Changes in substance use and engagement in gaming/gambling in persons with severe mental illness during the COVID-19 pandemic and earthquakes: a community study in two points

Introduction

External stressors, such as COVID-19 pandemic and earthquake, can cause an increase in substance use and addictive behavior in persons with severe mental illnesses (SMI). We analyzed the changes and predictors of substance use and addictive behavior in SMI during these double disasters in Croatia.

Methods

Questionnaires exploring the presence of substance or behavior addiction disorder, mental ill health [Depression Anxiety Stress Scales-21 (DASS-21), Insomnia Severity Index (ISI), Perceived Stress Scale (PSS), Obsessive-Compulsive Inventory-Revised], coping mechanisms, and perceived social support [Multidimensional Scale of Perceived Social Support (MSPSS)] were administered among 90 participants with SMI included in the RECOVER-E study in May/June 2020 (first COVID-19 wave, Zagreb earthquake) and in December 2020/January 2021 (second COVID-19 wave, Petrinja earthquake).

Results

In both time points, a major increase was observed in tobacco smoking (25.0%; 28.6%, respectively) predicted by discontinuation of antidepressants and higher DASS-21 score. Increased sedative use was observed (24.4%; 23.8%, respectively) predicted by higher PSS and ISI scores, lower MSPSS scores, antipsychotic discontinuation and not receiving community mental health team (CMHT) service.

Discussion

In persons with SMI during a double disaster special attention needs to be given to reducing mental-ill health and stress, providing social support and continuity of psychiatric care, through medications and CMHTs.

Pregnant women's perceptions of antenatal care and utilisation of digital health tools in Magu District, Tanzania: a qualitative study

Antenatal care is essential to promote maternal health. Prior research has focused on barriers women face to attending antenatal care, and improving quality of care is seen as a precondition for better attendance. Digital health tools are seen as a promising instrument to increase the quality of healthcare. It is less clear to what extent the use of digital health tools in low- and middle-income counties would be perceived as beneficial by end-users. The aim of this research was to explore women's experiences with antenatal care, and whether digital health tools would change their perceptions of quality of care. This qualitative research utilised an interpretative phenomenological approach on data from semi-structured in-depth interviews collected in 2016 with 19 randomly selected pregnant women from six different dispensaries in Magu District. Findings showed that pregnant women are motivated to attend antenatal care and are grateful for the services received. However, they also articulated a need for improvements in antenatal care services such as the availability of diagnostic tests and more interactions with healthcare workers. Participants indicated that a digital health tool could help in storing patient files and improving communication with health workers. Our results indicate that pregnant women are positive about the use of digital health tools during antenatal care but that the implementation of such a tool should be implemented in parallel to structural service delivery improvements, such as testing availability.

Challenges facing mental health systems arising from the COVID-19 pandemic: Evidence from 14 European and North American countries

We assessed challenges that the COVID-19 pandemic presented for mental health systems and the responses to these challenges in 14 countries in Europe and North America. Experts from each country filled out a structured questionnaire with closed- and open-ended questions between January and June 2021. We conducted thematic analysis to investigate the qualitative responses to open-ended questions, and we summarized the responses to closed-ended survey items on changes in telemental health policies and regulations. Findings revealed that many countries grappled with the rising demand for mental health services against a backdrop of mental health provider shortages and challenges responding to workforce stress and burnout. All countries in our sample implemented new policies or initiatives to strengthen mental health service delivery - with more than two-thirds investing to bolster their specialized mental health care sector. There was a universal shift to telehealth to deliver a larger portion of mental health services in all 14 countries, which was facilitated by changes in national regulations and policies; 11 of the 14 participating countries relaxed regulations and 10 of 14 countries made changes to reimbursement policies to facilitate telemental health care. These findings provide a first step to assess the long-term challenges and re-organizational effect of the COVID-19 pandemic on mental health systems in Europe and North America.

Atmiyata, a community champion led psychosocial intervention for common mental disorders: A stepped wedge cluster randomized controlled trial in rural Gujarat, India

BACKGROUND

While effective lay-health worker models for mental health care have been demonstrated through efficacy trials, there is limited evidence of the effectiveness of these models implemented in rural LMIC settings.

AIM

To evaluate the impact of a volunteer community-led intervention on reduction in depression and anxiety symptoms and improvement in functioning, and social participation among people living in rural Gujarat, India.

METHODS

Stepped-wedge cluster randomized controlled trial was used to assess the effectiveness of delivery of psychosocial intervention across 645 villages in Mehsana district of Gujarat, India between April 2017 and August 2019. The primary outcome was an improvement in depression and/or anxiety symptoms assessed using GHQ-12 at 3-month follow-up. Secondary outcomes were improvement in (a) depression and anxiety (Patient Health Questionnaire, (PHQ-9), Generalized Anxiety Disorder (GAD-7) & Self-Reporting Questionnaire-20 (SRQ-20); b) quality of life (EQ- 5D); c) functioning (WHO-DAS-12), and social participation (Social Participation Scale SPS). Generalized linear mixed-effects models were used to assess the independent effect of the intervention.

RESULTS

Out of a total of 1191 trial participants (608- intervention & 583-control), 1014 (85%) completed 3-month follow-up. In an adjusted analysis, participants in the intervention condition showed significant recovery from symptoms of depression or anxiety (OR 2.2; 95% CI 1.2 to 4.6; p<0.05) at the end of 3-months, with effects sustained at 8-month follow-up (OR 3.0; 95% CI 1.6 to 5.9). Intervention participants had improved scores on the PHQ-9 (Adjusted mean difference (AMD) -1.8; 95%CI -3.0 to -0.6), and SRQ-20 (AMD -1.7; 95%CI -2.7 to -0.6), at 3-months and PHQ-9, GAD-7, SRQ-20, EQ-5D and WHO-DAS at 8 months follow-up.

CONCLUSION

Findings suggest that Atmiyata had a significant effect on recovery from symptoms of depression and anxiety with sustained effects at 8-month follow-up.

TRIAL REGISTRATION

Trial registration details. The trial was registered prospectively with the "Clinical Trial Registry in India" (registry number: CTRI/2017/03/008139).

Lifestyle versus social determinants of health in the Dutch parliament: An automated analysis of debate transcripts

Although public health scholars increasingly recognize the importance of the social determinants of health (SDOH), health policy outputs tend to emphasize downstream lifestyle factors instead. We use an automated corpus research approach to analyse fourteen years of health policy debate in the Dutch House of Representatives' Health Committee, testing three potential causes of the lack of attention for SDOH: political ideology, by which members of parliament (MPs) from some political orientations may prioritize lifestyle factors over SDOH; lifestyle drift, by which early attention for SDOH during problem analysis is replaced by a lifestyle focus in the development of solutions as the challenges in addressing SDOH become clear; and focusing events, by which political or societal chance events, known to the public and political elites simultaneously, bolster the lifestyle perspective on health. Our analysis shows that overall, the committee spent most of its time discussing neither SDOH nor lifestyle: healthcare financing and service delivery dominated instead. When SDOH or lifestyle were referenced, left-leaning MPs referred significantly more to SDOH and right-leaning MPs significantly more to lifestyle. Temporal effects related to election cycles yielded inconsistent evidence. Finally, peak attention for both lifestyle and SDOH coincided with ongoing political debate instead of exogenous, unforeseen focusing events, and these peaks were rendered relatively insignificant by the larger and more consistent attention for health care. This paper provides a first step toward automated analysis of policy debates at scale, opening up new avenues for the empirical study of health political discourse.

Study protocol: development and randomized controlled trial of a preventive blended care parenting intervention for parents with PTSD

BACKGROUND

Children of parents with post-traumatic stress disorder (PTSD) are at increased risk of adverse psychological outcomes. An important risk mechanism is impaired parental functioning, including negative parenting behavior, perceived incompetence, and lack of social support. Several parenting interventions for trauma-exposed parents and parents with psychiatric disorders exist, but none have specifically targeted parents with PTSD. Our objective is to evaluate the effectiveness of a blended care preventive parenting intervention for parents with PTSD.

METHODS

The intervention was adapted from an existing online intervention, KopOpOuders Self-Help. In co-creation with parents with PTSD and partners, the intervention was adapted into KopOpOuders-PTSD, by adding PTSD-specific content and three in-person-sessions with a mental health prevention professional. Effectiveness will be tested in a randomized controlled trial among N = 142 parents being treated for PTSD at Arkin Mental Health Care (control condition: treatment as usual, n = 71; intervention condition: treatment as usual + intervention, n = 71). Online questionnaires at pretest, posttest, and three-month follow-up and ecological momentary assessment at pretest and posttest will be used. Intervention effects on primary (parenting behavior) and secondary outcomes (perceived parenting competence, parental social support, parenting stress, child overall psychological problems and PTSD symptoms) will be analyzed using generalized linear mixed modeling. We will also analyze possible moderation effects of parental PTSD symptoms at pretest on primary and secondary outcomes.

DISCUSSION

This study protocol describes the randomized controlled trial of KopOpOuders-PTSD, a blended care preventive parenting intervention for parents with PTSD. Findings can contribute to understanding of the effectiveness of parenting support in clinical practice for PTSD.

TRIAL REGISTRATION

This protocol (Version 1) was registered on 11-02-2022 at ClinicalTrials.gov under identification number NCT05237999.

The impact of the COVID-19 pandemic and earthquake on mental health of persons with severe mental illness: A survey study among people receiving community mental health care versus treatment as usual in Croatia

BACKGROUND

The COVID-19 pandemic led to the disruption of mental health services in most countries. Croatia has been developing and strengthening its mental health system, including the introduction of community mental health teams (CMHT) for persons with severe mental illness (SMI), whose implementation was ongoing during the pandemic through the RECOVER-E project.

AIMS

The aim of this study was to assess the differences in mental health outcomes, perceived social support and healthcare utilization in the group of participants receiving treatment as usual (TAU group) compared to the group receiving TAU and additional care by the CMHT (CMHT group) during the COVID-19 pandemic and two earthquakes.

METHOD

This is a cross-sectional survey administered among 90 participants with SMI at two time points: in May/June 2020 (first COVID-19 wave, earthquake) and in December 2020/January 2021 (second COVID-19 wave, earthquake).

RESULTS

A significantly larger proportion of participants from the CMHT group visited the general practitioners in both waves of COVID-19 (first wave: CMHT 72.1%, TAU 44.2%, p = .009; second wave: CMHT 91.1%, TAU 64.1%, p = .003), as well as psychiatric services in the second wave (CMHT 95.3%, TAU 79.5%, p = .028). The use of long-acting injectables was also more frequent in the CMHT group (p = .039). Furthermore, analysis of the first wave showed higher perceived support of significant others (p = .004) in the CMHT group. We did not identify any differences in mental health outcomes between groups in either wave.

CONCLUSIONS

While mental health outcomes did not differ between TAU and CMHT group, people in CMHT used services and treatments more frequently than those in TAU during the pandemic, which may indicate that CMHT services enable the continuity and accessibility of care for people with SMI under the circumstances where standard care is interruped (for example pandemic, disaster conditions).

Comparing a ses-sensitive and an all-ses implementation strategy to improve participation rates of patients with a lower socioeconomic background in a web-based intervention for depressive complaints: a cluster randomised trial in primary care

Background

Depression is a major public health concern, which is most pronounced in population segments with a lower social-economic status (SES). E-health interventions for depressive complaints are proven to be effective, but their reach needs to be improved, especially among people with a lower socioeconomic status (SES). Implementing e-health interventions in the primary care setting with SES-sensitive guidance from General Practice nurses (GP nurses) may be a useful strategy to increase the reach of e-health in lower SES groups. We implemented an evidence-based online intervention that targets depressive complaints in primary care.

Methods

A pragmatic cluster-randomised trial was conducted in two parallel groups where a SES sensitive (SES-sens) implementation strategy with additional face-to-face guidance by GP nurses was compared to an all-SES implementation strategy. The primary outcome was the percentage of lower SES participants in either condition. Participation was defined as completing at least 1 face-to-face session and 2 online exercises. Participation rates were evaluated using logistic mixed modelling.

Results

In both conditions, the participation rates of lower SES participants were quite high, but were notably lower in the SES-sens implementation condition (44%) than in the all-SES implementation condition (58%). This unexpected outcome remained statistically significant even after adjusting for potential confounders between the conditions (Odds Ratio 0.43, 95%-CI 0.22 to 0.81). Less guidance was provided by the GP nurses in the SES-sens group, contrary to the implementation instructions.

Conclusions

From a public health point of view, it is good news that a substantial number of primary care patients with a lower SES level used the implemented e-health intervention. It is also positive that an all-SES implementation strategy performed well, and even outperformed a SES-sensitive strategy. However, this was an unexpected finding, warranting further research into tailoring implementation strategies of e-health interventions towards specific target groups in the primary care setting.

Trial registration

Netherlands Trial Register, identifier: NL6595, registered on 12 November 2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01793-w.

A school-based program to prevent depressive symptoms and strengthen well-being among pre-vocational students (Happy Lessons): protocol for a cluster randomized controlled trial and implementation study

Background

Depression is one of the leading causes of illness and disability among young people. In the Netherlands, one in twelve Dutch adolescents has experienced depression in the last 12 months. Pre-vocational students are at higher risk for elevated depressive symptoms. Effective interventions, especially for this risk group, are therefore needed to prevent the onset of depression or mitigate the adverse long-term effects of depression. The aim of this study is to examine the effectiveness and implementation of a school-based program Happy Lessons (HL), that aims to prevent depression and promote well-being among pre-vocational students.

Methods

A cluster randomized controlled trial (RCT) with students randomized to HL or to care as usual will be conducted. Pre-vocational students in their first or second year (aged 12 to 14) will participate in the study. Subjects in both conditions will complete assessments at baseline and at 3- and 6-months follow-up. The primary outcome will be depressive symptoms using the Center for Epidemiologic Studies Depression Scale (CES-D) at 6-months follow-up. Secondary outcomes are well-being using the Warwick-Edinburgh Mental Well-Being Scale (WEMWBS) and life satisfaction (Cantril Ladder) measured at 6-months follow-up. Alongside the trial, an implementation study will be conducted to evaluate the implementation of HL, using both quantitative and qualitative methods (interviews, survey, and classroom observations).

Discussion

The results from both the RCT and implementation study will contribute to the limited evidence base on effective school-based interventions for the prevention of depression and promotion of well-being among pre-vocational adolescents. In addition, insights from the implementation study will aid identifying factors relevant for optimizing the future implementation and scale-up of HL to other schools and contexts.

Trial registration

This study was registered on 20 September 2021 in the Dutch Trial Register (NL9732).

Experiences of healthcare staff providing community-based mental healthcare as a multidisciplinary community mental health team in Central and Eastern Europe findings from the RECOVER-E project: an observational intervention study

BACKGROUND

Community Mental Health Teams (CMHTs) deliver healthcare that supports the recovery of people with mental illness. The aim of this paper was to explore to what extent team members of five CMHTs newly implemented in five countries perceived that they had introduced aspects of the recovery-oriented, strength-based approach into care after a training week on recovery-oriented practice. In addition, it evaluated what the team members' perceptions on their care roles and their level of confidence with this role were.

METHOD

An observational intervention study using a quantitative survey that was administered among 52 health professionals (21 Nurses, 13 Psychiatrists, 9 Psychologists, 8 Social Workers) and 14 peer workers including the Recovery Self-Assessment Tool Provider Version (RSA-P), the Team Member Self-Assessment Tool (TMSA), and demographic questions was conducted. The measures were self-reported. Descriptive statistics were used to calculate the means and standard deviations for continuous variables and frequencies and percentages for categorical variables (TMSA tool and demographic data). The standard technique to calculate scale scores for each subscale of the RSA-P was used. Bivariate linear regression analyses were applied to explore the impact of predictors on the subscales of the RSA-P. Predictors with significant effects were included in multiple regression models.

RESULT

The RSA-P showed that all teams had the perception that they provide recovery-oriented practice to a moderately high degree after a training week on recovery-oriented care (mean scores between 3.85-4.46). Health professionals with fewer years of professional experience perceived more frequently that they operated in a recovery-oriented way (p = 0.036, B = - 0.268). Nurses and peer workers did not feel confident or responsible to fulfil specific roles.

CONCLUSION

The findings suggest that a one-week training session on community-based practices and collaborative teamwork may enhance recovery-oriented practice, but the role of nurses and peer workers needs further attention.

TRIAL REGISTRATION

Each trial was registered before participant enrolment in the clinicaltrials.gov database: Croatia, Zagreb (Trial Reg. No. NCT03862209 ); Montenegro, Kotor (Trial Reg. No. NCT03837340 ); Romania, Suceava (Trial Reg. No. NCT03884933 ); Macedonia, Skopje (Trial Reg. No. NCT03892473 ); Bulgaria, Sofia (Trial Reg. No. NCT03922425 ).

The Development of an Electronic Clinical Decision and Support System to Improve the Quality of Antenatal Care in Rural Tanzania: Lessons Learned Using Intervention Mapping

It is widely recognised that high quality antenatal care is a key element in maternal healthcare. Tanzania has a very high maternal mortality ratio of 524 maternal deaths per 100,000 live births. Most maternal deaths are due to preventable causes that can be detected during pregnancy, and antenatal care therefore plays an important role in reducing maternal morbidity and mortality. Unfortunately, quality of antenatal care in Tanzania is low: Research has shown that healthcare workers show poor adherence to antenatal care guidelines, and the majority of pregnant women miss essential services. Digital health tools might improve the performance of healthcare workers and contribute to improving the quality of antenatal care. To this end, an electronic clinical decision and support system (the Nurse Assistant App) was developed and implemented in Tanzania in 2016 to provide digital assistance during antenatal care consultations to healthcare workers. The current study systematically evaluated the development and implementation process of the Nurse Assistant App in Magu District, Tanzania, with the aim of informing future programme planners about relevant steps in the development of a digital health intervention. Desk research was combined with semi-structured interviews to appraise the development process of the digital health tool. We employed the criteria stipulated by Godin et al., which are based on the six steps of Intervention Mapping [IM; Bartholomew Eldredge et al.]. Findings indicated that five of the six steps of IM were completed during the development and implementation of the Nurse Assistant App. Tasks related to community engagement, adjustment to local context, implementation in the practical context in collaboration with local partners, and rigorous evaluation were accomplished. However, tasks related to identifying theory-based behaviour change methods were not accomplished. Based on the lessons learned during the process of developing and implementing the Nurse Assistant App, we conclude that programme developers are recommended to (1) engage the community and listen to their insights, (2), focus on clear programme goals and the desired change, (3), consult or involve a behaviour change specialist, and (4), anticipate potential problems in unexpected circumstances.

How does income affect mental health and health behaviours? A quasi-experimental study of the earned income tax credit

BACKGROUND

Although research has repeatedly demonstrated the association between poverty, mental health, and health behaviours, there is limited evidence on the effects of interventions to improve these outcomes by addressing poverty directly. Moreover, most prior studies are often confounded by unobserved characteristics of individuals, making it difficult to inform possible interventions. We addressed this gap in the literature by leveraging quasi-random variation in the earned income tax credit (EITC)-the largest US poverty alleviation programme for families with children-to examine the effects on overall health, psychological distress, smoking, and alcohol consumption.

METHODS

We used a large diverse national sample drawn from the Panel Study of Income Dynamics (N=34 824). We first conducted ordinary least squares (OLS) models to estimate the association of income and the EITC with the outcomes of interest. We subsequently employed a quasi-experimental instrumental variables (IV) analysis-in which EITC refund size was the instrument-to estimate the effect of income itself.

RESULTS

In OLS models, higher income was associated with reductions in psychological distress, increased drinking, increased smoking, and more cigarettes per day, and larger EITC refunds were associated with reductions in psychological distress. In IV models, higher income was associated with decreased psychological distress.

CONCLUSION

These results suggest that typical correlational studies of the health effects of income may be confounded, although results may not generalise to income distributed in different ways than the EITC. The findings also provide valuable information for policymakers and researchers seeking to address socioeconomic disparities in mental health.

Identifying challenges and recommendations for advancing global mental health implementation research: A key informant study of the National Institute of Mental Health Scale-Up Hubs

OBJECTIVE

This study explored perspectives of researchers working with the National Institute of Mental Health (NIMH) Scale-Up Hubs, consisting of research partnerships for scaling up mental health interventions in low- and middle-income countries (LMICs), to: 1) identify common barriers to conducting impactful research on the implementation of evidence-based mental health services; and 2) provide recommendations to overcome these implementation challenges.

METHODS

A sequential qualitative approach was employed. First, an open-ended survey was distributed to the 10 Scale-Up Hubs and NIMH program staff asking informants to identify challenges in conducting mental health implementation research in LMICs. Second, survey findings guided an in-person workshop to generate implementation recommendations to inform the field.

RESULTS

In total, 46 respondents completed surveys, and 101 researchers attended the workshop. The workshop produced implementation recommendations for low-resource settings: 1) identifying impact of research on policy and practice; 2) sustaining careers of early researchers in global mental health; 3) engaging policymakers and donors to value mental health research; 4) supporting the workforce for delivering evidence-based treatments for mental disorders; and 5) promoting sustainability of programs.

CONCLUSIONS

These findings can strengthen collaboration between researchers and key stakeholders, and highlight important targets for improving mental health implementation research in LMICs.

Perceived Support for Recovery and Level of Functioning Among People With Severe Mental Illness in Central and Eastern Europe: An Observational Study

Background: Many people with severe mental illness experience limitations in personal and social functioning. Care delivered in a person's community that addresses needs and preferences and focuses on clinical and personal recovery can contribute to addressing the adverse impacts of severe mental illness. In Central and Eastern Europe, mental health care systems are transitioning from institutional-based care toward community-based care. The aim of this study is to document the level of functioning and perceived support for recovery in a large population of service users with severe mental illness in Central and Eastern Europe, and to explore associations between perceived support for recovery and the degree of functional limitations. Methods: The implementation of community mental health teams was conducted in five mental health centers in five countries in Central and Eastern Europe. The present study is based on trial data at baseline among service users across the five centers. Baseline data included sociodemographic, the World Health Organization Disability Assessment Schedule (WHODAS 2.0) for functional limitations, and the Recovery Support (INSPIRE) tool for perceived staff support toward recovery. We hypothesized that service users reporting higher levels of perceived support for their recovery would indicate lower levels of functional limitation. Results: Across all centers, the greatest functional limitations were related to participation in society (43.8%), followed by daily life activities (33.3%), and in education or work (35.6%). Service users (N = 931) indicated that they were satisfied overall with the support received from their mental health care provider for their social recovery (72.5%) and that they valued their relationship with their providers (80.3%). Service users who perceived the support they received from their provider as valuable (b = -0.10, p = 0.001) and who reported to have a meaningful relationship with them (b = -0.13, p = 0.003) had a lower degree of functional limitation. Conclusion: As hypothesized, the higher the degree of perceived mental health support from providers, the lower the score in functional limitations. The introduction of the community-based care services that increase contact with service users and consider needs and which incorporate recovery-oriented principles, may improve clinical recovery and functional outcomes of service users with severe mental illness.

Implementation of a comprehensive surveillance system for recording suicides and attempted suicides in rural India

INTRODUCTION

WHO reports that 78 of the 140 low-income and middle-income countries (LMICs) do not have a registration system for suicides and attempted suicides. Absence of data on suicide and attempted suicide in LMICs, which account for 79% of suicides worldwide, is a major impediment in understanding the magnitude of the problem and formulating prevention strategies to reduce suicide and self-harm. A comprehensive surveillance system has the potential to address this data gap. The objective of this study is to describe the development of a comprehensive surveillance system in rural India by adding a community based component and reflect on its added value in obtaining data on suicide and attempted suicide compared with relying only on hospital and police records.

METHOD

The comprehensive system consists of three components. Community surveillance involved collecting information on suicides and attempted suicides from third party key informants such as village heads, teachers, priests, shopkeepers, private physicians, private hospitals and community health workers. The second component consisted of data from public health facilities. The final component consisted of suicide data from police records. Information was collected for a period of 12 months from August 2018 to July 2019 from 116 villages (population 377 276) in Gujarat, India.

RESULTS

An average of 710 community informants were interviewed each month (mean: 6.72 informants per village). The community surveillance system identified 67 cases of suicide compared with 30 cases by hospital and police records (Cochran's Q test 67.9 p<0.01) and 70 attempted suicides compared with 51 from the hospital and police records (Cochran's Q test 66.6 p<0.01).

DISCUSSION

This is the first report of implementing a large-scale comprehensive surveillance system for suicide and attempted suicide in a LMIC. The combination of community surveillance system and official data from hospital and police records addresses the problem of under-reporting of suicide and suicide attempts in India and other LMIC.

Balancing COVID-19 preparedness and ‘business as usual’ in hospitals: lessons from executives in China, Norway and the UK

Background

During the first wave of COVID-19 pandemic, hospitals were forced to cancel or postpone non-COVID-19 care. With new outbreaks emerging, hospitals are now figuring out how to balance preparedness for future COVID-19 waves with their elective and regular services. This report discusses how four hospital systems deal with these dual responsibilities in China, Norway and the UK.

Reflections

Based on the experiences and combined reflections of hospital executives, we have formulated five strategic and leadership lessons for hospitals as they manage these dual responsibilities. (1) Redesign organisation to separate COVID-19 and non-COVID-19 services both within and across hospitals. (2) Expand virtual care strategies to improve access. (3) Use data-driven models to allocate resources across COVID-19 and non-COVID-19 units. (4) Invest in programmes to promote frontline staff well-being. (5) Secure financial support to continue to deliver on the dual responsibilities.

Conclusion

The COVID-19 pandemic gives rise to leadership challenges that have fuelled organisational change and new approaches to healthcare delivery. Leading hospitals during the pandemic is a balancing act—providing care for both patients with COVID-19 and non-COVID-19, while at the same time preparing for the next waves of the pandemic.

Healthcare workers’ and pregnant women’s perceptions of digital tools to improve antenatal care

Background

To reduce maternal mortality in rural Tanzania, the need to improve antenatal care remains an urgent priority. Digital health tools are seen as a promising instrument to increase the quality of healthcare in developing countries, but it remains unclear to what extent they are perceived as beneficial during the antenatal care visit. Therefore, the aim of this research was to identify factors that could improve the quality of antenatal care in rural Tanzania, and whether digital health tools would change healthcare workers' and pregnant women's perceptions of quality of care.

Methods

Semi-structured in-depth interviews were conducted with sixteen healthcare workers and nineteen pregnant women, recruited from various health facilities in Magu District, Tanzania.

Results

Both healthcare workers and pregnant women possess a positive attitude towards antenatal care and acknowledge its importance. However, they also expressed a need for (structural) improvements in antenatal care services, particularly increased availability of diagnostic tests, and increased performance and motivation of healthcare workers. In addition, healthcare workers indicated a need for more training and better supervision. While both groups expected quality of care to increase should a digital health tool be implemented, they placed more focus on investing in health infrastructure, like the availability of medication and other materials, than investments in digital health.

Conclusions

Infrastructural improvements, including better communication between healthcare workers and pregnant women, as well as training opportunities and supportive leadership, are necessary before a digital health tool can be expected to increase the quality of antenatal care.

Key messages

Both healthcare workers and pregnant women acknowledged the need for higher quality antenatal care. Both groups suggested a number of infrastructural improvements, among which the use of a digital health tool.

“The nurse assistant app” to improve healthcare worker performance during antenatal care in Tanzania

Background

The Nurse Assistant App (NAA) was developed to improve the quality of antenatal care in Magu District Tanzania by providing digital assistance to healthcare workers. The NAA guides healthcare workers step by step through all necessary antenatal care interventions and provides tailored advice and suggestions for follow-up actions. We used the Intervention Mapping framework to retrospectively evaluate the development of the NAA.

Methods

Desk research into the content, evidence base, and development of the NAA was performed combined with semi-structured interviews with two initial developers to fill in a planning tool consisting of 40 criteria for systematic evaluation of the data.

Results

Findings showed that the NAA was developed based on existing literature on antenatal care guidelines as well as the knowledge and experience of a broad variety of stakeholders and that five of the six steps of Intervention Mapping were performed. However, the development of the NAA lacked a theoretical foundation on behaviour change models. Future research will focus on the experiences of healthcare workers providing antenatal care using the NAA.

Conclusions

The NAA was developed in collaboration with relevant stakeholders and took practical matters as well as evidence from existing literature into account. However, we recommend that the responsibility and ownership of the NAA should be shared with the local government to increase the potential and sustainability of the NAA.

Key messages

The NAA was developed to improve the quality of antenatal care in rural Tanzania targeting healthcare workers. The current evaluation informs future digital health tool developers in sub-Saharan Africa about elements to take into account during the development phase such as systematic mapping of the process.

Evaluation of the SPIRIT Integrated Suicide Prevention Programme: study protocol for a cluster-randomised controlled trial in rural Gujarat, India

BACKGROUND

Suicide is a major public health challenge globally and specifically in India where 36.6% and 24.3% of all suicides worldwide occur in women and men, respectively. The United Nations Sustainable Development Goals uses suicide rate as one of two indicators for Target 3.4, aimed at reducing these deaths by one third by 2030. India has no examples of large-scale implementation of evidence-based interventions to prevent suicide; however, there is a sizeable evidence base to draw on for suicide prevention strategies that have been piloted in India or proven to be effective regionally or internationally.

METHOD

The SPIRIT study is designed as a cluster-randomized superiority trial and uses mixed methods to evaluate the implementation, effectiveness and costs of an integrated suicide prevention programme consisting of three integrated interventions including (1) a secondary-school-based intervention to reduce suicidal ideation among adolescents, (2) a community storage facility intervention to reduce access to pesticides and (3) training for community health workers in recognition, management, and appropriate referral of people identified with high suicidal risk.

DISCUSSION

Combining three evidence-based interventions that tackle suicide among high-risk groups may generate a synergistic impact in reducing suicides at the community level in rural areas in India. Examination of implementation processes throughout the trial will also help to prepare a roadmap for policymakers and researchers looking to implement suicide prevention interventions in other countries and at scale.

TRIAL REGISTRATION

Clinical Trial Registry of Indian Council of Medical Research, India: CTRI/2017/04/008313. Registered on 7 April 2017. http://ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=18256&EncHid=&userName=SPIRIT Trial registry was last modified on 28 June 2019.

Sustainability of Community-Based Specialized Mental Health Services in Five European Countries: Protocol for Five Randomized Controlled Trial-Based Health-Economic Evaluations Embedded in the RECOVER-E Program

Background

Community-based recovery-oriented mental health services for people with severe mental disorders have not been fully implemented in Bulgaria, Croatia, Macedonia, Montenegro, and Romania. The RECOVER-E project facilitates the implementation of specialized mental health care delivered by setting up services, implementing the services, and evaluating multidisciplinary community mental health teams. The outcomes of the RECOVER-E project are assessed in a trial-based outcome evaluation in each of the participating countries with a health-economic evaluation linked to these trials.

Objective

The aim of this protocol paper is to describe the methodology that will be used for the health-economic evaluation alongside the trials.

Methods

Implementation sites have been selected in each of the five countries where hospital-based mental health services are available (care as usual [CAU]) for patients with severe mental disorders (severe depression, bipolar disorder, schizophrenia, and other psychotic disorders). The newly implemented health care system will involve community-based recovery-oriented mental health care (CMHC). At each site, 180 consenting patients will be randomized to either CAU or CMHC. Patient-level outcomes are personal and social functioning and quality-adjusted life years (QALYs). Data on participants’ health care use will be collected and corresponding health care costs will be computed. This enables evaluation of health care costs of CMHC as compared with CAU, and these costs can be related to patient-level outcomes (functioning and QALY gains) in health-economic evaluation.

Results

Data collection was started in December 2018 (Croatia), February 2019 (Montenegro), April 2019 (Romania), June 2019 (North Macedonia), and October 2019 (Bulgaria). The findings of the outcome evaluations will be reported for each of the five countries separately, and the five trials will be pooled for multilevel analysis on a combined dataset.

Conclusions

The results of the health-economic evaluation of the RECOVER-E project will contribute to the growing evidence base on the health and economic benefits of recovery-oriented and community-based service models for health systems in transition.

Trial Registration

(1) ClinicalTrials.gov NCT03922425 (Bulgaria); https://clinicaltrials.gov/ct2/show/NCT03922425 (2) ClinicalTrials.gov NCT03862209 (Croatia); https://clinicaltrials.gov/ct2/show/NCT03862209 (3) ClinicalTrials.gov NCT03892473 (Macedonia); https://clinicaltrials.gov/ct2/show/NCT03892473 (4) ClinicalTrials.gov NCT03837340 (Montenegro); https://clinicaltrials.gov/ct2/show/NCT03837340 (5) ClinicalTrials.gov NCT03884933 (Romania); https://clinicaltrials.gov/ct2/show/NCT03884933

International Registered Report Identifier (IRRID)

DERR1-10.2196/17454

Towards community-based and recovery-oriented care for severe mental disorders in Southern and Eastern Europe: aims and design of a multi-country implementation and evaluation study (RECOVER-E)

Background

Substantial strides have been made around the world in reforming mental health systems by shifting away from institutional care towards community-based services. Despite an extensive evidence base on what constitutes effective care for people with severe mental ill-health, many people in Europe do not have access to optimal mental health care. In an effort to consolidate previous efforts to improve community mental health care and support the complex transition from hospital-based to community-based care delivery, the RECOVER-E (LaRge-scalE implementation of COmmunity based mental health care for people with seVere and Enduring mental ill health in EuRopE) project aims to implement and evaluate multidisciplinary community mental health teams in five countries in Central and Eastern Europe. This paper provides a brief overview of the RECOVER-E project and its methods.

Methods

Five implementation sites were selected (Sofia, Bulgaria; Zagreb, Croatia; Skopje, North Macedonia; Kotor, Montenegro; Siret-Suceava, Romania) where hospital-based mental health services are available (care as usual, CAU) for patients with severe mental disorders (severe depression, bipolar disorder, schizophrenia). The intervention consists of the introduction of a new service delivery model in each site, consisting of community-based recovery-oriented care delivered by trained multidisciplinary community mental health teams (including a peer worker with lived experience of a severe mental disorder). The implementation outcomes of the teams and the effect of the team’s approach on patient and service utilisation outcomes will be evaluated using a mix of research methods. The study includes five planned hybrid implementation-effectiveness trials (1 per site) with patient-level randomization (n = 180, with patients randomised to either care as usual or intervention condition). Effectiveness is evaluated using a pragmatic non-blinded design with patients randomised into two parallel groups: receiving new community-based care or receiving usual care in the form of institutional, hospital-based mental health care. Trial-based health economic evaluation will be conducted; implementation outcomes will be evaluated, with data aligned with dimensions from the RE-AIM framework. Pathways to sustaining project results will be developed through policy dialogue sessions, which will be carried out in each country and through ongoing policy engagement activities at the European level.

Discussion

The RECOVER-E project has been developed and conducted to demonstrate the impact of implementing an evidence-based service delivery model for people with severe mental illness in different contexts in middle-income countries in Central and Eastern Europe. It is expected that the results will contribute to the growing evidence-base on the health and economic benefits of recovery-oriented and community-based service models for health systems in transition.

Trial registration Each trial was registered before participant enrolment in the clinicaltrials.gov database: Site—Croatia, Zagreb (Trial Reg. No. NCT03862209); Montenegro, Kotor (Trial Reg. No. NCT03837340); Romania, Suceava (Trial Reg. No. NCT03884933); Macedonia, Skopje (Trial Reg. No. NCT03892473); Bulgaria, Sofia (Trial Reg. No. NCT03922425)

Atmiyata, a community-led intervention to address common mental disorders: Study protocol for a stepped wedge cluster randomized controlled trial in rural Gujarat, India

BACKGROUND

While lay-health worker models for mental health care have proven to be effective in controlled trials, there is limited evidence on the effectiveness and scalability of these models in rural communities in low- and middle-income countries (LMICs). Atmiyata is a rural community-led intervention using local community volunteers, called Champions, to identify and provide a package of community-based interventions for mental health, including evidence-based counseling for persons with common mental disorders (CMD).

METHODS

The impact of the Atmiyata intervention is evaluated through a stepped wedge cluster randomized controlled trial (SW-CRCT) with a nested economic evaluation. The trial is implemented across 10 sub-blocks (645 villages) in Mehsana district in the state of Gujarat, with a catchment area of 1.52 million rural adults. There are 56 primary health centers (PHCs) in Mehsana district and villages covered under these PHCs are equally divided into four groups of clusters of 14 PHCs each. The intervention is rolled out in a staggered manner in these groups of villages at an interval of 5 months. The primary outcome is symptomatic improvement measured through the GHQ-12 at a 3-month follow-up. Secondary outcomes include: quality of life using the EURO-QoL (EQ- 5D), symptom improvement measured by the Self-Reporting Questionnaire-20 (SRQ-20), functioning using the World Health Organization's Disability Assessment Scale (WHO-DAS-12), depression symptoms using the Patient Health Questionnaire (PHQ-9), anxiety symptoms using Generalized Anxiety Disorder Questionnaire (GAD-7), and social participation using the Social Participation Scale (SPS). Generalized linear mixed effects model is employed for binary outcomes and linear mixed effects model for continuous outcomes. A Return on Investment (ROI) analysis of the intervention will be conducted to understand whether the intervention generates any return on financial investments made into the project.

DISCUSSION

Stepped wedge designs are increasingly used a design to evaluate the real-life effectiveness of interventions. To the best of our knowledge, this is the first SW-CRCT in a low- and middle-income country evaluating the impact of the implementation of a community mental health intervention. The results of this study will contribute to the evidence on scaling-up lay health worker models for mental health interventions and contribute to the SW-CRCT literature in low- and middle-income countries.

TRIAL REGISTRATION

The trial is registered prospectively with the Clinical Trial Registry in India and the Clinical Trial Registry number- CTRI/2017/03/008139. URL http://ctri.nic.in/Clinicaltrials/regtrial.php?modid=1&compid=19&EncHid=70845.17209. Date of registration- 20/03/2017.

Feasibility and acceptability of a novel community-based mental health intervention delivered by community volunteers in Maharashtra, India: the Atmiyata programme

BACKGROUND

Many community-based intervention models for mental health and wellbeing have undergone robust experimental evaluation; however, there are limited accounts of the implementation of these evidence-based interventions in practice. Atmiyata piloted the implementation of a community-led intervention to identify and understand the challenges of delivering such an intervention. The goal of the pilot evaluation is to identify factors important for larger-scale implementation across an entire district in India. This paper presents the results of a feasibility and acceptability study of the Atmiyata intervention piloted in Nashik district, Maharashtra, India between 2013 and 2015.

METHODS

A mixed methods approach was used to evaluate the Atmiyata intervention. First, a pre-post survey conducted with 215 cases identified with a GHQ cut-off 6 using a 3-month interval. Cases enrolled into the study in one randomly selected month (May-June 2015). Secondly, a quasi-experimental, pre-post design was used to conduct a population-based survey in the intervention and control areas. A randomly selected sample (panel) of 827 women and 843 men age between 18 to 65 years were interviewed to assess the impact of the Atmiyata intervention on common mental disorders. Finally, using qualitative methods, 16 Champions interviewed to understand an implementation processes, barriers and facilitators.

RESULTS

Of the 215 participants identified by the Champions as being distressed or having a common mental disorder (CMD), n = 202 (94.4%) had a GHQ score at either sub-threshold level for CMD or above at baseline. Champions accurately identified people with emotional distress and in need of psychological support. After a 6-session counselling provided by the Champions, the percentage of participants with a case-level GHQ score dropped from 63.8 to 36.8%. The second sub-intervention consisted of showing films on Champions' mobile phones to raise community awareness regarding mental health. Films consisted of short scenario-based depictions of problems commonly experienced in villages (alcohol use and domestic violence). Champions facilitated access to social benefits for people with disability. Retention of Atmiyata Champions was high; 90.7% of the initial selected champions continued to work till the end of the project. Champions stated that they enjoyed their work and found it fulfilling to help others. This made them willing to work voluntarily, without pay. The semi-structured interviews with champions indicated that persons in the community experienced reduced symptoms and improved social, occupational and family functioning for problems such as depression, domestic violence, alcohol use, and severe mental illness.

CONCLUSIONS

This study shows that community-led interventions using volunteers from rural neighbourhoods can serve as a locally feasible and acceptable approach to facilitating access social welfare benefits, as well as reducing distress and symptoms of depression and anxiety in a low and middle-income country context. The intervention draws upon social capital in a community to engage and empower community members to address mental health problems. A robust evaluation methodology is needed to test the efficacy of such a model when it is implemented at scale.

Taking steps towards deinstitutionalizing mental health care within a low and middle-income country: A cross-sectional study of service user needs in the Republic of Moldova

AIM

The current research was conducted in the context of an ongoing reform of mental health services in the Republic of Moldova since 2014, where efforts have been devoted to creating community-based mental health services. This article presents a snapshot of the needs of mental health service users in the Republic of Moldova and helps to understand how and with which services their needs can be addressed.

METHODS

This cross-sectional study compared the levels of needs (CANSAS scale), quality of life (EQ-5D 3L), mental health status (MINI for psychotic disorders) and functioning (WHO-DAS) among mental health service users in the psychiatric hospital in Chisinau, Moldova. All service users resided in districts where community mental health services were being developed. Correlations between quality of life, functioning and unmet need were explored.

RESULTS

Of 83 participants, one third had a psychotic or a mood disorder. On average, participants reported needs in 9.41 domains (SD = 4.41), of which 4.29 were unmet (SD = 3.63). Most unmet needs related to intimacy and relation to others. The level of functioning and quality of life were reported. We found strong, negative associations between the number of unmet needs and level of functioning, as well as the quality of life. We also found that higher functioning levels were positively associated with higher quality of life.

CONCLUSION

There were a high number of unmet needs among this inpatient population, particularly social needs and service-related needs. A continuum of inpatient and outpatient care and individual treatment plans can help address the different needs of different patients. Individual treatment plans for patients and the choice of the appropriate treatment for patients could be guided by an assessment of service users' (unmet) needs of care and level of functioning.

Mental health system reform in Moldova: Description of the program and reflections on its implementation between 2014 and 2019

In 2014, the Republic of Moldova started a systematic process of reforming its mental health system, implementing priority actions set out in the National Mental Health Programme. The reform entailed a service delivery re-design, instituting mechanisms for collaboration across health and social sectors, and revision of the policy framework. Outcomes of the first 4 years of the reform included: 1) the establishment of a network of mental health services in 4 pilot districts embedding mental health diagnosis, treatment and referral in primary and specialized mental healthcare; 2) creation of an enabling policy environment at the national and district level; and 3) strengthened community support and acceptance of mental health issues. Objectives of the first Phase were achieved and the reform is now in its second Phase (2018-2022). The implementation strategy in Phase 1 focused efforts on 4 pilot districts, whereas Phase 2 harnesses lessons learned from Phase 1 and facilitates local leaders and actors to scale-up the model to all 32 districts and municipalities in Moldova. Ownership over the reform process shifted from project-led in Phase 1 to national and local government-led in Phase 2. We reflect on the process and contents of the mental health reform, discuss lessons learned and implementation challenges encountered. We conclude with learning points for policymakers and researchers considering mental health reform in other countries.

Recovery for all in the community; position paper on principles and key elements of community-based mental health care

BACKGROUND

Service providers throughout Europe have identified the need to define how high-quality community-based mental health care looks to organize their own services and to inform governments, commissioners and funders. In 2016, representatives of mental health care service providers, networks, umbrella organizations and knowledge institutes in Europe came together to establish the European Community Mental Health Services Provider (EUCOMS) Network. This network developed a shared vision on the principles and key elements of community mental health care in different contexts. The result is a comprehensive consensus paper, of which this position paper is an outline. With this paper the network wants to contribute to the discussion on how to improve structures in mental healthcare, and to narrow the gap between evidence, policy and practice in Europe.

MAIN TEXT

The development of the consensus paper started with an expert workshop in April 2016. An assigned writing group representing the workshop participants built upon the outcomes of this meeting and developed the consensus paper with the input from 100 European counterparts through two additional work groups, and two structured feedback rounds via email. High quality community-based mental health care: 1) protects human rights; 2) has a public health focus; 3) supports service users in their recovery journey; 4) makes use of effective interventions based on evidence and client goals; 5) promotes a wide network of support in the community and; 6) makes use of peer expertise in service design and delivery. Each principle is illustrated with good practices from European service providers that are members of the EUCOMS Network.

CONCLUSIONS

Discussion among EUCOMS network members resulted in a blueprint for a regional model of integrated mental health care based upon six principles.

Bringing Social Context into Diabetes Care: Intervening on Social Risks versus Providing Contextualized Care

PURPOSE OF REVIEW

Patient social and economic risk information can guide diabetes care through social risk-targeted care (directly intervening on social risk factors) or social risk-informed care (modifying or tailoring care to accommodate social risks). We review evidence supporting these approaches and highlight critical gaps in the current evidence.

RECENT FINDINGS

Literature is scarce on isolated social care interventions and the impact on glycemic control is unclear, while blended social-behavioral interventions more consistently point to reductions in HbA1c. Social risk-informed care naturally occurs at low rates, yet holds potential to improve care. Momentum is building around programs designed to intervene on social risk factors and/or to contextualize care based on social context. Future work will need to isolate the impacts of these programs, clarify the pathways through which social care programs can improve outcomes, and identify provider barriers and facilitators to using social risk information in care.

Mobilizing community action to improve maternal health in a rural district in Tanzania: lessons learned from two years of community group activities

Background: Community participation can provide increased understanding and more effective implementation of strategies that seek to improve outcomes for women and newborns. There is limited knowledge on how participatory processes take place and how this affects the results of an intervention. Objective: This paper presents the results of two years of implementing (2013-2015) community groups for maternal health care in Magu District, Tanzania. Method: A total of 102 community groups were established, and 77 completed the four phases of the participatory learning and action cycle. The four phases included identification of problems during pregnancy and childbirth (phase 1), deciding on solutions and planning strategies (phase 2), implementation of strategies (phase 3) and evaluation of impact (phase 4). Community group meetings were facilitated by 15 trained facilitators and groups met monthly in their respective villages. Data was collected as an ongoing process from facilitator and meeting reports, through interviews with facilitators and local leaders and from focus group discussions with community group participants. Results: The majority of groups prioritized problems related to the availability of and accessibility to health services. The most commonly actioned solution was the provision of health education to the community. Almost all groups (95%) experienced a positive impact on the community as results of their actions, including increased maternal health knowledge and positive behaviour changes among health care workers. Facilitators were positive about the community groups, stating that they were grateful for the gained knowledge on maternal health, and positively regarded the involvement of men in community groups, which are traditionally women-only. Conclusion: The process of establishing and undertaking community groups in itself appeared to have a positive perceived impact on the community. However, sustained behaviour change, power dynamics and financial incentives need to be carefully considered during implementation and sustaining the community groups.

Promoting wellbeing and improving access to mental health care through community champions in rural India: the Atmiyata intervention approach

Background

There are limited accounts of community-based interventions for reducing distress or providing support for people with common mental disorders (CMDs) in low and middle-income countries. The recently implemented Atmiyata programme is one such community-based mental health intervention focused on promoting wellness and reducing distress through community volunteers in a rural area in the state of Maharashtra, India.

Case presentation

This case study describes the content and the process of implementation of Atmiyata and how community volunteers were trained to become Atmiyata champions and mitras (friends). The Atmiyata programme trained Atmiyata champions to provide support and basic counselling to community members with common mental health disorders, facilitate access to mental health care and social benefits, improve community awareness of mental health issues, and to promote well-being. Challenges to implementation included logistical challenges (difficult terrain and weather conditions at the implementation site), content-related challenges (securing social welfare benefits for people with CMDs), and partnership challenges (turnover of public health workers involved in referral chain, resistance from public sector mental health specialists).

Conclusions

The case study serves as an example for how such a model can be sustained over time at low cost. The next steps of the programme include evaluation of the impact of the Atmiyata intervention through a pre-post study and adapting the intervention for further scale-up in other settings in India.