Lay Field-worker-Led School Health Program for Primary Schools in Low- and Middle-Income Countries

Psychosocial interventions for autistic children and adolescents delivered by non-specialists in low- and middle-income countries: a scoping review

Background

Most autistic individuals reside in low- and middle-income countries (LMIC) and have limited access to medical providers and specialists. Support for delivery of psychosocial interventions by non-specialists is growing to address this mental health care gap. This scoping review involved a systematic analysis of studies of non-specialist delivered psychosocial interventions for children and adolescents diagnosed with autism and living in low- and middle-income countries.

Methods

The primary objective of this review was to identify psychosocial interventions for autistic children and adolescents in LMIC delivered by non-specialists (parent, teacher, peer, community, multi-level) and to summarize resulting effects on targeted outcomes. The search strategy was completed in four databases with predetermined inclusion and exclusion criteria. The systematic search generated 3,601 articles. A total of 18 studies met inclusion/exclusion criteria. Data extraction was completed, and results summarized by; (1) participant sample; (2) intervention procedures; (3) implementation by non-specialists; (4) effect on evaluated outcomes; and (5) assessment of risk of bias. Studies examined a range of child and adolescent outcomes including assessment of communication skills, social skills, motor skills, functional and adaptive behaviors, emotional regulation, attention and engagement, sensory challenges, depression, anxiety, and quality of life. Several studies also evaluated intervention effects on family relationships, parent/caregiver stress and parent/caregiver mental health.

Results

Collectively, the 18 studies included a total of 952 ASC participants ranging in age from 2 to 16 years. Of the included studies, 8 studies were parent/caregiver-mediated, 1 study was peer-mediated, 2 studies were teacher-mediated, and 7 studies included multi-level non-specialist mediated components. Effects on evaluated outcomes are reported.

Conclusion

Non-specialist delivered interventions for autistic children and adolescents are effective for an array of outcomes and are particularly well suited for low- and middle-income countries. Implications for future research are discussed.

Teacher, caregiver, and student acceptability of teachers delivering task-shifted mental health care to students in Darjeeling, India: a mixed methods pilot study

Background

The acceptability of teachers delivering task-shifted mental health care to their school-aged students is understudied. Here, we evaluate teachers', students', and caregivers' acceptability of Tealeaf (Teachers Leading the Frontlines), an alternative system of care in which teachers are trained and supervised to deliver transdiagnostic, non-manualized task-shifted care to their students.

Methods

In a 2019 single-arm, mixed methods, pragmatic acceptability pilot study in Darjeeling, India, 13 teachers delivered task-shifted child mental health care to 26 students in need. Teachers delivered care through using a transdiagnostic, non-manualized therapy modality, "education as mental health therapy" (Ed-MH). Measured with validated scales, teachers' and students' acceptability were compared after teacher training (PRE) and at the end of intervention (POST) using paired t tests. Teachers (n = 7), students (n = 7), and caregivers (n = 7) completed semi-structured interviews POST.

Results

Teachers' quantitative measures indicated moderate acceptability PRE and POST and did not change PRE to POST. Children's measures showed acceptability PRE and POST but decreased PRE to POST. Teachers and caregivers universally expressed acceptability in interviews. Facilitators of acceptability included impact, trust of teachers, and teachers' ability to make adaptations. Conditions required for acceptability included supervision and teachers emphasizing academics benefits over mental health benefits to caregivers. Barriers to acceptability included a lack of teacher time and stigma. Interviewed students universally were unaware of receiving care; teachers intentionally avoided singling them out.

Conclusion

Teachers, caregivers, and children found teacher delivering task-shifted care acceptable, a key factor in care adoption and sustainability, though interviewed children were unaware of receiving care.Trial registration The trial was registered on January 01, 2018 with Clinical Trials Registry-India (CTRI), Reg. No. CTRI/2018/01/011471, Ref. No. REF/2017/11/015895. http://ctri.nic.in/Clinicaltrials/pdf_generate.php?trialid=21129&EncHid=&modid=&compid=%27,%2721129det%27.

Supplementary Information

The online version contains supplementary material available at 10.1007/s44192-022-00024-z.

Exploring Mental Health and Academic Outcomes of Children Receiving Non-manualized, Transdiagnostic, Task-Shifted Mental Health Care From Their Teachers in a Low-and-Middle Income Country

A majority of children worldwide who face mental health difficulties, especially in low-and-middle income countries, remain undiagnosed and untreated. This deficit roots in part from a lack of trained professionals qualified to provide care. Task-shifting the provision of treatment to teachers, individuals with consistent access to children, can reduce the care gap. The current study investigated whether the implementation of a pilot trial of Tealeaf-Mansik Swastha (Teachers Leading the Frontlines-Mental Health; "Tealeaf") was associated with improvements in child mental health and academic outcomes. Tealeaf is a transdiagnostic, non-manualized, task-shifting intervention in which teachers identify students in need of mental health care and then provide task-shifted care for them using an emerging, novel therapy modality, "education as mental health therapy" (Ed-MH). Pre-post standardized quantitative measures focused on child mental health status and academics. The measures were completed by multiple raters and compared to determine whether changes occurred. Results indicated that primary teacher raters observed significant improvements in child mental health symptoms overall, while secondary teacher raters and caregivers noted improvement for certain diagnostic categories. Caregivers observed on average a decreased impact of their children's mental health symptoms on their children's lives. Academically, math scores significantly improved while reading trended toward significance. Preliminary evidence overall supports the viability of Tealeaf and Ed-MH for positively impacting child mental health and academics. Future directions include the implementation of a formalized, randomized-controlled trial to strengthen preliminary outcomes.

An International Review to Characterize the Role, Responsibilities, and Optimal Setting for Health Literacy Mediators

Health literacy is a critically important determinant of health and is influenced by access to supportive social networks and services. Global investment in education throughout the life course is required to support health literacy development. The aim of this review is to characterize the role, responsibilities, and the optimal setting for the emergent role of a Health Literacy Mediator (HLM). A scoping review of recent literature was conducted. The review revealed a lack of consensus on who should be teaching health literacy, and variability in confidence when teaching health literacy. Professionals reported facing barriers such as a lack of time, a lack of knowledge, and recognized that the health literacy needs of children worldwide are not being met. Further research into the role of HLM is required to determine who is best suited to this role and what their responsibilities will be to ensure consistent health literacy education.

Teacher Nomination of School-aged Children for Mental Health Services in a Low and Middle Income Country

Background: Knowledgeable in child development, primary school teachers in low- and middle-income countries (LMICs) have the potential to identify their students needing mental health care. Objective: We evaluated whether teachers in Darjeeling, India can accurately nominate school-aged children for mental health services after training and aided by a novel tool. Methods: In 2018, 19 primary school teachers from five low-cost private (LCP) schools in rural Darjeeling were trained to nominate children needing care. Teachers evaluated all of their students aided by a novel tool, 'Behavior Type and Severity Tool' (BTST), completed the Achenbach Teacher Report Form (TRF) as a mental health status reference standard, and nominated two students for care. Sensitivity and specificity of being nominated compared to TRF overall and subdomain scores were calculated. BTST performance was determined by comparing BTST and TRF scores and creating Receiver Operating Characteristic curves to determine optimal cutoffs. Multivariable regression models were used to identify demographic predictors of teacher accuracy using the BTST. Results: For students demonstrating a clinical or borderline score in at least one TRF subdomain, the sensitivity (72%) and specificity (62%) of teacher nomination were moderately high. BTST overall scores and TRF Total Problem scores were correlated (Spearman's ρ = 0.34, p < 0.0001), as were all subdomains. For the TRF Total Problem score, a maximum Youden's J of 0.39 occurred at BTST cutoff >4 for borderline struggles and 0.54 at the BTST cutoff >6 for clinical struggles. Younger teacher age, less education, less formal education training, and more years of experience were positively associated with teacher accuracy. Conclusions: With training and a simple decision support tool, primary school teachers in an LMIC nominated students for mental health services with moderate accuracy. With the BTST being weakly accurate, teachers' judgment largely accounted for the moderate accuracy of nominations.

Perceptions, attitudes, and knowledge of teachers serving as mental health lay counselors in a low and middle income country: a mixed methods pragmatic pilot study

Background

Low and middle-income countries (LMICs) lack trained child mental health professionals. While teachers’ child development experience potentially positions them to fill the gap as lay mental health counselors, they have rarely delivered indicated child mental health care in LMICs. As part of assessing the feasibility of teachers serving as lay counselors, we explored teachers’ perceptions of serving as lay counselors and their mental health attitudes and knowledge.

Methods

In 2018, with training and supervision, 19 primary school teachers from five rural, low cost private schools in Darjeeling, India, served as lay counselors in their classrooms. Using mixed methods, we examined teacher perceptions of serving as lay counselor and mental health attitudes and knowledge through a survey (n = 15), a summative assessment (n = 14), and semi-structured interviews (n = 17). For the survey and summative assessment, pre-training, post-training, and post-intervention mean scores were compared using paired t tests. Post-intervention interviews were coded for teachers’ perceptions of serving as lay counselor and mental health attitudes and knowledge.

Results

Qualitatively, teachers expressed being willing to serve as lay counselor, having more inclusive mental health attitudes, and retaining mental health knowledge as applicable to use during instructional time or incorporation into the knowledge transfer process, their primary duty. By contrast, quantitatively, teachers’ attitudes appeared to become more inclusive on the study-specific survey pre versus post-training, but reverted to pre-training levels post-intervention. Teachers’ mental health knowledge on the summative assessment did not change pre-training versus post-training versus post-intervention.

Conclusions

Training, supervision, and serving as lay counselors led to teachers’ willingness to serve as lay counselors. Teachers served as lay counselors by utilizing therapeutic techniques during class time and incorporating them into their typical instruction, not through delivering traditional office-like care. Teacher practices may be pointing to the potential emergence of an “education as mental health therapy” system of care. Their changes in attitudes and knowledge reflected their emerging practices. Quantitative measures of knowledge and attitude changes did not capture these nuanced changes.

Trial Registration The parent feasibility trial was registered on January 01, 2018 with Clinical Trials Registry – India (CTRI), reg. no. CTRI/2018/01/011471, ref. no. REF/2017/11/015895. http://ctri.nic.in/Clinicaltrials/pdf_generate.php?trialid=21129&EncHid=&modid=&compid=%27,%2721129det%27..

Supplementary Information

The online version contains supplementary material available at 10.1186/s13033-021-00453-3.

The Potential Emergence of "Education as Mental Health Therapy" as a Feasible Form of Teacher-Delivered Child Mental Health Care in a Low and Middle Income Country: A Mixed Methods Pragmatic Pilot Study

Objective: We assessed task-shifting children's mental health care to teachers as a potential approach to improving access to child mental health care. Methods: In Darjeeling, India, we conducted a single-arm, mixed-methods feasibility study with 19 teachers and 36 children in five rural primary schools to determine whether teachers can deliver transdiagnostic mental health care to select children-in-need with fidelity to protocol, to assess which therapeutic options teachers chose to use within the protocol, and to evaluate for a potential signal of efficacy. Results: Participation rates for intervention activities were >80%. A majority of teachers met or exceeded quality benchmarks for all intervention activities. Teachers chose to deliver teacher-centric techniques, i.e., techniques that only teachers could deliver given their role in the child's life, 80% of the time. Children improved in mental health score percentiles on the Achenbach Teacher Report Form. Key facilitators included the flexibility to adapt intervention activities to their needs, while identified barriers included limited time for care delivery. Conclusion: Findings support the feasibility of task-shifting children's mental health care to classroom teachers in resource-limited schools. Fidelity to protocol appeared feasible, though the freedom to choose and adapt therapeutic techniques may also have enhanced feasibility. Surprisingly, teachers consistently chose to deliver teacher-centric therapeutic techniques that resulted in a potential signal of efficacy. This finding supports the potential emergence of "education as mental health therapy" (Ed-MH) as a new therapy modality. Continued investigation is required to test and refine strategies for involving teachers in the delivery of transdiagnostic mental health care.