Curriculum development in Liberia's first postgraduate psychiatry training programme

This paper describes the implementation of curricula for Liberia's first-ever psychiatry training programme in 2019 and the actions of the only two Liberian psychiatrists in the country at the time in developing and executing a first-year postgraduate psychiatry training programme (i.e. residency) with support from international collaborators. It explores cultural differences in training models among collaborators and strategies to synergise them best. It highlights the assessment of trainees' (residents') basic knowledge on entry into the programme and how it guided immediate and short-term priority teaching objectives, including integrated training in neuroscience and neurology. The paper describes the strengths and challenges of this approach as well as opportunities for continued growth.

A National Institutes of Health Approach for Advancing Research to Improve Youth Mental Health and Reduce Disparities

Even before the COVID-19 pandemic, mental health challenges were the leading cause of disability and poor health outcomes in youth. Challenges are even greater for youth from racially and ethnically minoritized groups in the United States. Racially and ethnically minoritized youth are more vulnerable to mental health problems than White adolescents, yet are less likely to use mental health services. In late 2021, the National Institutes of Health (NIH) sponsored a virtual conference to examine the state of the science around youth mental health disparities (YMHD), focusing on youth from racially and ethnically minoritized populations and the intersection of race and ethnicity with other drivers of mental health disparities. Key findings and feedback gleaned from the conference have informed strategic planning processes related to YMHD, which has included the development of a strategic framework and funding opportunities, designed to reduce YMHD. This commentary briefly describes the collaborative approach used to develop this framework and other strategies implemented across the NIH to address YMHD and serves as an urgent call to action.

Evaluating an Interprofessional Trauma-Based Education Course to Advance the Care and Health of Refugees

Refugee patients benefit from interdisciplinary approaches that address trauma-related migration in culturally responsive ways. This qualitative evaluation assessed the interdisciplinary trauma-based course for refugee populations. The qualitative data comes from focus groups and surveys to evaluate medical, social work, and public health students' perceptions of the interprofessional education course of refugee patient care. The evaluators analyzed qualitative data through a thematic content analysis method. Following key themes emerged from students' reflections: (1) collaboration in interdisciplinary learning, (2) role of clinical learning, (3) skills and knowledge related to refugee population care, (4) improvements for interprofessional education, and (5) strengths of the interprofessional education course. The Interprofessional Refugee Health Elective course enhanced their knowledge and competence in refugee health care. Educators, students, and the patient population will benefit from investing in interprofessional education courses that focus on specific needs and complex care management for refugee patients.

Trauma, risk, and resilience: A qualitative study of mental health in post-conflict Liberia

The Liberian civil wars led to widespread destruction and devastation for its individuals, communities, and economy. However, individuals' subjective trauma experiences and long-term psychological impact remain relatively understudied. This study aims to explore context-specific traumatic events and examine how risk and protective factors combine with traumas to influence trajectories of suffering and recovery over time. We conducted 43 semi-structured interviews with Liberian adults who were present during the Liberian civil wars, and we used line-by-line open coding, thematic analysis, and axial coding to analyze and contextualize the data. Eight key trauma themes emerged: Abuse (emotional, physical, and sexual), Captivity, Combat, Killings, Physical Illness, Resource Loss, Family Separation, and War Environment. The risk and protective factors that were reported as salient were: Age, Biological Sex, Socioeconomic Status, and Community Support. Further, key patterns emerged across interviews that indicated greater risk for long-term suffering: 1) exposure to multiple traumatic events, 2) certain types of traumatic events (like killing of a close family member), and 3) the combination of specific traumatic events and risk and protective factors (like older women witnessing the killing of their children). This study provides culturally relevant information on trauma, suffering, and resilience in post-conflict Liberia, with the aim of guiding the development of screening tools and targeted psychological interventions that improve well-being over time.

Building a postgraduate psychiatry training program in Liberia through cross-country collaborations: initiation stages, challenges, and opportunities

Background

About 80% of the nearly 2 billion people experiencing psychiatric conditions worldwide do not have access to quality, affordable mental health care. In Africa, there are 0.004 psychiatrists per 10,000 people, with the shortage exacerbated by a limited number of postgraduate psychiatry training opportunities. As of 2018, there were only two psychiatrists in Liberia.

Methods

This paper aims to offer a framework for developing postgraduate (i.e., residency) psychiatry training in resource-constrained settings to disseminate best practices and lessons learned. This article describes the approach to developing the formal global academic partnership that supported the initiation of Liberia's first postgraduate psychiatry training program in July 2019.

Results

Authors describe strengths, challenges, and opportunities for improvement in the planning and initiation stages of the postgraduate program. Key strengths of the program planning process include: (1) collaboration with a coalition of local and national stakeholders committed to improving mental health care in Liberia; (2) early procurement of quality video conferencing equipment and internet service to facilitate remote learning and broaden access to digital materials; and (3) leveraging of intra-continental partnerships for subspecialty training. Challenges experienced include: (1) navigating the intricacies of local political and administrative processes; (2) recruiting candidates to a medical specialty with historically lower salaries; and (3) the added burden placed on the limited number of local specialists. Identified opportunities include building a monitoring, evaluation, and learning (MEL) framework, further diversifying subspecialty areas of psychiatric and neurological training, and obtaining full accreditation of the postgraduate psychiatry program through the West African College of Physicians (WACP).

Conclusion

The successful launch of the postgraduate psychiatry training program in Liberia is attributed to several factors, including a long-standing academic collaboration of over 10 years and support for mental health capacity-building efforts at national and local levels.

Novel Methods for Leveraging Large Cohort Studies for Qualitative and Mixed-Methods Research

Qualitative research methods, while rising in popularity, are still a relatively underutilized tool in public health research. Usually reserved for small samples, qualitative research techniques have the potential to enhance insights gained from large questionnaires and cohort studies, both deepening the interpretation of quantitative data and generating novel hypotheses that might otherwise be missed by standard approaches; this is especially true where exposures and outcomes are new, understudied, or rapidly changing, as in a pandemic. However, methods for the conduct of qualitative research within large samples are underdeveloped. Here, we describe a novel method of applying qualitative research methods to free-text comments collected in a large epidemiologic questionnaire. Specifically, this method includes: 1) a hierarchical system of coding through content analysis; 2) a qualitative data management application; and 3) an adaptation of Cohen's κ and percent agreement statistics for use by a team of coders, applying multiple codes per record from a large codebook. The methods outlined in this paper may help direct future applications of qualitative and mixed methods within large cohort studies.

The Patient-Reported Outcomes Measurement Information System (PROMIS) pediatric and parent-proxy short forms for anxiety: Psychometric properties in the Kids FACE FEARS sample

There is tremendous need for brief and supported, non-commercial youth- and caregiver-report questionnaires of youth anxiety. The pediatric and parent proxy short forms of the Patient-Reported Outcomes Measurement Information System (PROMIS) Anxiety scale (8a v2.0) are free, brief, publicly accessible measures of youth- and caregiver-reported anxiety in children and adolescents. Despite increased use of the PROMIS, no study has evaluated performance of its anxiety scales in a sample of treatment-engaged anxious youth. Analyses were conducted on baseline data from the first 265 families (child M_Age=11.14 years, 70% racial/ethnic minoritized youth) to enroll in the Kids FACE FEARS trial, a multisite comparative effectiveness trial of therapist-led vs. self-administered treatment for elevated youth anxiety. Confirmatory factor analysis (CFA) examined factor structure; omega coefficients and regression models examined internal consistency, convergent validity, and cross-informant reliability. CFA supported adjusted single-factor solutions across youth and caregiver reports, and internal consistency was high. Convergent validity was supported by medium-to-large associations with anxiety-related impairment and severity. Moderate cross-informant reliability between reports was found. Results showcase the first psychometric study of the PROMIS Anxiety scale short forms among treatment-engaged youth with elevated anxiety. Findings highlight the PROMIS Anxiety scale's utility in typical care settings for youth anxiety.

Long-Term Trends in Psychiatric Emergency Services Delivered by the Boston Emergency Services Team

Rising psychiatric emergency department (ED) presentations pose significant financial and administrative burdens to hospitals. Alternative psychiatric emergency services programs have the potential to alleviate this strain by diverting non-emergent mental health issues from EDs. This study explores one such program, the Boston Emergency Services Team (BEST), a multi-channel psychiatric emergency services provider intended for the publicly insured and uninsured population. BEST provides evaluation and treatment for psychiatric crises through specialized psychiatric EDs, a 24/7 hotline, psychiatric urgent care centers, and mobile crisis units. This retrospective review examines the sociodemographic and clinical characteristics of 225,198 BEST encounters (2005-2016). Of note, the proportion of encounters taking place in ED settings decreased significantly from 70 to 58% across the study period. Findings suggest that multi-focal, psychiatric emergency programs like BEST have the potential to reduce the burden of emergency mental health presentations and improve patient diversion to appropriate psychiatric care.

A qualitative analysis of barriers to opioid agonist treatment for racial/ethnic minoritized populations

INTRODUCTION

Clinical guidelines strongly recommend opioid agonist treatment (OAT) as first-line treatment for opioid use disorder (OUD). However, racial/ethnic minoritized patients are less likely to receive OAT compared to non-Hispanic White patients. Reasons for this treatment gap must be elucidated to address racial/ethnic disparities in OAT. Our objective is to evaluate perceptions of and barriers to OAT across racial/ethnic groups in individuals with OUD (not on OAT).

METHODS

This qualitative study used semi-structured telephone interviews of adult patients (n = 41) with OUD (not currently being treated with OAT) from the Boston area from September 2020 through February 2021. We developed a codebook through author consensus based on review of themes in initial transcripts. We performed qualitative thematic analysis of the transcripts. We evaluated patients' perceptions of treatment for OUD across the study population and analyzed differences and similarities in perceptions between racial and ethnic groups.

RESULTS

Across all racial/ethnic categories in our sample, anticipated stigma was the most frequently reported barrier to OAT and most patients preferred non-OAT methods for treatment. Non-Hispanic White participants had more favorable opinions of OAT compared to racial/ethnic minoritized participants. Racial/ethnic minoritized participants reported social support as the main facilitator to addiction treatment, while non-Hispanic White participants reported self-motivation as the most important factor. Racial/ethnic minoritized participants preferred treatment for OUD via non-OAT treatments and their second most preferred option was residential treatment. Non-Hispanic White participants preferred naltrexone and their second most preferred option was non-OAT treatments.

CONCLUSIONS

Racial/ethnic minoritized patients' preference for residential treatment and social support, along with their distrust of OAT, illustrates a desire for psychosocial and peer recovery-based care that addresses social determinants of health. Addiction specialists may improve engagement with and treatment of racial/ethnic minoritized groups with culturally tailored interventions for OUD that offer psychosocial treatment in combination with OAT, and by partnering with organizations with strong ties to racial/ethnic minoritized communities. This kind of response would reflect the structural and cultural humility that is needed to adequately address the OUD needs of these underserved populations.

"Shelter is Stressing Me Out": Challenges Meeting Health Care Needs of Older Adults in Congregate Shelters

Older adults experiencing homelessness are a growing population with high rates of medical, psychiatric, and substance use-related health conditions. This mixed-methods study sampled older adults experiencing homelessness admitted to an academic safety-net hospital. We analyzed chart review data on the cohorts' medical and psychiatric conditions and their health care utilization. Qualitative interviews examined the impact of the congregate shelter environment on health. The sixteen participants with experiences living in a shelter had high rates of depression (56%), alcohol use disorder (52%) and hypertension (39%). Annually, participants averaged 2.8 hospitalizations and 8.5 emergency department visits. Forty-four percent (44%) of participants were discharged from hospital to shelter. Qualitative interviews linked living in congregate shelters to challenges meeting daily physical and psychological needs and barriers to medical system engagement. Our study highlights the complex health and psychological needs of this population, and challenges meeting those needs across congregate shelters and acute hospital settings.

"If he doesn't buy in, it's a waste of time": Perspectives from diverse parents and adolescents on engaging children in ADHD treatment

Engaging children and adolescents in ADHD care is critical for future independent disease management. However, there is a lack of evidence guiding health professionals and parents on how best to engage their children and adolescents in ADHD care. We recruited 41 diverse parents of children and adolescents with ADHD and 11 adolescents with ADHD from an urban, safety-net hospital to participate in in-depth, semi-structured qualitative interviews and then analyzed this data using thematic analysis. Children's level of illness insight about ADHD and self-esteem emerged as two major contributors to engagement of children and adolescents in ADHD care, and their intersection created four styles of engagement: proactive (high insight, high self-esteem), anxious (high insight, low self-esteem), apathetic (low insight, high self-esteem), and resistant (low insight, low self-esteem). This framework can help health professionals engage children and adolescents in care for ADHD and guide development of interventions to improve engagement in care.

A qualitative analysis of psychosocial stressors and health impacts of the COVID-19 pandemic on frontline healthcare personnel in the United States

There is a dearth of qualitative studies exploring the lived experiences of frontline healthcare personnel (HCP) during the coronavirus disease (COVID-19) pandemic. We examined workplace stressors, psychological manifestations of said stressors, and coping strategies reported through coded open-text responses from 1024 online surveys completed over two months by 923 HCP participating in three nationwide cohorts from Spring 2020. Our findings suggest that risk, job insecurity, frustration with hospital administration, inadequate access to personal protective equipment, and witnessing patient suffering and death contributed to deteriorating mental and physical health. Negative health impacts included the onset or exacerbation of anxiety, depression, and somatic symptoms, including weight fluctuation, fatigue, and migraines. Coping mechanisms included substance use and food consumption, meditation and wellness, fitness, socializing with loved ones, and religious activities. Insights garnered from participants' responses will enable more personalized and effective psychosocial crisis prevention and intervention for frontline HCP in future health crises.

Orphans in post-conflict Liberia: Seeking care in fractured communities

Orphans in post-conflict settings have unique needs that have not been well-characterized. In post-conflict Liberia, maternal orphans are more likely to be without care than paternal orphans. This study examined the experiences of maternal orphans in Liberia, as they attempted to care for themselves and seek care from others, and the barriers they faced. In-depth interviews were conducted with 75 post-conflict Liberian orphans. We performed a secondary narrative analysis of interview transcripts from all maternal or double orphans (n = 17). We identified similar elements across narratives: traumatic loss, disconnection from family and community, and the desire for a savior. Female high-risk orphans were more likely to have formal substitute caregiving arrangements in which they were living with someone who was a relative or had been selected by a relative. Male orphans more commonly lacked arranged substitute care, but this allowed them to form relationships with substitute caregivers of their choosing. Sex also played a role in the provision of caregiving; substitute care was provided by women. Findings highlighted the syndemic relationship between poverty, violence, transactional sex, trauma, and substance use that traps high-risk Liberian orphans. Interventions are needed to improve access to mental health care, sober communities, housing, and education support. The need to integrate these services into indigenous institutions and address barriers related to stigma is explored.

The measurement of war-related trauma amongst internally displaced men and women in South Sudan: Psychometric analysis of the Harvard Trauma Questionnaire

BACKGROUND

Studies from armed conflict settings, including South Sudan, have revealed the deleterious mental health impact of exposure to war atrocities. However, there is little consensus on what is meant by war trauma, how it should be measured, and how levels of trauma vary across men and women.

METHODS

We used psychometric analyses to measure war trauma among 1178 internally displaced adults (mean age = 39 years, 50% women) in the Malakal region of South Sudan. We used cross-sectional survey data and applied classical test theory, factor analysis, item response theory, and differential item functioning with the war events subscale (17 items) of the Harvard Trauma Questionnaire (HTQ).

RESULTS

We found good validity and internal consistency reliability for the HTQ. We found evidence for unidimensionality using factor analyses, and item response theory models showed that some war events (like witnessing the killing of family or friends) were more sensitive to the underlying 'war-related trauma' trait than others (like abduction). Differential item functioning analyses revealed that the measure performed differently for men and women, indicating the need for sex-stratified analysis in the measurement of trauma.

LIMITATIONS

The use of self-report may lead to recall and response bias, and the study sample may not be representative of the broader population in South Sudan.

CONCLUSION

This study emphasizes the need for cultural adaptation and psychometric evaluation of commonly used measurement instruments, especially in humanitarian settings where survey data are used to set priorities for mental health and psychosocial support services.

"Making Room": A Thematic Analysis Study of the Process of Postpartum Maternal Adjustment

OBJECTIVES

Mothers are especially vulnerable to the onset or recurrence of psychological symptoms during the postpartum period. However, protective psychosocial factors may provide a stress buffering effect and promote a positive adjustment trajectory. Previous research has demonstrated the importance of positive maternal adjustment for maternal mental health and child outcome. However, research is needed that explores (1) the psychosocial components of maternal adjustment, (2) the process of maternal adjustment as subjectively experienced by mothers, and (3) clinical targets that can help postpartum healthcare teams to facilitate positive adjustment during the perinatal period.

METHODS

This qualitative study utilized thematic analysis in order to understand the dimensions and properties of themes related to maternal adjustment. Through narrative interviews, this study investigated processes associated with maternal adjustment in a sample of n = 23 mothers receiving obstetric care.

RESULTS

Thematic analysis uncovered three key developmental processes: (1) "Stretching Identity; Transitioning Roles", (2) "Navigating Stressors; Approaching Self-Efficacy", and (3) "Changing Relationships; Strengthening Support." Negative maternal self-attributions emerged as a key target for supportive intervention. Each process is complex and susceptible to both downward and upward spirals, consistent with the broaden-and-build theory of positive emotion.

CONCLUSIONS FOR PRACTICE

Negative maternal attributions of self are discussed as a key target precipitating postpartum adjustment trajectories. Given this, parenting interventions that teach cognitive reappraisal or mindfulness strategies may be especially beneficial for mothers in the perinatal period.

Former Inpatient Psychiatric Patients' Past Experiences With Traditional Frontline Staff and Their Thoughts on the Benefits of Peers as Part of Frontline Staff

Little is known about how integrating peers into frontline staff might improve the quality of inpatient psychiatric care. In the current study, we interviewed 18 former adult patients of inpatient psychiatric facilities using semi-structured interviews. We first asked about positive and negative past experiences with traditional staff. We then asked participants to share their opinions on the potential benefits of peers as part of frontline staff. We identified themes through a joint inductive and deductive approach. Participants reported past positive experiences with traditional staff as being (a) personable and caring, (b) validating feelings and experiences, (c) de-escalating, and (d) providing agency. Past negative experiences included (a) not sharing information, (b) being inattentive, (c) not providing agency, (d) being dehumanizing/disrespectful, (e) incompetency, (f) escalating situations, and (g) being apathetic. Participants believed that peers as part of frontline staff could champion emotional needs in humanizing and nonjudgmental ways, help navigate the system, and disrupt power imbalances between staff and patients. Further research is needed to understand financial, organizational, and cultural barriers to integrating peers into frontline staff. [Journal of Psychosocial Nursing and Mental Health Services, 60(3), 15-22.].

A Systematic Review of Interventions That Integrate Perinatal Mental Health Care Into Routine Maternal Care in Low- and Middle-Income Countries

BACKGROUND

Women in low- and middle-income countries (LMICs) are disproportionally affected by perinatal depression and anxiety and lack access to mental health care. Integrating perinatal mental health care into routine maternal care is recommended to address gaps in access to mental health care in such under-resourced settings. Understanding the effectiveness of interventions that integrate perinatal mental health care into routine maternal care in LMICs is critical to inform ongoing intervention development, implementation, and scale-up. This systematic review aims to assess the effectiveness of interventions that integrate perinatal mental health care into routine maternal care to improve maternal mental health and infant health outcomes in LMICs.

METHOD

In accordance with the PRISMA guidelines, an electronic database search was conducted seeking publications of controlled trials examining interventions that aimed to integrate perinatal mental health care into routine maternal care in LMICs. Abstracts and full text articles were independently reviewed by two authors for inclusion utilizing Covidence Review Software. Data was extracted and narrative synthesis was conducted.

FINDINGS

Twenty studies met eligibility criteria from the initial search results of 2,382 unique citations. There was substantial heterogeneity between the study samples, intervention designs, and outcome assessments. Less than half of the studies focused on women with active depression or anxiety. Most studies (85%) implemented single intervention designs involving psychological, psychosocial, psychoeducational, or adjuvant emotion/stress management. There were few interventions utilizing multicomponent approaches, pharmacotherapy, or referral to mental health specialists. Outcome measures and assessment timing were highly variable. Eighteen studies demonstrated significantly greater improvement on depression and/or anxiety measures in the intervention group(s) as compared to control.

CONCLUSION

Integrated interventions can be effective in LMICs. The findings provide a critical understanding of current interventions design gaps. This includes the lack of comprehensive intervention designs that incorporate increasing intensity of treatment for more severe illness, pharmacotherapy, mental health specialist referrals, and non-mental health professional training and supervision. The findings also provide strategies to overcome design and implementation barriers in LMICs. Study findings provide a foundation for future evidence-based adaptation, implementation, and scale-up of interventions that integrate perinatal mental health care into routine maternal care in LMICs.

SYSTEMATIC REVIEW REGISTRATION

[https://www.crd.york.ac.uk/prospero/display_ record.php?ID=CRD42021259092], identifier [CRD42021259092].

Prevalence of metabolic syndrome among patients with schizophrenia in Ethiopia

BACKGROUND

Globally, the prevalence of metabolic syndrome (MetS) is higher among patients with schizophrenia than the general population, and this leads to higher morbidity and mortality in this population. The aim of this study was to investigate the MetS prevalence among patients with schizophrenia in Ethiopia.

METHODS

We conducted a cross-sectional analysis of baseline data of 200 patients with schizophrenia recruited from Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia. Lipid profile and blood glucose levels were measured using Roche Cobas 6000 clinical chemistry analyzer. The prevalence of MetS was assessed based on National Cholesterol Education Program Adult Treatment Panel III criteria. Patients' demographic information, clinical and laboratory data, lifestyle habits, particularly smoking and Khat chewing, were evaluated vis-à-vis MetS.

RESULTS

The overall prevalence of MetS in patients with schizophrenia was 21.5% (17.1% male, 29.6% female) where Low HDL-cholesterol value was the most common metabolic disorders components in both males and females subgroups. In the multivariate analysis, the positive and negative symptoms score (PANSS, AOR = 1.03, 95% CI 1.001-1.054) was associated factors with MetS.

CONCLUSION

In Ethiopia, patients with schizophrenia were found to have higher prevalence of MetS than the general population. Physicians/health care providers should routinely screen patients with schizophrenia for MetS and initiate timely management of those who develop the syndrome to reduce the health cost from caring for NCDs, improve the patients' quality of life, and prevent premature mortality.

"How can I hug someone now [over the phone]?": Impacts of COVID-19 on peer recovery specialists and clients in substance use treatment

Introduction

The COVID-19 pandemic has disproportionately affected underserved, low-income, ethnoracial minority communities, as well as those with substance use disorders (SUDs). The workforce of peer recovery specialists (PRSs), individuals with lived substance use and recovery experience, has rapidly expanded in response to a shortage of access to substance use treatment, particularly for those from underserved communities. As PRSs are likely serving individuals disproportionately affected by the pandemic, it is important to understand how COVID-19 has affected the PRS role and the individuals with SUD who they are supporting.

Method

This study aimed to examine: (1) the impact of COVID-19 on the PRS role and experience, (2) the impact of COVID-19 on clients in or seeking SUD treatment, (3) facilitators for clients engaging in treatment and adapting to new changes, and (4) sustainability of new treatment methods post-pandemic.

Results

Findings suggest that PRSs have had to adapt their role and responsibilities to meet changing client needs; however, PRS strengths, such as their shared experience and expertise navigating treatment barriers, make them uniquely suited to assist clients during the pandemic. The study identified various barriers and facilitators to clients seeking treatment or living with SUD, such as the loss of interpersonal connection. PRSs also identified some drawbacks to utilizing telehealth, but identified this as a potentially sustainable approach to delivering care after the pandemic.

Conclusion

Future research could explore how challenges to fulfilling the PRS role, as well as adaptations to overcome these challenges, have changed over time.

Program sustainability post PEPFAR direct service support in the Western Cape, South Africa

BACKGROUND

Public health practitioners have little guidance around how to plan for the sustainability of donor sponsored programs after the donor withdraws. The literature is broad and provides no consensus on a definition of sustainability. This study used a mixed-methods methodology to assess program sustainability factors to inform donor-funded programs.

METHODS

This study examined 61 health facilities in the Western Cape, South Africa, supported by four PEPFAR-funded non-governmental organizations from 2007 to 2012. Retention in care (RIC) was used to determine health facility performance. Sustainability was measured by comparing RIC during PEPFAR direct service (20072012), to RIC in the post PEPFAR period (2013 to 2015). Forty-three semi-structured in-depth interviews were conducted with key informants. The qualitative data were used to examine how predictor variables were operationalized at a health facility and NGO level.

RESULTS

Our qualitative results suggest the following lessons for the sustainability of future programs: Sufficient and stable resources (i.e., financial, human resources, technical expertise, equipment, physical space)Investment in organizations that understand the local context and have strong relationships with local government.Strong leadership at a health facility levelJoint planning/coordination and formalized skill transferLocal positive perceived value of the programPartnerships.

CONCLUSION

Sustainability is complex, context dependent, and is reliant on various processes and outcomes. This study suggests additional health facility and community level staff should be employed in the health system to ensure RIC sustainability. Sustainability requires joint donor coordination with experienced local organizations with strong managers before during and after program implementation. If the program is as large as the South African HIV effort some dedicated additional resources in the long term would be required.

Perceived major experiences of discrimination, ethnic group, and risk of psychosis in a six-country case-control study

BACKGROUND

Perceived discrimination is associated with worse mental health. Few studies have assessed whether perceived discrimination (i) is associated with the risk of psychotic disorders and (ii) contributes to an increased risk among minority ethnic groups relative to the ethnic majority.

METHODS

We used data from the European Network of National Schizophrenia Networks Studying Gene-Environment Interactions Work Package 2, a population-based case-control study of incident psychotic disorders in 17 catchment sites across six countries. We calculated odds ratios (OR) and 95% confidence intervals (95% CI) for the associations between perceived discrimination and psychosis using mixed-effects logistic regression models. We used stratified and mediation analyses to explore differences for minority ethnic groups.

RESULTS

Reporting any perceived experience of major discrimination (e.g. unfair treatment by police, not getting hired) was higher in cases than controls (41.8% v. 34.2%). Pervasive experiences of discrimination (≥3 types) were also higher in cases than controls (11.3% v. 5.5%). In fully adjusted models, the odds of psychosis were 1.20 (95% CI 0.91-1.59) for any discrimination and 1.79 (95% CI 1.19-1.59) for pervasive discrimination compared with no discrimination. In stratified analyses, the magnitude of association for pervasive experiences of discrimination appeared stronger for minority ethnic groups (OR = 1.73, 95% CI 1.12-2.68) than the ethnic majority (OR = 1.42, 95% CI 0.65-3.10). In exploratory mediation analysis, pervasive discrimination minimally explained excess risk among minority ethnic groups (5.1%).

CONCLUSIONS

Pervasive experiences of discrimination are associated with slightly increased odds of psychotic disorders and may minimally help explain excess risk for minority ethnic groups.

Relationship between quality of life and social integration among patients with schizophrenia attending a Nigerian tertiary hospital

BACKGROUND

Despite decades of de-institutionalization and the best efforts of community mental health services, individuals with schizophrenia living outside the hospital may be described as in the community but not of the community, and remain in a very real sense socially excluded.

AIM AND OBJECTIVES

To determine the relationship between social integration and quality of life among patients with schizophrenia attending the outpatient clinic of the Neuropsychiatric Hospital Abeokuta in Nigeria.

METHODS

One hundred and fifty-one patients were recruited. Sociodemographic questionnaire, MINI-PLUS, WHOQOL-BREF, Social Integration Scale and PANSS were administered. Multivariable regression analyses were performed to identify the determinants of quality of life and the relationship with social integration.

RESULTS

The mean (± SD) age of the respondents was 40.00 (± 10.23), 56.3% were males, 37.1% were single. Independent predictors of lower quality of life were: (1) more severe psychopathology for the domains of general health (p = 0.003), social relationship (p = 0.019) and environment (p = 0.008); (2) longer duration of illness for the social relationship (p = 0.028) and environment (p = 0.015) domains; and (3) negative symptoms (p = 0.034) for the physical domain.

CONCLUSION

There is a need to pay closer attention to social outcome measures such as quality of life and level of social integration among patients with schizophrenia who come in contact with psychiatry services, and not just on symptom remission only.

Mixed-methods evaluation of family medicine research training and peer mentorship in Lesotho

Background

Strengthening primary care research capacity is a priority globally. Family medicine training programmes in sub-Saharan Africa represent an important opportunity to build primary care research; however, they are often limited by insufficient research training and mentorship. Peers can be used to extend research mentorship capacity, but have not been evaluated in this context.

Aim

The aim of this study was to evaluate one family medicine training programme’s research capacity building efforts through a blended research curriculum and peer mentorship.

Setting

Lesotho is a landlocked country within South Africa of approximately two million people. The Family Medicine Specialty Training Programme (FMSTP) is the only accredited postgraduate medical education programme in Lesotho.

Methods

This two-year mixed-methods evaluation used: (1) Likert-scale surveys measuring trainee research confidence, (2) written evaluations by trainees, peers, programme faculty and administrators and (3) in-depth, semi-structured interviews. Survey data were analysed using Friedman and sign tests. Interview and written data were analysed thematically via a mixed inductive-deductive approach using Cooke’s framework.

Results

Family Medicine Specialty Training Programme trainees (n = 8) experienced moderate increases in research confidence that were statistically significant. Skill-building occurred primarily via experiential learning. Research was grounded in trainees’ clinical practice and locally relevant. A positive research culture was created, promising for sustainability. We identified infrastructure gaps, including funding and protected time. Peer research mentorship supported trainees’ motivation and provided a safe space for questions.

Conclusion

The FMSTP research curriculum and peer mentorship programme were successful in positively impacting a number of Cooke’s research capacity domains. This evaluation identified improvements that are now being implemented.

Establishing reliability and validity for mental health screening instruments in resource-constrained settings: Systematic review of the PHQ-9 and key recommendations

Mental illness is one of the largest contributors to the global disease burden. The importance of valid and reliable mental health measures is crucial in order to accurately measure said burden, to capture symptom improvement, and to ensure that symptoms are appropriately identified and quantified. This is of particular importance in low and middle-income countries (LMICs), where the burden of mental illness is relatively high, and there is heterogeneity in linguistic, racial, and ethnic groups. Using the PHQ-9 as an illustrative example, this systematic review aims to provide an overview of existing work and highlight common validation and reporting practices. A systematic review of published literature validating the use of the PHQ-9 in LMICs as indexed in the PubMed and PsychInfo databases was conducted. The review included n = 49 articles (reduced from n = 2,349). This manuscript summarizes these results in terms of the frequency of reporting on important procedures and in regards to the types of reliability and validity measured. Then, building off of the existing literature, we provide key recommendations for measure validation in LMICs, which can be generalized for any type of measure used in a setting in which it was not initially developed.

Correlates of depression and quality of life among patients with epilepsy in Nigeria

OBJECTIVES

To determine the prevalence of Major Depressive Disorders (MDD) and its relationship to Quality of life.

DESIGN

A cross-sectional observational study.

SETTING

Out-Patient Clinic of the Neuropsychiatric Hospital, Abeokuta, Nigeria.

SUBJECTS

Patients with diagnosis of Epilepsy with Electroencephalogram (EEG) confirmation.

OUTCOME MEASURES

Depression and Quality of life.

RESULTS

The prevalence of current MDD was 11.9 %, and patients having at least 1 seizure per week were 5 times more likely to develop MDD (OR = 5.104, p = 0.014). The mean (SD) QOLIE-31 scores was 77.98 (13.32), with presence of MDD (β = -11.101, p = 0.0001); having at least 1 seizure/week (β = -6.653, p = 0.037) being independent predictors.

CONCLUSION

Depression is a common comorbidity in patients with epilepsy and is associated with a lower quality of life.

The HEAAL Project: Applying Community-Based Participatory Research (CBPR) Methodology in a Health and Mental Health Needs Assessment With an African Immigrant and Refugee Faith Community in Lowell, Massachusetts

Community-based participatory research methodology is driven by community interests and rooted in community involvement throughout the research process. This article describes the use of community-based participatory research methodology in the HEAAL project (Health and Mental Health Education and Awareness for Africans in Lowell), a research collaboration between Christ Jubilee International Ministries-a nondenominational Christian church in Lowell, Massachusetts, that serves an African immigrant and refugee congregation-and the Massachusetts General Hospital Department of Psychiatry. The objective of the HEAAL project was to better understand the nature, characteristics, scope, and magnitude of health and mental health issues in this faith community. The experience of using community-based participatory research in the HEAAL project has implications for research practice and policy as it ensured that research questions were relevant and meaningful to the community; facilitated successful recruitment and navigation through challenges; and can expedite the translation of data to practice and improved care.

Risk factors for readmission among a cohort of psychiatric inpatients in Lilongwe, Malawi

Objectives: Inpatient psychiatric capacity is limited in Malawi and no published studies have assessed psychiatric readmissions there. Information about factors associated with readmission may help guide strategies to reduce readmission rates and keep patients stabilised in the community. Our goal was to determine factors associated with readmission among a cohort of psychiatric inpatients in Lilongwe, Malawi.Methods: We conducted a retrospective chart review of all patients admitted to an inpatient psychiatric unit in Lilongwe, Malawi from January 1 to December 31, 2011. We used logistic regression to test for associations between readmissions during the study period and patient variables.Results: 419 patients were hospitalised during the study period. Twenty-nine patients (6.9%) were readmitted at least once during the study period. Readmission was associated only with intentional medication non-adherence at home (aOR: 3.33, p = 0.02).Conclusions: Intentional medication non-adherence is a potentially modifiable behaviour associated with psychiatric readmission. Efforts to improve medication adherence among patients following hospital discharge may help decrease the risk of readmission.KEY POINTSThe prevalence of readmission among psychiatric inpatients in Lilongwe, Malawi was 6.9% during the 1-year study period.Readmission was associated with intentional medication non-adherence at home.Future research efforts in Malawi should focus on improving medication adherence among psychiatric patients in the community to help decrease rates of readmission.

Training needs among nonmental health professionals working with service members: A qualitative investigation

Though many service members will not directly seek mental health care due to stigma and other factors, they may interact with the healthcare system in other ways including contact with first responders, nurses and allied health care professionals. However, little attention has been spent in this regard on the educational needs of these professionals whose contact with service members and veterans may provide the opportunity to assist veterans in need with overcoming barriers to accessing mental health care. This qualitative study investigates the educational training needs of first responders and health care professionals in contact with military families and trauma survivors to determine whether, and what type, of additional training is needed. A sample of 42 first responders and health care professionals including emergency medical technicians, police officers, fire fighters, speech language pathologists, occupational therapists, physical therapists, and nurses, were recruited to participate in one of six focus groups. Sessions were audio-taped and transcribed verbatim. Data analysis was guided by a thematic analysis approach. Thematic analyses suggest there is a significant knowledge gap with unmet educational needs of these professionals such as information on the invisible wounds of war, military culture, and screening and referring patients who present symptoms falling outside professionals' scope of practice. Findings point to a need and desire for more robust education for first responders and health care providers around mental health concerns of military populations, including topics such as trauma, military culture, and screening tools. Efforts to develop curricula addressing these concerns are warranted.

Facilitators of and barriers to high-resolution anoscopy adherence among men who have sex with men: a qualitative study

Background Anal cancer is a rare malignancy that disproportionately affects men who have sex with men (MSM) and HIV-infected people. Anal cancer is associated with human papillomavirus (HPV) in upward of 90% of cases and is preceded by pre-cancerous changes in cells of the anal canal. High-resolution anoscopy (HRA) is used for the detection, treatment and continued monitoring of anal dysplasia. Practice guidelines regarding anal cancer prevention vary by jurisdiction and institution, and patient engagement is low for high-risk populations such as MSM. The purpose of this study is to characterise perceptions among MSM of barriers to and facilitators of their adherence to HRA follow-up recommendations.

METHODS

Surveys and in-person focus groups with MSM who were either adherent or non-adherent to HRA follow-up recommendations at a Federally Qualified Health Centre in Boston, MA, which specialises in sexual and gender minority care, were conducted. Facilitators of and barriers to follow-up were identified by deductive content analysis.

RESULTS

Focus group participants identified the following barriers to and facilitators of HRA follow up: (1) patient-level beliefs about HPV-related disease or HRA, ability to engage in care, internalised stigma and physical discomfort; (2) provider-level knowledge and expertise, communication skills and relationship-building with patient; and (3) systems-level societal stigma and healthcare system inefficiencies.

CONCLUSIONS

Reinforcing facilitators of and reducing barriers to HRA follow up may improve adherence among MSM. This includes improvements to: patient education, provider training to increase knowledge and cultural sensitivity, public awareness about HPV-related anal cancer, physical discomfort associated with HRA and systems inefficiencies.

"He can send her to her parents": The interaction between marriageability, gender and serious mental illness in rural Ethiopia

BACKGROUND

For women in most low- and middle-income countries, the diagnosis with serious mental illness (SMI) leads to stigma and challenges related to starting or maintaining marriages. The purpose of this qualitative study was to explore perspectives on marriage, divorce and family roles of women with SMI in rural Ethiopia.

METHODS

A qualitative study was conducted in a rural setting of Butajira, South Central Ethiopia. A total of 39 in-depth interviews were carried out with service users (n = 11), caregivers (n = 12), religious leaders (n = 6), health extension workers (n = 4), police officers (n = 2), teachers (n = 2) and government officials (n = 2). Data were analyzed using a thematic approach.

RESULTS

Three themes emerged. (1) Marriage and SMI: Chances of getting married for individuals with SMI in general was perceived to be lower: Individuals with SMI experienced various challenges including difficulty finding romantic partner, starting family and getting into a long-term relationship due to perceived dangerousness and the widespread stigma of mental illness. (2) Gendered experiences of marriageability: Compared to men, women with SMI experienced disproportionate levels of stigma which often continued after recovery. SMI affects marriageability for men with SMI, but mens' chances of finding a marital partner increases following treatment. For women in particular, impaired functioning negatively affects marriageability as ability to cook, care and clean was taken as the measure of suitability. (3) Acceptability of divorce and separation from a partner with SMI: Divorce or separation from a partner with SMI was considered mostly acceptable for men while women were mostly expected to stay married and care for a partner with SMI. For men, the transition from provider to dependent was often acceptable. However, women who fail to execute their domestic roles successfully were considered inept and would be sent back to their family of origin.

CONCLUSION

Women with SMI or those married to partners with SMI are at greater disadvantage. Reducing vulnerabilities through stigma reduction efforts such as community outreach and mental health awareness raising programs might contribute for better social outcomes for women with SMI.

Gender-specific experiences of serious mental illness in rural Ethiopia: A qualitative study

Considerable variation in the gender-specific prevalence of serious mental illness (SMI) has been reported in low- and middle-income countries (LMICs). In the rural setting of Butajira, Ethiopia, the male-to-female prevalence ratio of schizophrenia was reported to be 5:1. This qualitative study explores gender-specific experiences of SMI and the extent to which sociocultural factors may explain the observed difference in prevalence estimates. Using purposive sampling, 39 in-depth interviews were conducted with community members from Butajira, a rural district in South Central Ethiopia. Transcripts were analysed using thematic analysis to elicit community perspectives on cultural explanatory models of SMI and experiences in this region. Gender-specific experiences were reported to differ due to visibility of symptoms, community responses, and varying levels of family support towards individuals with SMI. Overall, respondents described how various sociocultural factors subject women with SMI to higher levels of physical and social isolation compared to men, greatly affecting community health workers' ability to identify and provide care to women with mental illness. Future case detection methods should involve family members as they interact with women with SMI early on in the development of their symptoms and play an essential role in their path to mental health care.

Long-Term Retention in an Outpatient Behavioral Health Clinic With Buprenorphine

BACKGROUND AND OBJECTIVES

Despite high comorbidity between substance use disorders and other mental health diagnoses, there is a paucity of literature on buprenorphine treatment outcomes in outpatient mental health settings. This study aimed to identify rates and predictors of outpatient buprenorphine treatment retention in a Behavioral Health Clinic (BHC).

METHODS

This retrospective cohort study of adults on buprenorphine used multiple logistic regression to identify clinical and demographic factors associated with 1- and 2-year treatment retention and buprenorphine adherence.

RESULTS

Of 321 subjects, 169 (52.6%) were retained in treatment for at least 1 year; 114 (35.5%) were retained for 2 years or more. Buprenorphine adherence was 95.8% and 97.3% for 1- and 2-year retention groups, respectively. Predictors of 1-year retention included benzodiazepine co-prescription (adjusted odds ratio [AOR] = 2.4; 95% CI [1.30, 4.55]), having a diagnosis of other mood disorder (AOR = 3.4; [1.95, 5.98]), or nicotine use disorder (AOR = 2.4; [1.35, 4.27]). Predictors of 2-year retention included female gender (AOR = 2.1; [1.16, 3.73]), having a diagnosis of depressive disorder (AOR = 4.6; [1.49, 14.29]), other mood disorder (AOR = 3.6; [1.88, 6.88]), or nicotine use disorder (AOR = 2.0; [1.13, 3.52]).

DISCUSSION AND CONCLUSION

During the study period, 52.7% and 35.5% of BHC patients treated with buprenorphine were retained for 1 and 2 years, respectively, comparable to the studies performed within primary care. Providing buprenorphine treatment within mental health clinics may serve patients who are already engaged with mental health providers but are reluctant to start new treatment within another treatment setting.

SCIENTIFIC SIGNIFICANCE

Identifying common predictors of retention can help determine which patients require additional substance use treatment support. (Am J Addict 2019;28:339-346).

Factors associated with long length of stay in an inpatient psychiatric unit in Lilongwe, Malawi

PURPOSE

Studies of factors affecting length of stay during psychiatric hospitalization in sub-Saharan Africa are sparse. A better understanding of such factors may lead to interventions resulting in quicker patient stabilization and discharge, freeing up needed psychiatric beds and reducing health care system expenditures. Therefore, we sought to identify factors associated with long length of stay in Malawi.

METHODS

We reviewed the charts of 417 patients hospitalized at Kamuzu Central Hospital's Bwaila Psychiatric Unit in Lilongwe, Malawi from January 1 to December 31, 2011. Multivariate logistic regression analysis was employed to test for associations between patient factors and long length of stay (defined as more than 28 days).

RESULTS

Mean length of stay was 22.08 ± 27.70 days (range 0-243). 21.82% (91/417) of patients stayed longer than 28 days. Long length of stay was associated with living outside of Lilongwe district [aOR: 3.65 (1.66-8.01), p = 0.001] and treatment for antipsychotic extrapyramidal side effects (EPS) during hospitalization [aOR: 3.45 (1.32-9.03), p = 0.012]. Patients who had more interactions with medical providers for this episode of illness prior to presentation at the unit were less likely to have a long length of stay [aOR: 0.35 (0.16-0.76), p = 0.008].

CONCLUSIONS

Our findings demonstrate areas of possible intervention to reduce length of stay, including securing means for patient transport home, rapid identification and treatment of EPS, and reducing the risk of EPS by decreased use of high potency first-generation antipsychotics.

A Qualitative Analysis of Stress and Relaxation Themes Contributing to Burnout in First-Year Psychiatry and Medicine Residents

OBJECTIVE

Qualitative research on trainee well-being can add nuance to the understanding of propagators of burnout, and the role for interventions aimed at supporting well-being. This qualitative study was conducted to identify (i) situations and environments that cause stress for trainees, (ii) stress-reducing activities that trainees utilize, and (iii) whether trainees who report distress (high burnout and depression scores) describe different stressors and relaxation factors than those who do not.

METHODS

The study was conducted with a convenience sample of first-year medicine and psychiatry residents at a large urban teaching hospital. Participants were asked to complete electronic stress and relaxation diaries daily for 1 week. Diary entries were coded for recurrent themes. Participants were screened for burnout and depression. Codes were compared by subgroup based on baseline burnout and depression status to elucidate if specific themes emerged in these subgroups.

RESULTS

Study sample included 51 interns. Sixteen (16/50, 32%) screened positive for burnout and three (3/50, 14%) had a positive depression screen. The most common stressors related to aspects of the learning environment, compounded by feeling under-equipped, overwhelmed, or out of time. The majority of relaxation activities involved social connection, food, other comforts, and occurred outside of the hospital environment.

CONCLUSIONS

This study reveals that interns (regardless of burnout or depression screen) identify stressors that derive primarily from organizational, interpersonal, and cultural experiences of the learning environment; whereas relaxation themes are diversely represented across realms (home, leisure, social, health), though emphasize activities that occur outside of the work place.

Three-dose HPV vaccine completion among sexual and gender minority young adults at a Boston community health center

BACKGROUND

Disparities in human papillomavirus (HPV) vaccination completion have been noted among sexual and gender minority (SGM) people. Little is known about factors associated with HPV vaccination among SGM people. This study examines factors linked with completion of HPV vaccination among SGM patients.

METHODS

We collected cross-sectional data from electronic health records (EHRs) of SGM patients receiving primary care at a Boston community health center specialized in SGM health. We employed a binomial logistic regression model to identify factors associated with 3-dose HPV vaccine completion.

RESULTS

Patients were 70.3% white, with mean age of 26.3 years (SD = 2.48), 26.9% identifying as gender minorities and 79% as sexual minorities, 48.9% with 4-year college or graduate degrees, 59.4% employed, 65.9% with private insurance, 39.1% living at or below the federal poverty level, and 8.3% living with HIV. Seventy-seven percent of patients who were offered HPV vaccination had completed the series. Factors significantly associated with HPV vaccine completion included: 4-year college or graduate degree (OR: 2.87; 95% CI = 1.26-6.53), completion of primary care appointments (OR: 1.03; 95% CI: 1.01-1.05), Hepatitis A or B vaccine completion (OR: 2.59; 95% CI: 1.2-5.59), and visits for a sexually transmitted infection (STI) screen (OR: 1.22; 95% CI: 1.03-1.43).

CONCLUSION

Vaccine completion was higher among SGM with higher levels of education, Hepatitis A or B vaccination, and completed health visits. These findings highlight potential ways to increase HPV vaccination, such as offering tailored HPV vaccine education, bundling with other vaccines, and incorporating HPV vaccination with STI screenings.

Factors associated with anal cancer screening follow-up by high-resolution anoscopy

OBJECTIVES

High-resolution anoscopy (HRA) is a potential screening method for detection of anal cancer precursors. We evaluated factors associated with adherence to recommended HRA follow-up time intervals among men who have sex with men (MSM).

METHODS

We employed a retrospective, observational cohort study with 155 MSM screened by HRA between 1 April 2011 and 31 March 2016 at a Federally Qualified Health Centre in Boston, Massachusetts.

RESULTS

The sample was 80% white, with a median age of 48 (non-normal distribution, IQR 15). All patients were assigned male sex at birth and none identified as transgender. Fifty patients (32%) followed up with a HRA appointment within 6 months of previous HRA detection of anal high-grade squamous intraepithelial lesion (HSIL). Among patients, 112 (72%) were HIV infected, 56 (36%) had a syphilis diagnosis during the study period, 89 (57.4%) had initiated Hepatitis A or B vaccination series, 70 (45.2%) accessed case management services and 19 (12.3%) utilised pre-exposure prophylaxis (PrEP). In bivariate analysis, patients who underwent recommended follow-up HRA within 6 months of HSIL diagnosis were less likely to report: case management utilisation (p=0.023), initiation of Hepatitis A or B vaccination (p=0.047), HIV diagnosis (p<0.001) and syphilis diagnosis (p=0.001), but were more likely to use HIV PrEP (p<0.001). In binomial logistic regression modelling after adjusting for age and race/ethnicity, patients who had follow-up with HRA within a recommended period of 6 months after HSIL diagnosis were less likely to have initiated Hepatitis A or B vaccination (adjusted OR 0.43, 95% CI 0.20 to 0.94), more likely to use PrEP (adjusted OR 4.47, 95% CI 1.30 to 15.49) and less likely to have a syphilis diagnosis (adjusted OR 0.34, 95% CI 0.14 to 0.86).

CONCLUSIONS

Three-quarters of patients with HSIL did not have follow-up HRA within the clinic's recommended follow-up period of 6 months following HSIL diagnosis by HRA. Future studies ought to explore whether addressing anal health during other STI-related care helps improve adherence to recommended time intervals for follow-up HRA. Given the high prevalence of STI and PrEP use, studies might also evaluate whether integrating HRA follow-up with other sexual health screenings helps improve adherence to recommended HRA follow-up.

Facilitators of and barriers to HPV vaccination among sexual and gender minority patients at a Boston community health center

BACKGROUND

Young sexual minority individuals have lower human papillomavirus (HPV) vaccine completion rates than the general population, and little is known about how gender minority people perceive HPV vaccination. The aim of this study was to qualitatively identify patient-, provider-, and systems-level barriers and facilitators for HPV vaccination among sexual and gender minority (SGM) people.

METHODS

Fifteen SGM-identified individuals, ages 23-26, were recruited at an urban community health center in Boston, MA, that specializes in care for SGM. Participants were enrolled in a study that utilized surveys and in-person focus groups. During focus groups, participants were asked to describe their perceived barriers and facilitators for completion of HPV vaccination.

RESULTS

Fourteen participants reported having a sexual minority identity, and five participants reported having a gender minority identity. Participants described the following factors influencing HPV vaccination: (1) at the patient level, low HPV-related knowledge and lack of engagement in care were associated with less vaccination, whereas fear of HPV-related disease motivated vaccination; (2) at the provider level, knowledge and SGM cultural-competence related to HPV was associated with patient willingness to be vaccinated; (3) at the systems level, SGM identity-affirming healthcare settings were associated with increased vaccination, whereas historical trends in HPV vaccine marketing selectively for cisgender women and lack of public awareness of HPV-related disease among SGM were associated with decreased vaccincation.

CONCLUSION

Our study identified internal and external barriers for HPV vaccination related among SGM patients. These findings highlight the need to increase public awareness about the risks of HPV-related disease among SGM and educate SGM youth about HPV-related disease and vaccine importance. Finally, this study supports the need for future interventions to cultivate SGM-competent providers and SGM identity-affirming healthcare settings as a way to increase HPV vaccination.

Reflections from the Lebanese field: "First, heal thyself"

Humanitarian aid workers caring for Syrian refugees face major stressors as they attend to refugees’ needs on the field. Without adequate psychosocial support, evidence has shown that fieldworkers experience high burnout and turnover as well as long-term poor mental health. Unfortunately, scarce training in this regard leaves them ill-equipped to care for themselves and practice resilience while handling trauma in the field. This paper highlights our reflection on working with mindfulness programs during humanitarian crises, specifically how our program, Stress Management and Relaxation Response Training (SMART), has helped over time fieldworkers and the community they cared for. We propose that programs targeting the wellbeing of fieldworkers should be prioritized as part of efforts to improve the international aid response although they may require impeccable coordination and generous resources. We encourage donors to fund those projects viewed as special social protection programs building resilience and strengthening within system support. We argue that this will increase the efficacy of the crisis intervention and work towards sustainable peace building.

Closing the Mental Health Treatment Gap through the Collaboration of Traditional and Western Medicine in Liberia

Liberians have experienced significant psychological trauma following fourteen years of violent civil war and the 2014-2015 Ebola epidemic, but there are only two psychiatrists for the entire population. However, many traditional healers commonly treat mental health-related illnesses throughout the country. This paper examines the potential for collaboration between traditional and Western medicine to close the mental health treatment gap in Liberia. We conducted 35 semi-structured qualitative interviews with Liberian traditional healers and utilizers of traditional medicine asking questions about common health problems, treatments, beliefs, and personal preferences. Participants discussed cultural attitudes, beliefs, and structural factors that may influence collaboration between traditional and Western medicine. Healers expressed willingness to collaborate in order to strengthen their skills, though realized Western physicians were hesitant to collaborate. Additionally, Liberians believed in both medical traditions, though preferred Western medicine. Finally, structural factors such as geographic distance and financial barriers made traditional medicine more accessible than Western medicine. Traditional healers and utilizers support collaboration as evidenced by their perceptions of cultural attitudes, beliefs, and structural factors within the Liberian context. With Liberia's overwhelming mental illness burden, collaboration between traditional healers and Western medicine physicians offers a solution to the treatment gap in Liberian mental health care.

Needs assessment with elder Syrian refugees in Lebanon: Implications for services and interventions

Currently, over 1 million Syrian and Palestinian refugees have fled Syria to take refuge in Lebanon. Among this vulnerable population, elder refugees warrant particular concern, as they shoulder a host of additional health and safety issues that require additional resources. However, the specific needs of elder refugees are often overlooked, especially during times of crisis. Our study used a semi-structured interview to survey the needs of elder refugees and understand their perceived support from Lebanese fieldworkers. Results indicate a high prevalence of depression and cognitive deficits in elder refugees, who expressed concerns surrounding illness, loneliness, war, and instability. Elders highlighted the importance of family connectedness in fostering security and normalcy and in building resilience during times of conflict. Elders spoke of their role akin that of the social workers with whom they interacted, in that they acted as a source of emotional support for their communities. Overall, this study clarifies steps to be taken to increase well-being in elder refugee populations and urges the response of humanitarian organisations to strengthen psychological support structures within refugee encampments.

Humanitarian space and well-being: effectiveness of training on a psychosocial intervention for host community-refugee interaction

Social and fieldworkers face enormous challenges in assisting millions of Syrian refugees in Lebanon since the Syrian war in 2011. We sought to assess the feasibility and acceptability of an adapted version of the SMART-3RP (Stress Management Relaxation Response Resilience Training) training to address the emotional and physical burden on the humanitarian field. Data were collected using the Symptom Checklist-90 (SCL-90), blood pressure, pulse and a brief qualitative survey at months 0, 3, 6 and 9. We compared mean SCL-90 scores and physiological measures from these time points and subjected qualitative data to a thematic analysis. Mean values of all measures decreased from months 0 to 9, with significance in SCL-90 changes increasing at each visit. Qualitative themes included decreased stress, increased positivity and problem-solving skills, interpersonal and personal benefits of mindfulness practice and the need to continue and expand the programme. Qualitative and quantitative analyses showed a decrease in stress perception and blood pressure, demonstrating the physiological benefits of mind body approaches. We highlight the importance of self-care for humanitarian workers as the basis for the mission's success. We invite additional research to confirm these findings and their implications for the humanitarian field.

A systematic review of randomized controlled trials of interventions designed to decrease child abuse in high-risk families

Child abuse is a global problem, and parents with histories of childhood abuse are at increased risk of abusing their offspring. The objective of this systematic review is to provide a clear overview of the existing literature of randomized controlled trials evaluating the effectiveness of interventions to prevent child abuse. PubMed, PsychINFO, Web of Science, Sociological Abstracts, and CINAHL were systematically searched and expanded by hand search. This review includes all randomized controlled trials (RCTs) of interventions designed to prevent abuse among mothers identified as high-risk. Of the eight studies identified, only three found statistically significant reductions in abuse by any measure, and only two found reductions in incidents reported to child protective services. While much has been written about child abuse in high-risk families, few RCTs have been performed. Only home visitation has a significant evidence base for reducing child abuse, and the findings vary considerably. Also, data from low- and middle-income countries are limited.

A qualitative analysis of parental loss and family separation among youth in post-conflict Liberia

Between 1989 and 2003, the Republic of Liberia experienced a brutal civil war. In 2008, the population was approximately 3.5 million people, and there were an estimated 340,000 orphans. Nearly 6000 more children were orphaned by the Ebola epidemic from 2014-2015. The goal of this research was to explore the impact of parental loss, identify moderating factors, and consider interventions that could help vulnerable youth in post-conflict societies following the loss of a parent. Seventy-five young people (age 13-18 years) in Monrovia, the capital city of Liberia, were recruited in 2012. Semi-structured interviews were conducted, and demographic data were collected. Interviews were then transcribed and coded thematically. The loss of a parent or other primary caregiver had a significant impact on psychosocial and emotional health. The timing of the loss, strength of connection with the deceased parent, and relationship with surviving parent or substitute caregiver were all relevant factors. Children separated from living parents were functioning better than those whose parents were deceased. The case of Liberian children underscores the importance of early caregiver relationships and the difficulties children face when such relationships are disrupted. Children who did not experience stable early relationships suffered disconnection from their families and communities.

A qualitative analysis of factors impacting resilience among youth in post-conflict Liberia

BACKGROUND

In 2008, 5 years after the Liberian civil war ended, there were an estimated 340,000 orphans in Liberia, 18 % of the total child population of the country. Given that children make up half the population and that these children experienced significant trauma and loss both through direct exposure to the war and then to the Ebola epidemic, and indirectly as a result of the trauma experienced by their parents, the recovery of these children is essential to the recovery of the nation as a whole. The goal of this research was to identify factors contributing to resilience among youth in post-conflict Liberia. Resilience was defined as evidence of adaptive functioning and psychological health.

METHODS

Seventy-five young people (age 13-18) in the capital city of Monrovia, Liberia were recruited in 2012. Semi-structured interviews were conducted, and demographic data were collected. Interviews were then transcribed and coded thematically.

RESULTS

Forty-six of the participants were attending school, and 29 were not enrolled in school. Youth enrolled in school demonstrated greater adaptive functioning. This was particularly true for boys in any school setting and girls attending private school. Youth not attending school were more likely to have lost family members or become estranged from them, and many were also engaging in substance use. Emotion regulation, cognitive flexibility, agency, social intelligence and, in some cases, meaning-making were found in participants who showed resilient outcomes.

CONCLUSIONS

Caregiver relationships mediate the development of psychological capacities that impact resilience. These findings suggest that youth who have lost a caregiver, many of whom are not attending school, are experiencing a significant ongoing burden in terms of their daily functioning and psychological health in the post-war period and should be the focus of further study and intervention targeting substance use and community reintegration. Trial registration Partners Healthcare IRB Protocol# 2012P000367.

The Effect of Attending Good Psychiatric Management (GPM) Workshops on Attitudes Toward Patients With Borderline Personality Disorder

The effect that attending a 1-day workshop on Good Psychiatric Management (GPM) had on attitudes about borderline personality disorder (BPD) was assessed among 297 clinicians. Change was recorded by comparing before and after scores on a 9-item survey previously developed to assess the effects of workshops on Systems Training for Emotional Predictability and Problem Solving (STEPPS). Participants reported decreased inclination to avoid borderline patients, dislike of borderline patients, and belief that BPD's prognosis is hopeless, as well as increased feeling of competence, belief that borderline patients have low self-esteem, feeling of being able to make a positive difference, and belief that effective psychotherapies exist. Less clinical experience was related to an increased feeling of competence and belief that borderline patients have low self-esteem. These findings were compared to those from the STEPPS workshop. This assessment demonstrates GPM's potential for training clinicians to meet population-wide needs related to borderline personality disorder.

Cognitive Processing Therapy for Spanish-speaking Latinos: A Formative Study of a Model-Driven Cultural Adaptation of the Manual to Enhance Implementation in a Usual Care Setting

OBJECTIVE

As part of a larger implementation trial for cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) in a community health center, we used formative evaluation to assess relations between iterative cultural adaption (for Spanish-speaking clients) and implementation outcomes (appropriateness and acceptability) for CPT.

METHOD

Qualitative data for the current study were gathered through multiple sources (providers: N = 6; clients: N = 22), including CPT therapy sessions, provider fieldnotes, weekly consultation team meetings, and researcher fieldnotes. Findings from conventional and directed content analysis of the data informed refinements to the CPT manual.

RESULTS

Data-driven refinements included adaptations related to cultural context (i.e., language, regional variation in wording), urban context (e.g., crime/violence), and literacy level. Qualitative findings suggest improved appropriateness and acceptability of CPT for Spanish-speaking clients.

CONCLUSION

Our study reinforces the need for dual application of cultural adaptation and implementation science to address the PTSD treatment needs of Spanish-speaking clients.