Studies that described strategies to address the psychological impacts experienced by those responding to a public health emergency (i.e., a pandemic, epidemic, natural disaster, or mass casualty event) were eligible for inclusion. No limitations were placed based on study design, language, publication status, or publication date. Two reviewers independently screened studies, extracted data, and assessed methodological quality using the Joanna Briggs Institute critical appraisal tools. Discrepancies were resolved through discussion and a third reviewer when needed. Results were synthesized narratively due to the heterogeneity of populations and interventions. Outcomes were displayed graphically using harvest plots.

Results

A total of 20,018 records were screened, with 36 unique studies included in the review, 15 randomized controlled trials, and 21 quasi-experimental studies. Results indicate that psychotherapy, psychoeducation, and mind-body interventions may reduce symptoms of anxiety, burnout, depression, and Post Traumatic Stress Disorder, with the lowest risk of bias found among psychotherapy interventions. Psychoeducation appears most promising to increase resilience, with mind-body interventions having the most substantial evidence for increases in quality of life. Few organizational interventions were identified, with highly heterogeneous components.

Conclusion

Promoting healthcare workers' mental health is essential at an individual and health system level. This review identifies several promising practices that could be used to support healthcare workers at risk of adverse mental health outcomes as they respond to future public health emergencies.Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=203810, identifier #CRD42020203810 (PROSPERO).

Effectiveness of psychological first aid in infectious disease pandemics: An overview of systematic reviews

There is insufficient research on the usefulness of psychological interventions, such as psychological first aid (PFA), during outbreaks. We searched for and critically appraised systematic reviews that examined the effectiveness of PFA during infectious disease outbreaks, such as the novel coronavirus disease (COVID-19). Systematic reviews that examined the efficacy of PFA in the severe acute respiratory syndrome, Middle East respiratory syndrome coronavirus, Ebola virus disease, and COVID-19 outbreaks were searched through PubMed on February 19, 2021. The three included systematic reviews were critically appraised and assessed using AMSTAR-2. One review's overall confidence in its findings was evaluated as "high," which suggested that PFA training had a favorable effect on healthcare personnel. Furthermore, the review also demonstrated that PFA was commonly used during outbreaks and could be delivered through multiple methods, such as a phone or video call. Although it was anticipated that PFA would improve subjective well-being, reports showed no evidence of reduced depression or insomnia. Future studies should examine additional numbers of PFA recipients and conduct quasi-experimental studies to better understand the effectiveness of PFA. Evidence on its effectiveness in infectious disease outbreaks is still lacking, along with research and evaluation methods. Quasi-experimental studies, such as comparisons with other psychological interventions, are required to better understand the effectiveness of PFA.

Mental health and psychosocial support strategies in highly contagious emerging disease outbreaks of substantial public concern: A systematic scoping review

BACKGROUND

Acute disease outbreaks such as the COVID-19 pandemic cause a high burden of psychological distress in people worldwide. Interventions to enable people to better cope with such distress should be based on the best available evidence. We therefore performed a scoping review to systematically identify and summarize the available literature of interventions that target the distress of people in the face of highly contagious disease outbreaks.

METHODS

MEDLINE, Cochrane CENTRAL, Web of Science (January 2000 to May 7, 2020), and reference lists were systematically searched and screened by two independent reviewers. Quantitative and qualitative studies investigating the effects of psychological interventions before, during, and after outbreaks of highly contagious emerging infectious diseases, such as SARS, MERS, Ebola, or COVID-19 were included. Study effects were grouped (e.g. for healthcare professionals, community members, people at risk) and intervention contents at the individual and organizational level summarized. We assessed the level of evidence using a modified scheme from the Oxford Centre for Evidence-based Medicine and the Australian National Health and Medical Research Council.

RESULTS

Of 4030 records found, 19 studies were included (two RCTs). Most interventions were delivered during-exposure and face-to-face, focused on healthcare workers and crisis personnel, and combined psychoeducation with training of coping strategies. Based on two high-quality studies, beneficial effects were reported for resilience factors (e.g. positive cognitive appraisal) and professional attitudes of healthcare workers, with mixed findings for mental health (e.g. depression). Across all studies, there was positive qualitative feedback from participants and facilitators. We identified seven ongoing studies mostly using online- and mobile-based deliveries.

CONCLUSIONS

There is preliminary evidence for beneficial effects of interventions to enable people to better cope with the distress of highly contagious emerging disease outbreaks. Besides the need for more high-quality studies, the summarized evidence may inform decision makers to plan interventions during the current pandemic and to develop pandemic preparedness plans.

Effectiveness of small group cognitive behavioural therapy for anxiety and depression in Ebola treatment centre staff in Sierra Leone

Following the 2014 Ebola outbreak, South London and Maudsley NHS Foundation Trust (SLAM) were commissioned to provide a 'culturally appropriate, effective and sustainable' intervention to address the psychological needs of the Sierra Leonean Ebola Treatment Centre (ETC) staff. The study evaluated the effectiveness of group Cognitive Behavioural Therapy (CBT) developed to treat anxiety, depression and functional impairment amongst a sample of former ETC staff in Sierra Leone. Group comparisons explored whether the effect of the intervention differed dependent on the facilitators that delivered it, as well as whether it differed between former staff of high- and low-risk ETC roles. A sample of 253 former ETC staff attended the group CBT intervention comprised of eight sessions over six weeks. Outcome measures were administered upon entry and within two weeks after the intervention. At post-intervention, anxiety, depression and functional impairment significantly reduced. Reading ability (RA) was introduced as a covariate having impacted the outcomes. The intervention effect differed by facilitators delivering the sessions but not by ETC role risk. The implications of these results are discussed. Group CBT is a promising psychological intervention for treating the anxiety, depression and functional impairment of former ETC staff in Sierra Leone. Furthermore, as part of a stepped-care approach, it may provide a model for psychological support for staff that have worked on the frontline during future epidemics.

Interventions to support the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic: a mixed methods systematic review

BACKGROUND

Evidence from disease epidemics shows that healthcare workers are at risk of developing short- and long-term mental health problems. The World Health Organization (WHO) has warned about the potential negative impact of the COVID-19 crisis on the mental well-being of health and social care professionals. Symptoms of mental health problems commonly include depression, anxiety, stress, and additional cognitive and social problems; these can impact on function in the workplace. The mental health and resilience (ability to cope with the negative effects of stress) of frontline health and social care professionals ('frontline workers' in this review) could be supported during disease epidemics by workplace interventions, interventions to support basic daily needs, psychological support interventions, pharmacological interventions, or a combination of any or all of these.

OBJECTIVES

Objective 1: to assess the effects of interventions aimed at supporting the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic. Objective 2: to identify barriers and facilitators that may impact on the implementation of interventions aimed at supporting the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic.

SEARCH METHODS

On 28 May 2020 we searched the Cochrane Database of Systematic Reviews, CENTRAL, MEDLINE, Embase, Web of Science, PsycINFO, CINAHL, Global Index Medicus databases and WHO Institutional Repository for Information Sharing. We also searched ongoing trials registers and Google Scholar. We ran all searches from the year 2002 onwards, with no language restrictions.

SELECTION CRITERIA

We included studies in which participants were health and social care professionals working at the front line during infectious disease outbreaks, categorised as epidemics or pandemics by WHO, from 2002 onwards. For objective 1 we included quantitative evidence from randomised trials, non-randomised trials, controlled before-after studies and interrupted time series studies, which investigated the effect of any intervention to support mental health or resilience, compared to no intervention, standard care, placebo or attention control intervention, or other active interventions. For objective 2 we included qualitative evidence from studies that described barriers and facilitators to the implementation of interventions. Outcomes critical to this review were general mental health and resilience. Additional outcomes included psychological symptoms of anxiety, depression or stress; burnout; other mental health disorders; workplace staffing; and adverse events arising from interventions.

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently applied selection criteria to abstracts and full papers, with disagreements resolved through discussion. One review author systematically extracted data, cross-checked by a second review author. For objective 1, we assessed risk of bias of studies of effectiveness using the Cochrane 'Risk of bias' tool. For objective 2, we assessed methodological limitations using either the CASP (Critical Appraisal Skills Programme) qualitative study tool, for qualitative studies, or WEIRD (Ways of Evaluating Important and Relevant Data) tool, for descriptive studies. We planned meta-analyses of pairwise comparisons for outcomes if direct evidence were available. Two review authors extracted evidence relating to barriers and facilitators to implementation, organised these around the domains of the Consolidated Framework of Implementation Research, and used the GRADE-CERQual approach to assess confidence in each finding. We planned to produce an overarching synthesis, bringing quantitative and qualitative findings together.

MAIN RESULTS

We included 16 studies that reported implementation of an intervention aimed at supporting the resilience or mental health of frontline workers during disease outbreaks (severe acute respiratory syndrome (SARS): 2; Ebola: 9; Middle East respiratory syndrome (MERS): 1; COVID-19: 4). Interventions studied included workplace interventions, such as training, structure and communication (6 studies); psychological support interventions, such as counselling and psychology services (8 studies); and multifaceted interventions (2 studies). Objective 1: a mixed-methods study that incorporated a cluster-randomised trial, investigating the effect of a work-based intervention, provided very low-certainty evidence about the effect of training frontline healthcare workers to deliver psychological first aid on a measure of burnout. Objective 2: we included all 16 studies in our qualitative evidence synthesis; we classified seven as qualitative and nine as descriptive studies. We identified 17 key findings from multiple barriers and facilitators reported in studies. We did not have high confidence in any of the findings; we had moderate confidence in six findings and low to very low confidence in 11 findings. We are moderately confident that the following two factors were barriers to intervention implementation: frontline workers, or the organisations in which they worked, not being fully aware of what they needed to support their mental well-being; and a lack of equipment, staff time or skills needed for an intervention. We are moderately confident that the following three factors were facilitators of intervention implementation: interventions that could be adapted for local needs; having effective communication, both formally and socially; and having positive, safe and supportive learning environments for frontline workers. We are moderately confident that the knowledge or beliefs, or both, that people have about an intervention can act as either barriers or facilitators to implementation of the intervention.

AUTHORS' CONCLUSIONS

There is a lack of both quantitative and qualitative evidence from studies carried out during or after disease epidemics and pandemics that can inform the selection of interventions that are beneficial to the resilience and mental health of frontline workers. Alternative sources of evidence (e.g. from other healthcare crises, and general evidence about interventions that support mental well-being) could therefore be used to inform decision making. When selecting interventions aimed at supporting frontline workers' mental health, organisational, social, personal, and psychological factors may all be important. Research to determine the effectiveness of interventions is a high priority. The COVID-19 pandemic provides unique opportunities for robust evaluation of interventions. Future studies must be developed with appropriately rigorous planning, including development, peer review and transparent reporting of research protocols, following guidance and standards for best practice, and with appropriate length of follow-up. Factors that may act as barriers and facilitators to implementation of interventions should be considered during the planning of future research and when selecting interventions to deliver within local settings.

Mental health services for infectious disease outbreaks including COVID-19: a rapid systematic review

The upsurge in the number of people affected by the COVID-19 is likely to lead to increased rates of emotional trauma and mental illnesses. This article systematically reviewed the available data on the benefits of interventions to reduce adverse mental health sequelae of infectious disease outbreaks, and to offer guidance for mental health service responses to infectious disease pandemic. PubMed, Web of Science, Embase, PsycINFO, WHO Global Research Database on infectious disease, and the preprint server medRxiv were searched. Of 4278 reports identified, 32 were included in this review. Most articles of psychological interventions were implemented to address the impact of COVID-19 pandemic, followed by Ebola, SARS, and MERS for multiple vulnerable populations. Increasing mental health literacy of the public is vital to prevent the mental health crisis under the COVID-19 pandemic. Group-based cognitive behavioral therapy, psychological first aid, community-based psychosocial arts program, and other culturally adapted interventions were reported as being effective against the mental health impacts of COVID-19, Ebola, and SARS. Culturally-adapted, cost-effective, and accessible strategies integrated into the public health emergency response and established medical systems at the local and national levels are likely to be an effective option to enhance mental health response capacity for the current and for future infectious disease outbreaks. Tele-mental healthcare services were key central components of stepped care for both infectious disease outbreak management and routine support; however, the usefulness and limitations of remote health delivery should also be recognized.

Mental health interventions and supports during COVID- 19 and other medical pandemics: A rapid systematic review of the evidence

BACKGROUND

Novel coronavirus pneumonia (COVID-19) is a global reminder of the need to attend to the mental health of patients and health professionals who are suddenly facing this public health crisis. In the last two decades, a number of medical pandemics have yielded insights on the mental health impact of these events. Based on these experiences and given the magnitude of the current pandemic, rates of mental health disorders are expected to increase. Mental health interventions are urgently needed to minimize the psychological sequelae and provide timely care to affected individuals.

METHOD

We conducted a rapid systematic review of mental health interventions during a medical pandemic, using three electronic databases. Of the 2404 articles identified, 21 primary research studies are included in this review.

RESULT

We categorized the findings from the research studies using the following questions: What kind of emotional reactions do medical pandemics trigger? Who is most at risk of experiencing mental health sequelae? What works to treat mental health sequelae (psychosocial interventions and implementation of existing or new training programs)? What do we need to consider when designing and implementing mental health interventions (cultural adaptations and mental health workforce)? What still needs to be known?

CONCLUSION

Various mental health interventions have been developed for medical pandemics, and research on their effectiveness is growing. We offer recommendations for future research based on the evidence for providing mental health interventions and supports to those most in need.

Beyond the COVID-19 pandemic: 'Learning the hard way' - adapting long-term IAPT service provision using lessons from past outbreaks

Infectious disease outbreaks have occurred sporadically over the centuries. The most significant ones of this century, as reported by the World Health Organization, include the EVD epidemic, SARS pandemic, Swine Flu pandemic and MERS pandemic. The long-term mental health consequences of outbreaks are as profound as physical ones and can last for years post-outbreak. This highlights the need for enhancing the preparedness of pragmatic mental health service provision. Due to its magnitude, the novel COVID-19 pandemic has proven to be the most impactful. Compared with previous outbreaks, COVID-19 has also occurred at higher rates in frontline staff in addition to patients. As COVID-19 is more contagious than earlier outbreaks, there is a need to identify infected people quickly and isolate them and their contacts. This is the current context in which mental health services including IAPT have had to operate. Evidently, Improving Access to Psychological Therapies (IAPT) services are a major mental health service provider in the UK that have demonstrated variability in their response to COVID-19. While some IAPT services quickly adapted their existing strengths and resources (e.g. remote working), other services were less prepared. To date, there are no clear unitary guidelines on how IAPT services can use their pre-existing resources to respond to the long-term effects of outbreaks. In light of this, the current paper aims to reflect on the lessons learned from past outbreaks in order to consider how an enhanced remit of IAPT might integrate with other services to meet the long-term needs of patients and staff affected by COVID-19.

KEY LEARNING AIMS

(1)To understand the development of IAPT within the NHS mental health services.(2)To understand the nature of past outbreaks and COVID-19.(3)To reflect on lessons from past outbreaks in order to understand how IAPT can respond to the long-term effects of COVID-19.

Managing Mental Health in Pandemic COVID-19 and Movement Control Order

COVID-19 and the Movement Control Order (MCO) may trigger a 'next wave' of mental health problems. However, the relationship is not linear. Human psychology also has an impact on the outbreak. Thus, proper strategies to manage human psychology, especially mental health, is very important to break the vicious cycle. This article aims to discuss ways to manage mental health using cognitive-behavioural approaches, mindfulness and spirituality. Specific cognitive-behavioural and mindfulness strategies are listed and suggestions to return to the foundation of human existence are discussed. By practising the cognitive-behavioural, mindfulness, and spirituality strategies described, we may enhance our acceptance, optimism and commitment to prepare for a 'new or renewed normal'.

Adapting IAPT services to support frontline NHS staff during the Covid-19 pandemic: the Homerton Covid Psychological Support (HCPS) pathway

The Coronavirus (Covid-19) pandemic is exerting unprecedented pressure on NHS Health and Social Care provisions, with frontline staff, such as those of critical care units, encountering vast practical and emotional challenges on a daily basis. Although staff are being supported through organisational provisions, facilitated by those in leadership roles, the emergence of mental health difficulties or the exacerbation of existing ones amongst these members of staff is a cause for concern. Acknowledging this, academics and healthcare professionals alike are calling for psychological support for frontline staff, which not only addresses distress during the initial phases of the outbreak but also over the months, if not years, that follow. Fortunately, mental health services and psychology professional bodies across the United Kingdom have issued guidance to meet these needs. An attempt has been made to translate these sets of guidance into clinical provisions via the recently established Homerton Covid Psychological Support (HCPS) pathway delivered by Talk Changes (Hackney & City IAPT). This article describes the phased, stepped-care and evidence-based approach that has been adopted by the service to support local frontline NHS staff. We wish to share our service design and pathway of care with other Improving Access to Psychological Therapies (IAPT) services who may also seek to support hospital frontline staff within their associated NHS Trusts and in doing so, lay the foundations of a coordinated response.

KEY LEARNING AIMS

(1)To understand the ways staff can be psychologically and emotionally impacted by working on the frontline of disease outbreaks.(2)To understand the ways in which IAPT services have previously supported populations exposed to crises.(3)To learn ways of delivering psychological support and interventions during a pandemic context based on existing guidance and research.

A systematic review of mental health programs among populations affected by the Ebola virus disease

OBJECTIVES

The Ebola virus disease (EVD) is associated with major mental health consequences (e.g., depression, anxiety, PTSD). Studies have shown a need for relevant and effective programs to address mental health consequences associated to EVD. This systematic review aimed to describe programs implemented following EVD outbreaks and to evaluate their effectiveness and relevance in order to provide evidence-based data to improve mental health services.

METHODS

We first searched EMBASE, PubMed, PsycINFO, PILOTS, Cochrane Library and MEDLINE for a systematic review on EVD and on MHPSS programs. Then, we searched the grey literature. The search generated 2827 publications. Eleven studies were retained according to the PRISMA statement.

RESULTS

This systematic review revealed that most programs were implemented by international organizations in collaboration with local partners. Many of them were implemented following WHO mhGAP and Psychological First Aid guidelines. Programs were implemented in hospitals, Ebola treatment centres, communities among different categories of individuals exposed to EVD (survivors, health workers and volunteers, other frontline workers, children, adults, etc.). Only two of the identified programs which integrated cultural factors were empirically evaluated. Results from the evaluations showed mental health improvement for both children and adults.

CONCLUSIONS

This study provides the first systematic review on MHPSS programs among communities affected by EVD. This study shows the need to increase efforts to systematically document and evaluate the implemented programs. Results also provide preliminary evidence about the value of culturally sensitive MHPSS programs and of the implication of local mental health professionals.