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Hamdani SU, Huma ZE, Malik A, Nizami AT, Baneen UU, Suleman N, Javed H, Wang D, van Ommeren M, Mazhar S, Khan SA, Minhas FA, Rahman A. Improving psychosocial distress for young adolescents in rural schools of Pakistan: study protocol of a cluster randomised controlled trial. BMJ Open 2022; 12:e063607. [PMID: 36153028 PMCID: PMC9511576 DOI: 10.1136/bmjopen-2022-063607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION Emotional problems are leading contributors to health burden among adolescents worldwide. There is an urgent need for evidence-based psychological interventions for young people. This study aims to evaluate the effectiveness of a school-based, group psychological intervention, Early Adolescent Skills for Emotions (EASE) developed by the WHO to improve psychosocial distress in Pakistani adolescents. METHOD AND ANALYSIS A two-arm, single-blinded, cluster randomised controlled trial, with a wait-list control arm is being conducted in school settings of rural Pakistan. Forty eligible public-school clusters have been randomised (stratified by gender) on a 1:1 allocation ratio into intervention (n=20) and control arm (n=20). Following informed consent, 564 adolescents with psychosocial distress (Youth-reported Paediatric Symptoms Checklist, cut-off ≥28) from 40 schools have been enrolled into the trial (14±3 average cluster size) between 2 November 2021 and 30th November 2021. Participants in the intervention arm will receive EASE in 7-weekly adolescents and 3-biweekly caregivers group sessions in schools. The adolescent sessions involve the components of psychoeducation, stress management, behavioural activation, problem-solving and relapse prevention. Caregivers will receive training to learn and implement active listening; spending quality time and using praise as a strategy to help their children. The primary outcome is reduction in psychosocial distress at 3 months postintervention. Secondary outcomes include symptoms of depression and anxiety, caregiver-adolescent relationship and caregivers' well-being. Outcomes will be assessed at baseline, immediate 1 week and 3-months postintervention. Qualitative process evaluation will explore barriers and facilitators to programme implementation in low-resource school settings. ETHICS Ethics approval has been obtained from Central Ethics Committee of University of Liverpool, UK, Ethics Review Committee of WHO Geneva and from the Institutional Review Board of Human Development Research Foundation (HDRF), Pakistan. DISSEMINATION The findings of the study will be disseminated by WHO and through peer-reviewed publications. TRIAL REGISTRATION NUMBER ISRCTN17755448.
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Affiliation(s)
- Syed Usman Hamdani
- Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan
- Department of Primary Care and Mental Health, University of Liverpool Faculty of Health and Life Sciences, Liverpool, UK
- Child and Adolescent Mental Health, Human Development Research Foundation, Islamabad, Pakistan
| | - Zill-E- Huma
- Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan
- Department of Primary Care and Mental Health, University of Liverpool Faculty of Health and Life Sciences, Liverpool, UK
- Child and Adolescent Mental Health, Human Development Research Foundation, Islamabad, Pakistan
| | - Aiysha Malik
- Department of Mental Health and Substance Use, World Health Organization, Geneve, Switzerland
| | | | - Um Ul Baneen
- Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan
- Child and Adolescent Mental Health, Human Development Research Foundation, Islamabad, Pakistan
| | - Nadia Suleman
- Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan
- Child and Adolescent Mental Health, Human Development Research Foundation, Islamabad, Pakistan
| | - Hashim Javed
- Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan
- Child and Adolescent Mental Health, Human Development Research Foundation, Islamabad, Pakistan
| | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Mark van Ommeren
- Department of Mental Health and Substance Use, World Health Organization, Geneve, Switzerland
| | - Samra Mazhar
- Noncommunicable Diseases and Mental Health Department, Pakistan Ministry of National Health Services Regulations and Coordination, Islamabad, Pakistan
| | - Shahzad Alam Khan
- Noncommunicable Diseases and Mental Health Department, World Health Organization, Islamabad, Pakistan
| | - Fareed Aslam Minhas
- Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Atif Rahman
- Department of Primary Care and Mental Health, University of Liverpool Faculty of Health and Life Sciences, Liverpool, UK
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Hamdani SU, Huma ZE, Wissow LS. Technology-assisted task-sharing to bridge the treatment gap for childhood developmental disorders in rural Pakistan: an implementation science case study. Implement Sci Commun 2022; 3:99. [PMID: 36109792 PMCID: PMC9479305 DOI: 10.1186/s43058-022-00343-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 09/01/2022] [Indexed: 11/10/2022] Open
Abstract
Background As in many low-income countries, the treatment gap for developmental disorders in Pakistan is nearly 100%. The World Health Organization (WHO) has developed the mental Health Gap Intervention guide (mhGAP-IG) to train non-specialists in the delivery of evidence-based mental health interventions in low-resource settings. However, a key challenge to scale-up of non-specialist-delivered interventions is designing training programs that promote fidelity at scale in low-resource settings. In this case study, we report the experience of using a tablet device-based application to train non-specialist, female family volunteers in leading a group parent skills training program, culturally adapted from the mhGAP-IG, with fidelity at scale in rural community settings of Pakistan. Methods The implementation evaluation was conducted as a part of the mhGAP-IG implementation in the pilot sub-district of Gujar Khan. Family volunteers used a technology-assisted approach to deliver the parent skills training in 15 rural Union Councils (UCs). We used the Proctor and RE-AIM frameworks in a mixed-methods design to evaluate the volunteers’ competency and fidelity to the intervention. The outcome was measured with the ENhancing Assessment of Common Therapeutic factors (ENACT), during training and program implementation. Data on other implementation outcomes including intervention dosage, acceptability, feasibility, appropriateness, and reach was collected from program trainers, family volunteers, and caregivers of children 6 months post-program implementation. Qualitative and quantitative data were analyzed using the framework and descriptive analysis, respectively. Results We trained 36 volunteers in delivering the program using technology. All volunteers were female with a mean age of 39 (± 4.38) years. The volunteers delivered the program to 270 caregivers in group sessions with good fidelity (scored 2.5 out of 4 on each domain of the fidelity measure). More than 85% of the caregivers attended 6 or more of 9 sessions. Quantitative analysis showed high levels of acceptability, feasibility, appropriateness, and reach of the program. Qualitative results indicated that the use of tablet device-based applications, and the cultural appropriateness of the adapted intervention content, contributed to the successful implementation of the program. However, barriers faced by family volunteers like community norms and family commitments potentially limited their mobility to deliver the program and impacted the program’ reach. Conclusions Technology can be used to train non-specialist family volunteers in delivering evidence-based intervention at scale with fidelity in low-resource settings of Pakistan. However, cultural and gender norms should be considered while involving females as volunteer lay health workers for the implementation of mental health programs in low-resource settings. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-022-00343-w.
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Hamdani SU, Zill-E-Huma, Zafar SW, Suleman N, Um-Ul-Baneen, Waqas A, Rahman A. Effectiveness of relaxation techniques 'as an active ingredient of psychological interventions' to reduce distress, anxiety and depression in adolescents: a systematic review and meta-analysis. Int J Ment Health Syst 2022; 16:31. [PMID: 35765083 PMCID: PMC9238062 DOI: 10.1186/s13033-022-00541-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 06/06/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Adolescent depression and anxiety are among the leading contributors to health burden worldwide. 'Relaxation Techniques (RTs)' are a "set of strategies to improve physiological response to stress" and are frequently cited as an active ingredient of trans-diagnostic, psychosocial interventions for scaling-up care for preventing and treating these conditions in adolescents. However, there is a little evidence on the effectiveness of 'relaxation techniques' for this age group. AIM As a part of the Wellcome Trust's Active Ingredients commission, we did a systematic review and meta-analysis to evaluate the effectiveness of RTs to reduce the symptoms of distress, anxiety and depression in young people, aged 14 to 24 years old, globally. METHODS We searched 10 academic databases to include 65 Randomized Controlled Trials (RCTs) of relaxation-based interventions for young people with the symptoms of anxiety and depression. Primary outcomes were reduction in symptoms of distress, anxiety and/or depression. We employed the Cochrane risk of bias tool and GRADE (Grading of Recommendations, Assessment, Development and Evaluations) guidelines to assess certainty of outcomes pertaining to anxiety, depression and distress. Standardized mean difference was estimated using effect size. RESULTS The analysis of 65 RCTs with 8009 young people showed that RTs were highly effective in treating anxiety (pooled effect size of (Standardized Mean Difference-SMD) - 0.54 (95% CI - 0.69 to - 0.40); moderately effective in reducing distress (SMD = - 0.48, 95% CI - 0.71 to - 0.24) and had only a weak effect on improving depression in young people (SMD = - 0.28 (95% CI - 0.40% to - 0.15). Face-to-face delivered relaxation techniques yielded higher effect size (SMD = - 0.47, 95% CI - 0.64 to - 0.30) compared to online delivery (SMD = - 0.22, 95% CI - 0.48 to 0.04) for anxiety. CONCLUSION Most of the included studies were from High Income Countries (HICs) and had a high risk of bias. Further high-quality studies with low risk of bias, especially from low resource settings are needed to evaluate the evidence for effectiveness of RTs as an active ingredient of psychological interventions to reduce the symptoms of distress, anxiety and depression in young people.
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Affiliation(s)
- Syed Usman Hamdani
- Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan.
- Human Development Research Foundation (HDRF), Rawalpindi, Pakistan.
- Institute of Population Health, Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK.
| | - Zill-E-Huma
- Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan
- Human Development Research Foundation (HDRF), Rawalpindi, Pakistan
- Institute of Population Health, Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK
| | - Syeda Wajeeha Zafar
- Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan
- Human Development Research Foundation (HDRF), Rawalpindi, Pakistan
| | - Nadia Suleman
- Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan
- Human Development Research Foundation (HDRF), Rawalpindi, Pakistan
| | - Um-Ul-Baneen
- Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan
- Human Development Research Foundation (HDRF), Rawalpindi, Pakistan
| | - Ahmed Waqas
- Human Development Research Foundation (HDRF), Rawalpindi, Pakistan
- Institute of Population Health, Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK
| | - Atif Rahman
- Institute of Population Health, Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK
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Hamdani SU, Huma ZE, Tamizuddin-Nizami A, Baneen UU, Suleman N, Javed H, Malik A, Wang D, Mazhar S, Khan SA, Minhas FA, Rahman A. Feasibility and acceptability of a multicomponent, group psychological intervention for adolescents with psychosocial distress in public schools of Pakistan: a feasibility cluster randomized controlled trial (cRCT). Child Adolesc Psychiatry Ment Health 2022; 16:47. [PMID: 35729589 PMCID: PMC9210054 DOI: 10.1186/s13034-022-00480-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 06/02/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Child and adolescent mental health problems are a global public mental health priority. However, there is a lack of evidence-based scalable psychological interventions for adolescents living in low resource settings. This trial was designed to evaluate the feasibility and acceptability of delivering the World Health Organization's Early Adolescent Skills for Emotions (EASE) intervention at public schools in a rural sub-district in Rawalpindi, Pakistan. METHODS A two arm, single blinded, feasibility cluster randomized controlled trial with mixed-methods evaluation was conducted with 59 adolescents and their caregivers from 8 public schools. In the 4 intervention arm schools, 6 non-specialist facilitators delivered the culturally-adapted EASE group sessions to the adolescents (n = 29) and their caregivers with desired fidelity under the supervision of in-country supervisors. RESULTS The participation rate of adolescents in the intervention sessions was 83%. The intervention strategies were implemented by the adolescents. However, attending biweekly sessions at schools was challenging for caregivers with only 50% caregivers attending the sessions. CONCLUSIONS The results of this study support the feasibility and acceptability of delivering this culturally adapted intervention through non-specialist facilitators in school settings in Pakistan and pave the way to conduct a fully powered cluster randomized controlled trial to test the effectiveness of intervention to improve psychological outcomes in adolescents. Trial registration Trial registered with Clinicaltrials.gov prospectively; NCT04254393.
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Affiliation(s)
- Syed Usman Hamdani
- Human Development Research Foundation (HDRF), Islamabad, Pakistan. .,Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK. .,Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan. .,Benazir Bhutto Hospital, Institute of Psychiatry, Rawalpindi Medical University, Rawalpindi, Pakistan.
| | - Zill-e Huma
- grid.490844.5Human Development Research Foundation (HDRF), Islamabad, Pakistan ,grid.10025.360000 0004 1936 8470Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK ,grid.419158.00000 0004 4660 5224Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Asad Tamizuddin-Nizami
- grid.415712.40000 0004 0401 3757Benazir Bhutto Hospital, Institute of Psychiatry, Rawalpindi Medical University, Rawalpindi, Pakistan
| | - Um-ul Baneen
- grid.490844.5Human Development Research Foundation (HDRF), Islamabad, Pakistan ,grid.419158.00000 0004 4660 5224Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Nadia Suleman
- grid.490844.5Human Development Research Foundation (HDRF), Islamabad, Pakistan ,grid.419158.00000 0004 4660 5224Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Hashim Javed
- grid.490844.5Human Development Research Foundation (HDRF), Islamabad, Pakistan ,grid.419158.00000 0004 4660 5224Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | | | - Duolao Wang
- grid.48004.380000 0004 1936 9764Global Health Trials Unit, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Samra Mazhar
- Ministry of National Health Services, Regulations and Coordination, Islamabad, Pakistan
| | - Shahzad Alam Khan
- grid.475671.6World Health Organization (WHO), Pakistan Office, Islamabad, Pakistan
| | - Fareed Aslam Minhas
- grid.419158.00000 0004 4660 5224Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Atif Rahman
- grid.10025.360000 0004 1936 8470Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK
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Abstract
OBJECTIVE To evaluate the effectiveness of vortioxetine in major depressive disorder (MDD) when used as a first-line versus second-line treatment or later. METHODS This was a post-hoc analysis of three 3-month non-interventional, prospective studies of vortioxetine in MDD - REVIDA (Malaysia, Philippines, Singapore, Thailand), PREVIDA (Pakistan) and TREVIDA (Taiwan). Improvements in depressive symptoms (PHQ-9, CGI-S), cognitive function (PDQ-D) and work productivity (WPAI) were compared between studies, and in a pooled analysis of patients using vortioxetine as the first line versus second-line treatment or later. Safety was compared between studies. RESULTS Overall, 798 patients were analyzed (PREVIDA = 425, REVIDA = 130, TREVIDA = 243). Most patients in PREVIDA (60.5%)/REVIDA (57.4%) used vortioxetine as first-line treatment versus TREVIDA (21.8%). Generally, greater improvements from baseline were observed across outcome measures in PREVIDA/REVIDA versus TREVIDA (Month 3, p < .0001). Vortioxetine as first-line treatment was associated with greater improvements in depression severity, cognition, functioning outcomes compared to second-line or later users (PHQ-9: -16.1 [6.4] vs -10.8 [8.9]; CGI-S: -2.7 [1.1] vs -2.0 [1.4]; PDQ-D: -29.5 [17.7] vs -18.5 [21.4]; p < .0001 at Month 3) as well as greater response (PHQ-9: 88.6% vs 61.5%; p < .0001) and remission rates (PHQ-9: 75.4% vs 47.7%; p < .0001). No new adverse events were reported outside of the product label. CONCLUSIONS In the Asian real-world setting, vortioxetine showed greater improvements in depressive and cognitive symptoms, work functioning, and response and remission rates when used as first-line versus second-line treatment or later. Vortioxetine was well-tolerated irrespective of the study population across Asia.
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Affiliation(s)
- Rohini Bose
- Lundbeck Singapore Pte Ltd, Singapore, Singapore
| | - Syed Usman Hamdani
- Human Development Research Foundation, Islamabad, Pakistan
- Institute of Psychiatry, Rawalpindi Medical University, Rawalpindi, Pakistan
- Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Fareed Aslam Minhas
- Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan
- Karakoram International University, Gilgit, Pakistan
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Hall J, Jordan S, van Ommeren M, Au T, Sway RA, Crawford J, Ghalayani H, Hamdani SU, Luitel NP, Malik A, Servili C, Sorsdahl K, Watts S, Carswell K. Sustainable Technology for Adolescents and youth to Reduce Stress (STARS): a WHO transdiagnostic chatbot for distressed youth. World Psychiatry 2022; 21:156-157. [PMID: 35015345 PMCID: PMC8751560 DOI: 10.1002/wps.20947] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Jennifer Hall
- 1Department of Mental Health and Substance Use, World Health Organization, Geneva, Switzerland
| | - Stewart Jordan
- 1Department of Mental Health and Substance Use, World Health Organization, Geneva, Switzerland
| | - Mark van Ommeren
- 1Department of Mental Health and Substance Use, World Health Organization, Geneva, Switzerland
| | - Teresa Au
- 1Department of Mental Health and Substance Use, World Health Organization, Geneva, Switzerland
| | - Rajiah Abu Sway
- WHO Office for West Bank and Gaza, occupied Palestinian territories
| | | | | | - Syed Usman Hamdani
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK
- Human Development Research Foundation, Punjab, Pakistan
| | | | - Aiysha Malik
- 1Department of Mental Health and Substance Use, World Health Organization, Geneva, Switzerland
| | - Chiara Servili
- 1Department of Mental Health and Substance Use, World Health Organization, Geneva, Switzerland
| | - Katherine Sorsdahl
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Sarah Watts
- 1Department of Mental Health and Substance Use, World Health Organization, Geneva, Switzerland
| | - Kenneth Carswell
- 1Department of Mental Health and Substance Use, World Health Organization, Geneva, Switzerland
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Akhtar A, Koyiet P, Rahman A, Schafer A, Hamdani SU, Cuijpers P, Sijbrandij M, Bryant RA. Residual posttraumatic stress disorder symptoms after provision of brief behavioral intervention in low- and middle-income countries: An individual-patient data meta-analysis. Depress Anxiety 2022; 39:71-82. [PMID: 34752690 PMCID: PMC9299611 DOI: 10.1002/da.23221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/22/2021] [Accepted: 10/26/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND To address shortages of mental health specialists in low- and middle-income countries, task-shifting approaches have been employed to train nonspecialists to deliver evidence-based scalable psychosocial interventions. Problem Management Plus (PM+) is a brief transdiagnostic nontrauma focused intervention for people affected by adversity. This study reports on the capacity of PM+ to address specific symptoms of posttraumatic stress disorder (PTSD). METHODS Individual patient data from three randomised controlled trials were combined and analysed to observe the impacts of PM+ (n = 738) or enhanced treatment as usual (ETAU) (n = 742) interventions on specific PTSD symptoms at posttreatment and 3-month follow-up. The PTSD-Checklist for DSM-5 (PCL-5) was used to index PTSD symptoms, and presence of each symptom was defined as moderate severity (score ≥ 2 on individual items). RESULTS The average PCL-5 score at baseline was 26.1 (SD: 16.8) with 463 (31.3%) scoring above 33, indicative of a diagnosis of PTSD. Following intervention, 12.5% and 5.8% of participants retained a score greater than 33 at postassessment and follow-up, respectively. There was greater symptom reduction for PM+ than for ETAU for most symptoms. Hyperarousal symptoms were the most common residual symptoms after PM+, with more than 30% of participants reporting persistent sleep disturbance, concentration difficulties, and anger. CONCLUSION PM+ led to greater reduction in symptoms relating to re-experiencing and avoidance. The evidence indicates that strategies focusing on hyperarousal symptoms including sleep, concentration, and anger difficulties, could be strengthened in this brief intervention.
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Affiliation(s)
- Aemal Akhtar
- Clinical, Neuro and Developmental Psychology, World Health Organization Collaborating Centre for Research and Dissemination of Psychological Interventions, Vrije Universiteit, Amsterdam, The Netherlands.,School of Psychology, University of New South Wales, Sydney, Australia
| | | | | | | | - Syed Usman Hamdani
- University of Liverpool, Liverpool, England.,Human Development Research Foundation, Islamabad, Pakistan
| | - Pim Cuijpers
- Clinical, Neuro and Developmental Psychology, World Health Organization Collaborating Centre for Research and Dissemination of Psychological Interventions, Vrije Universiteit, Amsterdam, The Netherlands
| | - Marit Sijbrandij
- Clinical, Neuro and Developmental Psychology, World Health Organization Collaborating Centre for Research and Dissemination of Psychological Interventions, Vrije Universiteit, Amsterdam, The Netherlands
| | - Richard A Bryant
- School of Psychology, University of New South Wales, Sydney, Australia
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Huma ZE, Gillani A, Shafique F, Rashid A, Mahjabeen B, Javed H, Wang D, Rahman A, Hamdani SU. Evaluating the impact of a common elements-based intervention to improve maternal psychological well-being and mother-infant interaction in rural Pakistan: study protocol for a randomised controlled trial. BMJ Open 2021; 11:e047609. [PMID: 34233989 PMCID: PMC8264893 DOI: 10.1136/bmjopen-2020-047609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 06/21/2021] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Millions of children in low resource settings are at high risk of poor development due to factors such as under nutrition, inadequate stimulation and maternal depression. Evidence-based interventions to address these risk factors exist, but often as a separate and overlapping package. The current study aims to evaluate the effectiveness of a common elements-based intervention to improve mother-infant interaction at 12 months post-partum. METHOD AND ANALYSIS A two-arm, single-blinded, individual randomised controlled trial is being carried out in the community settings of the rural subdistrict of Gujar Khan in Rawalpindi, Pakistan. 250 pregnant women in third trimester with distress (Self-Reporting Questionnaire, cut-off score >9) have been randomised on 1:1 allocation ratio into intervention (n=125) and treatment-as-usual arms (n=125). The participants in the intervention arm will receive 15 individual sessions of intervention on a monthly basis by non-specialist facilitators. The intervention involves components of early stimulation, learning through play, responsive feeding, guided discovery using pictures, behavioural activation and problem solving. The primary outcome is caregiver-infant interaction at 12 months postpartum. The secondary outcomes include maternal psychological well-being, quality of life, social support and empowerment. Infant secondary outcomes include growth, nutrition and development. The data will be collected at baseline, 6 and 12 months postpartum. A qualitative process evaluation will be conducted to inform the feasibility of intervention delivery. ETHICS Ethics approval for the present study was obtained from the Human Development Research Foundation Institutional Review Board, Islamabad Pakistan. DISSEMINATION If proven effective, the study will contribute to scale-up care for maternal and child mental health in low resource settings, globally. The findings of the present study will be published in peer-reviewed journals and presented at conferences and community forums. TRIAL REGISTRATION NUMBER NCT04252807.
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Affiliation(s)
- Zill-E- Huma
- Implementation Science, Human Development Research Foundation, Islamabad, Punjab, Pakistan
- Department of Primary Care and Mental Health, University of Liverpool Faculty of Health and Life Sciences, Liverpool, UK
- Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Ayella Gillani
- Implementation Science, Human Development Research Foundation, Islamabad, Punjab, Pakistan
- Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Fakhira Shafique
- Implementation Science, Human Development Research Foundation, Islamabad, Punjab, Pakistan
- Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Alina Rashid
- Implementation Science, Human Development Research Foundation, Islamabad, Punjab, Pakistan
- Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Bushra Mahjabeen
- Implementation Science, Human Development Research Foundation, Islamabad, Punjab, Pakistan
- Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Hashim Javed
- Implementation Science, Human Development Research Foundation, Islamabad, Punjab, Pakistan
- Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Atif Rahman
- Department of Primary Care and Mental Health, University of Liverpool Faculty of Health and Life Sciences, Liverpool, UK
| | - Syed Usman Hamdani
- Implementation Science, Human Development Research Foundation, Islamabad, Punjab, Pakistan
- Department of Primary Care and Mental Health, University of Liverpool Faculty of Health and Life Sciences, Liverpool, UK
- Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan
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Hamoda HM, Chiumento A, Alonge O, Hamdani SU, Saeed K, Wissow L, Rahman A. Addressing the Consequences of the COVID-19 Lockdown for Children's Mental Health: Investing in School Mental Health Programs. Psychiatr Serv 2021; 72:729-731. [PMID: 33502220 PMCID: PMC8192330 DOI: 10.1176/appi.ps.202000597] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Children are likely to struggle with mental health consequences relating to the COVID-19 pandemic. School closures and home confinement increase the risk for emotional distress, domestic violence and abuse, and social isolation, as well as for disruption of sleep-wake and meal cycles, physical exercise routines, and health care access. As schools reopen, school mental health programs (SMHPs) incorporating universal approaches will be important for all children, and targeted approaches will be necessary for those more severely affected. Using their experience in Pakistan, the authors provide a roadmap for extending the World Health Organization's eastern Mediterranean region's SMHP to address the mental health consequences of COVID-19 among children globally.
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Affiliation(s)
- Hesham M Hamoda
- Department of Psychiatry, Boston Children's Hospital and Harvard Medical School, Boston (Hamoda); Department of Primary Care and Mental Health, University of Liverpool, Liverpool, United Kingdom (Chiumento, Hamdani, Rahman); Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore (Alonge); Human Development Research Foundation, Rawalpindi, Punjab, Pakistan (Hamdani, Rahman); Institute of Psychiatry, World Health Organization Collaborating Center for Mental Health Research and Training, Benazir Bhutto Hospital and Rawalpindi Medical University, Rawalpindi, Punjab, Pakistan (Hamdani); World Health Organization Regional Office for the Eastern Mediterranean, Cairo (Saeed); Division of Child and Adolescent Psychiatry, School of Medicine, University of Washington, Seattle (Wissow). Kathleen M. Pike, Ph.D., is editor of this column
| | - Anna Chiumento
- Department of Psychiatry, Boston Children's Hospital and Harvard Medical School, Boston (Hamoda); Department of Primary Care and Mental Health, University of Liverpool, Liverpool, United Kingdom (Chiumento, Hamdani, Rahman); Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore (Alonge); Human Development Research Foundation, Rawalpindi, Punjab, Pakistan (Hamdani, Rahman); Institute of Psychiatry, World Health Organization Collaborating Center for Mental Health Research and Training, Benazir Bhutto Hospital and Rawalpindi Medical University, Rawalpindi, Punjab, Pakistan (Hamdani); World Health Organization Regional Office for the Eastern Mediterranean, Cairo (Saeed); Division of Child and Adolescent Psychiatry, School of Medicine, University of Washington, Seattle (Wissow). Kathleen M. Pike, Ph.D., is editor of this column
| | - Olakunle Alonge
- Department of Psychiatry, Boston Children's Hospital and Harvard Medical School, Boston (Hamoda); Department of Primary Care and Mental Health, University of Liverpool, Liverpool, United Kingdom (Chiumento, Hamdani, Rahman); Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore (Alonge); Human Development Research Foundation, Rawalpindi, Punjab, Pakistan (Hamdani, Rahman); Institute of Psychiatry, World Health Organization Collaborating Center for Mental Health Research and Training, Benazir Bhutto Hospital and Rawalpindi Medical University, Rawalpindi, Punjab, Pakistan (Hamdani); World Health Organization Regional Office for the Eastern Mediterranean, Cairo (Saeed); Division of Child and Adolescent Psychiatry, School of Medicine, University of Washington, Seattle (Wissow). Kathleen M. Pike, Ph.D., is editor of this column
| | - Syed Usman Hamdani
- Department of Psychiatry, Boston Children's Hospital and Harvard Medical School, Boston (Hamoda); Department of Primary Care and Mental Health, University of Liverpool, Liverpool, United Kingdom (Chiumento, Hamdani, Rahman); Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore (Alonge); Human Development Research Foundation, Rawalpindi, Punjab, Pakistan (Hamdani, Rahman); Institute of Psychiatry, World Health Organization Collaborating Center for Mental Health Research and Training, Benazir Bhutto Hospital and Rawalpindi Medical University, Rawalpindi, Punjab, Pakistan (Hamdani); World Health Organization Regional Office for the Eastern Mediterranean, Cairo (Saeed); Division of Child and Adolescent Psychiatry, School of Medicine, University of Washington, Seattle (Wissow). Kathleen M. Pike, Ph.D., is editor of this column
| | - Khalid Saeed
- Department of Psychiatry, Boston Children's Hospital and Harvard Medical School, Boston (Hamoda); Department of Primary Care and Mental Health, University of Liverpool, Liverpool, United Kingdom (Chiumento, Hamdani, Rahman); Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore (Alonge); Human Development Research Foundation, Rawalpindi, Punjab, Pakistan (Hamdani, Rahman); Institute of Psychiatry, World Health Organization Collaborating Center for Mental Health Research and Training, Benazir Bhutto Hospital and Rawalpindi Medical University, Rawalpindi, Punjab, Pakistan (Hamdani); World Health Organization Regional Office for the Eastern Mediterranean, Cairo (Saeed); Division of Child and Adolescent Psychiatry, School of Medicine, University of Washington, Seattle (Wissow). Kathleen M. Pike, Ph.D., is editor of this column
| | - Larry Wissow
- Department of Psychiatry, Boston Children's Hospital and Harvard Medical School, Boston (Hamoda); Department of Primary Care and Mental Health, University of Liverpool, Liverpool, United Kingdom (Chiumento, Hamdani, Rahman); Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore (Alonge); Human Development Research Foundation, Rawalpindi, Punjab, Pakistan (Hamdani, Rahman); Institute of Psychiatry, World Health Organization Collaborating Center for Mental Health Research and Training, Benazir Bhutto Hospital and Rawalpindi Medical University, Rawalpindi, Punjab, Pakistan (Hamdani); World Health Organization Regional Office for the Eastern Mediterranean, Cairo (Saeed); Division of Child and Adolescent Psychiatry, School of Medicine, University of Washington, Seattle (Wissow). Kathleen M. Pike, Ph.D., is editor of this column
| | - Atif Rahman
- Department of Psychiatry, Boston Children's Hospital and Harvard Medical School, Boston (Hamoda); Department of Primary Care and Mental Health, University of Liverpool, Liverpool, United Kingdom (Chiumento, Hamdani, Rahman); Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore (Alonge); Human Development Research Foundation, Rawalpindi, Punjab, Pakistan (Hamdani, Rahman); Institute of Psychiatry, World Health Organization Collaborating Center for Mental Health Research and Training, Benazir Bhutto Hospital and Rawalpindi Medical University, Rawalpindi, Punjab, Pakistan (Hamdani); World Health Organization Regional Office for the Eastern Mediterranean, Cairo (Saeed); Division of Child and Adolescent Psychiatry, School of Medicine, University of Washington, Seattle (Wissow). Kathleen M. Pike, Ph.D., is editor of this column
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10
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Hamdani SU, Huma ZE, Suleman N, Akhtar P, Nazir H, Masood A, Tariq M, Koukab A, Salomone E, Pacione L, Brown F, Shire S, Sikander S, Servili C, Wang D, Minhas FA, Rahman A. Effectiveness of a technology-assisted, family volunteers delivered, brief, multicomponent parents' skills training intervention for children with developmental disorders in rural Pakistan: a cluster randomized controlled trial. Int J Ment Health Syst 2021; 15:53. [PMID: 34059074 PMCID: PMC8165981 DOI: 10.1186/s13033-021-00476-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 05/21/2021] [Indexed: 11/10/2022] Open
Abstract
Background Globally, there is a large documented gap between needs of families and children with developmental disorders and available services. We adapted the World Health Organization’s mental health Gap-Intervention Guidelines (mhGAP-IG) developmental disorders module into a tablet-based android application to train caregivers of children with developmental disorders. We aimed to evaluate the effectiveness of this technology-assisted, family volunteers delivered, parents’ skills training intervention to improve functioning in children with developmental disorders in a rural community of Rawalpindi, Pakistan. Methods In a single-blinded, cluster randomized controlled trial, 30 clusters were randomised (1:1 ratio) to intervention (n = 15) or enhanced treatment as usual (ETAU) arm (n = 15). After screening, 540 children (18 participants per cluster) aged 2–12 years, with developmental disorders and their primary caregivers were recruited into the trial. Primary outcome was child’s functioning, measured by Childhood Disability Assessment Schedule for Developmental Disorders (DD-CDAS) at 6-months post-intervention. Secondary outcomes were parents’ health related quality of life, caregiver-child joint engagement, socio-emotional well-being of children, family empowerment and stigmatizing experiences. Intention-to-treat analyses were done using mixed-models adjusted for covariates and clusters. Results At 6-months post-intervention, no statistically significant mean difference was observed on DD-CDAS between intervention and ETAU (mean [SD], 47.65 [26.94] vs. 48.72 [28.37], Adjusted Mean Difference (AMD), − 2.63; 95% CI − 6.50 to 1.24). However, parents in the intervention arm, compared to ETAU reported improved health related quality of life (mean [SD] 65.56 [23.25] vs. 62.17 [22.63], AMD 5.28; 95% CI 0.44 to 10.11). The results were non-significant for other secondary outcomes. Conclusions In the relatively short intervention period of 6 months, no improvement in child functioning was observed; but, there were significant improvements in caregivers’ health related quality of life. Further trials with a longer follow-up are recommended to evaluate the impact of intervention. Trial registration Clinicaltrials.gov, NCT02792894. Registered April 4, 2016, https://clinicaltrials.gov/ct2/show/NCT02792894
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Affiliation(s)
- Syed Usman Hamdani
- Institute of Psychiatry, Rawalpindi Medical University (RMU) and Benazir Bhutto Hospital, Rawalpindi, Pakistan. .,University of Liverpool, Liverpool, UK. .,Human Development Research Foundation, Islamabad, Pakistan.
| | - Zill-E- Huma
- University of Liverpool, Liverpool, UK.,Human Development Research Foundation, Islamabad, Pakistan
| | - Nadia Suleman
- Human Development Research Foundation, Islamabad, Pakistan
| | - Parveen Akhtar
- Human Development Research Foundation, Islamabad, Pakistan
| | - Huma Nazir
- Human Development Research Foundation, Islamabad, Pakistan
| | - Aqsa Masood
- Human Development Research Foundation, Islamabad, Pakistan
| | | | | | - Erica Salomone
- Department of Mental Health and Substance Abuse, World Health Organisation, Geneva, Switzerland.,Department of Psychology, University of Milan-Bicocca, Milan, Italy
| | - Laura Pacione
- Department of Mental Health and Substance Abuse, World Health Organisation, Geneva, Switzerland.,Department of Psychiatry, Division of Child and Youth Mental Health, University of Toronto, Toronto, ON, Canada
| | - Felicity Brown
- Research and Development Department, War Child Holland, Amsterdam, The Netherlands.,Institute of Social Science Research, University of Amsterdam, Amsterdam, The Netherlands
| | - Stephanie Shire
- Special Education and Clinical Sciences, College of Education, University of Oregon, Eugene, OR, USA
| | | | - Chiara Servili
- Department of Mental Health and Substance Abuse, World Health Organisation, Geneva, Switzerland
| | - Duolao Wang
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Fareed Aslam Minhas
- Institute of Psychiatry, Rawalpindi Medical University (RMU) and Benazir Bhutto Hospital, Rawalpindi, Pakistan
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11
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Hamdani SU, Huma ZE, Tamizuddin-Nizami A. Debate: Child and adolescent mental health services in Pakistan; Do we need in-patient mental health facilities for children and young people? Child Adolesc Ment Health 2021; 26:182-183. [PMID: 33754481 DOI: 10.1111/camh.12463] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/10/2021] [Indexed: 12/01/2022]
Abstract
Depression and anxiety are leading causes of morbidity in children and adolescents worldwide. In Pakistan, young people are exposed to many chronic adversities including violence, social and economic inequalities, and are at greater risk of developing mental health problems. Yet there is a lack of trained human resources, in-patient child and adolescent mental healthcare facilities, and training opportunities in child and adolescent psychiatry and mental health in Pakistan. Given the poor economic condition of the country, which has been made even worse by the COVID-19 pandemic, it is very unlikely that dedicated resources will be made available in near future to develop specialist child and adolescent mental health services in Pakistan. To bridge this treatment gap, we propose a multitiered, transdiagnostic, task-shifting strategy-based model for child and adolescent mental health services in Pakistan.
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Affiliation(s)
- Syed Usman Hamdani
- Institute of Psychiatry, Benazir Bhutto Hospital, Rawalpindi Medical University, Rawalpindi, Pakistan.,Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK.,Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Zill-E- Huma
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK.,Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Asad Tamizuddin-Nizami
- Institute of Psychiatry, Benazir Bhutto Hospital, Rawalpindi Medical University, Rawalpindi, Pakistan
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12
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Divan G, Bhavnani S, Leadbitter K, Ellis C, Dasgupta J, Abubakar A, Elsabbagh M, Hamdani SU, Servili C, Patel V, Green J. Annual Research Review: Achieving universal health coverage for young children with autism spectrum disorder in low- and middle-income countries: a review of reviews. J Child Psychol Psychiatry 2021; 62:514-535. [PMID: 33905120 DOI: 10.1111/jcpp.13404] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Autism presents with similar prevalence and core impairments in diverse populations. We conducted a scoping review of reviews to determine key barriers and innovative strategies which can contribute to attaining universal health coverage (UHC), from early detection to effective interventions for autism in low- and middle-income countries (LAMIC). METHODS A systematic literature search of review articles was conducted. Reviews relevant to the study research question were included if they incorporated papers from LAMIC and focused on children (<eight years old) with autism or their caregivers. The database search was supplemented with bibliographic search of included articles and key informant suggestions. Data were extracted and mapped onto a Theory of Change model toward achieving UHC for autism in LAMIC. RESULTS We identified 31 articles which reviewed data from over fifty countries across Africa, Latin America, Middle East, and Asia and addressed barriers across one or more of four inter-related domains: (a) the social context and family experience for a child with autism; (b) barriers to detection and diagnosis; (c) access to appropriate evidence-based intervention; and (d) social policy and legislation. Key barriers identified included: lack of appropriate tools for detection and diagnosis; low awareness and experienced stigma impacting demand for autism care; and the prevalence of specialist models for diagnosis and treatment which are not scalable in LAMIC. CONCLUSIONS We present a Theory of Change model which describe the strategies and resources needed to realize UHC for children with autism in LAMIC. We highlight the importance of harnessing existing evidence to best effect, using task sharing and adapted intervention strategies, community participation, and technology innovation. Scaling up these innovations will require open access to appropriate detection and intervention tools, systematic approaches to building and sustaining skills in frontline providers to support detection and deliver interventions embedded within a stepped care architecture, and community awareness of child development milestones.
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Affiliation(s)
- Gauri Divan
- Child Development Group, Sangath, Bardez, Goa, India
| | | | - Kathy Leadbitter
- Division of Neuroscience & Experimental Psychology, University of Manchester, Manchester, UK
| | - Ceri Ellis
- Division of Neuroscience & Experimental Psychology, University of Manchester, Manchester, UK
| | | | - Amina Abubakar
- Institute of Human Development, Aga Khan University, Nairobi, Kenya
| | - Mayada Elsabbagh
- Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Syed Usman Hamdani
- Human Development Research Foundation, Punjab, Pakistan.,University of Liverpool, Liverpool, UK
| | - Chiara Servili
- Department of Mental Health and Substance Use, World Health Organization, Geneva, Switzerland
| | - Vikram Patel
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Jonathan Green
- Child and Adolescent Psychiatry, University of Manchester and Manchester Academic Health Sciences Centre, Manchester, UK.,Royal Manchester Children's Hospital, Manchester, UK
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Rahman A, Hamdani SU. Debate: Implementation Science can help bridge the gap between evidence and policy - a case study from the Eastern Mediterranean Region. Child Adolesc Ment Health 2021; 26:80-82. [PMID: 33372717 DOI: 10.1111/camh.12446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 12/11/2020] [Indexed: 11/28/2022]
Abstract
The burden from mental disorder in the Eastern Mediterranean Region (EMR) has risen steadily over the last three decades. The unmet need for interventions puts pressure on policymakers for urgent action, often leading to the introduction of programmes developed in high-income countries, with very little attention to how well these meet local needs. Till well-designed local research including randomised controlled trials become common practice in low- and middle-income countries, implementation science could provide relatively cheaper and quicker ways of ensuring that these interventions do indeed lead to patient benefit. We present a case study of a teacher-delivered school mental health intervention developed by international experts, and implemented in the EMR under the auspices of the World Health Organization. We used an implementation research framework to adapt the programme to local needs, obtain stakeholder buy-in, and design an online-training programme for rapid dissemination in local schools in Egypt, Iran, Jordan and Pakistan. Within the official roll-out of the programme in one EMR country (Pakistan), we embedded a hybrid effectiveness-implementation cluster randomised control trial to evaluate both clinical and implementation outcomes of the adapted intervention. The approach allows for rapid adaptation and evidence building within real-world implementation settings. Capacity in low- and middle-income countries for such research needs to be developed.
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Affiliation(s)
- Atif Rahman
- Department of Primary Care and Mental Health, Institute of Population Health, University of Liverpool, Liverpool, UK
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14
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Hamdani SU, Huma ZE, Masood A, Zhou K, Ahmed Z, Nazir H, Amin H, Akhtar P, Bryant RA, Dawson K, van Ommeren M, Wang D, Rahman A, Minhas FA. Effect of adding a psychological intervention to routine care of common mental disorders in a specialized mental healthcare facility in Pakistan: a randomized controlled trial. Int J Ment Health Syst 2021; 15:11. [PMID: 33468192 PMCID: PMC7814584 DOI: 10.1186/s13033-020-00434-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 12/30/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND In many low resource settings, the provision of government mental health care services is limited to specialized psychiatry units in urban hospital care facilities, where the most common treatment for common mental disorders (CMDs) is pharmacotherapy, occasionally with adjunct nonspecific psychological support. We aimed to evaluate the effectiveness of adding a low intensity, psychological intervention, Problem Management Plus (PM+) for CMDs into routine care in a specialized mental health care facility in Pakistan. METHODS A two arm, single-blind individual randomized controlled trial (RCT) was carried out with adults (N = 192), referred for psychological support by psychiatrists. The study participants were randomized (1:1) to PM + plus Treatment as Usual (TAU) (n = 96) or TAU only (n = 96). The primary outcomes were symptoms of anxiety and depression, measured by the Hospital Anxiety and Depression Scale (HADS) and functional impairment as measured by WHO Disability Assessment Schedule (WHODAS 2.0) at 20 weeks after baseline. RESULTS The analysis was done on intention-to-treat principle. The linear mixed model analysis showed that at 20 weeks after baseline, there was a significant reduction in symptoms of anxiety and depression (mean [SD], 16.23 [8.81] vs 19.79 [7.77]; AMD, - 3.10; 95% CI, - 0.26 to - 5.76); p = 0.03 and improvement in functioning (mean [SD], 22.94 [9.37] vs 27.37 [8.36]; AMD, - 4.35; 95% CI, - 1.45 to - 7.24); p = 0.004 in PM + plus TAU versus TAU arm. The follow-up rate was 67% at primary end-point. CONCLUSIONS Specialized care facilities in LMICs may consider adding brief, evidence-based psychological treatments for CMDs to their routine care. Trial Registration Australian New Zealand Clinical Trials Registry, ACTRN12616000381482. Registered March 23, 2016. Retrospectively registered, https://www.anzctr.org.au/Default.aspx/ ACTRN12616000381482.
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Affiliation(s)
- Syed Usman Hamdani
- University of Liverpool, Liverpool, UK.
- Human Development Research Foundation, Islamabad, Pakistan.
- Institute of Psychiatry, WHO Collaborating Center for Mental Health Research and Training, Rawalpindi, Pakistan.
| | - Zill-E- Huma
- University of Liverpool, Liverpool, UK
- Human Development Research Foundation, Islamabad, Pakistan
| | - Aqsa Masood
- Human Development Research Foundation, Islamabad, Pakistan
| | - Kaina Zhou
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Zainab Ahmed
- Institute of Psychiatry, WHO Collaborating Center for Mental Health Research and Training, Rawalpindi, Pakistan
| | - Huma Nazir
- Human Development Research Foundation, Islamabad, Pakistan
| | - Hania Amin
- Institute of Psychiatry, WHO Collaborating Center for Mental Health Research and Training, Rawalpindi, Pakistan
| | - Parveen Akhtar
- Human Development Research Foundation, Islamabad, Pakistan
| | | | - Katie Dawson
- University of New South Wales, Sydney, Australia
| | | | - Duolao Wang
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Fareed Aslam Minhas
- Institute of Psychiatry, WHO Collaborating Center for Mental Health Research and Training, Rawalpindi, Pakistan
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Hamdani SU, Huma ZE, Suleman N, Warraitch A, Muzzafar N, Farzeen M, Minhas FA, Rahman A, Wissow LS. Scaling-up school mental health services in low resource public schools of rural Pakistan: the Theory of Change (ToC) approach. Int J Ment Health Syst 2021; 15:8. [PMID: 33436049 PMCID: PMC7802314 DOI: 10.1186/s13033-021-00435-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 01/02/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ninety percent of children with mental health problems live in low or middle-income countries (LMICs). School-based programs offer opportunities for early identification and intervention, however implementation requires cross-sector collaboration to assure sustainable delivery of quality training, ongoing supervision, and outcomes monitoring at scale. In Pakistan, 35% of school-aged children are reported to have emotional and behavioral problems. As in many other LMICs, the government agencies who must work together to mount school-based programs have limited resources and a limited history of collaboration. The "Theory of Change" (ToC) process offers a way for new partners to efficiently develop mutual goals and long-term prospects for sustainable collaboration. OBJECTIVE Develop a model for scale-up of school based mental health services in public schools of Pakistan. METHODS We used ToC workshops to develop an empirically supported, 'hypothesized pathway' for the implementation of WHO's School Mental Health Program in the public schools of rural Pakistan. Three workshops included 90 stakeholders such as policy makers from education and health departments, mental health specialists, researchers, head teachers, teachers and other community stakeholders including non-governmental organizations. RESULTS The ToC process linked implementers, organizations, providers and consumers of school mental health services to develop common goals and relate them (improved child socioemotional wellbeing, grades and participation in activities) to interventions (training, monitoring and supervision of teachers; collaboration with parents, teachers and primary health care facilities and schools). Key testable assumptions developed in the process included buy-in from health care providers, education officials and professionals, community-based organizations and families. For example, teachers needed skills for managing children's problems, but their motivation might come from seeking improved school performance and working conditions. Poverty, stigma and lack of child mental health literacy among teachers, administration, and parents were identified as key hypothesized barriers. Children and their families were identified as key stakeholders to make such a program successful. DISCUSSION ToC workshops assisted in team building and served as a stakeholders' engagement tool. They helped to develop and support testable hypotheses about the structures, collaborations, and knowledge most important to scaling-up school based mental health services in Pakistan.
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Affiliation(s)
- Syed Usman Hamdani
- University of Liverpool, Liverpool, UK. .,Human Development Research Foundation, Islamabad, Pakistan. .,Institute of Psychiatry, Rawalpindi, Pakistan.
| | - Zill-E- Huma
- University of Liverpool, Liverpool, UK.,Human Development Research Foundation, Islamabad, Pakistan
| | - Nadia Suleman
- Human Development Research Foundation, Islamabad, Pakistan
| | - Azza Warraitch
- Human Development Research Foundation, Islamabad, Pakistan
| | - Naila Muzzafar
- Human Development Research Foundation, Islamabad, Pakistan
| | - Midhat Farzeen
- Human Development Research Foundation, Islamabad, Pakistan
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16
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Hamdani SU, Warraitch A, Suleman N, Muzzafar N, Minhas FA, Nizami AT, Sikander S, Pringle B, Hamoda HM, Wang D, Rahman A, Wissow LS. Technology-Assisted Teachers' Training to Promote Socioemotional Well-Being of Children in Public Schools in Rural Pakistan. Psychiatr Serv 2021; 72:69-76. [PMID: 32838678 PMCID: PMC7775896 DOI: 10.1176/appi.ps.202000005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND The World Health Organization's (WHO) Eastern Mediterranean Regional Office (EMRO) developed a school mental health program (SMHP) to help reduce the burden of youth mental health problems. Designed in collaboration with international consultants, the SMHP draws on evidence-based interventions to train personnel to identify students in need, respond therapeutically, and engage families in seeking care. METHODS Teams from Pakistan, Egypt, Iran, and Jordan collaborated with the WHO EMRO and British and U.S. universities to form the School Health Implementation Network: Eastern Mediterranean Region (SHINE), a National Institute of Mental Health-funded global mental health hub. SHINE partners used a "theory of change" process to adapt the SMHP to be more readily adopted by school personnel and replicated with fidelity. The adapted SMHP more directly addresses teachers' priorities and uses technology to facilitate training. RESULTS A cluster-randomized implementation effectiveness trial enrolling 960 children ages 8-13 in 80 Pakistani schools will test the adapted SMHP against the original. Children who screen positive on first the teacher and subsequently the parent Strengths and Difficulties Questionnaires (SDQs) will be enrolled and tracked for 9 months. The primary trial outcome is reduction in parent-rated SDQ total difficulties scores. Secondary outcomes include children's well-being, academic performance, absenteeism, and perceived stigma; parent-teacher interaction; teachers' self-efficacy and subjective well-being; and school environment. Implementation outcomes include change in teachers' behavior and sense of program acceptability, cultural appropriateness, feasibility, penetration, and sustainability. NEXT STEPS The trial began in October 2019, and the expected completion date is March 2021. Outcomes will inform dissemination of the SMHP in Pakistan and elsewhere.
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Affiliation(s)
- Syed Usman Hamdani
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, United Kingdom (Hamdani, Huma, Rahman); Institute of Psychiatry, World Health Organization Collaborating Centre for Mental Health Research and Training, Rawalpindi, Pakistan (Hamdani, Minhas, Nizami); Human Development Research Foundation, Islamabad, Pakistan (Hamdani, Huma, Warraitch, Suleman, Muzzafar, Sikander); National Institute of Mental Health, Bethesda, Maryland (Pringle); Department of Psychiatry, Boston Children's Hospital and Harvard Medical School, Boston (Hamoda); Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom (Wang); Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle (Wissow)
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- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, United Kingdom (Hamdani, Huma, Rahman); Institute of Psychiatry, World Health Organization Collaborating Centre for Mental Health Research and Training, Rawalpindi, Pakistan (Hamdani, Minhas, Nizami); Human Development Research Foundation, Islamabad, Pakistan (Hamdani, Huma, Warraitch, Suleman, Muzzafar, Sikander); National Institute of Mental Health, Bethesda, Maryland (Pringle); Department of Psychiatry, Boston Children's Hospital and Harvard Medical School, Boston (Hamoda); Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom (Wang); Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle (Wissow)
| | - Azza Warraitch
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, United Kingdom (Hamdani, Huma, Rahman); Institute of Psychiatry, World Health Organization Collaborating Centre for Mental Health Research and Training, Rawalpindi, Pakistan (Hamdani, Minhas, Nizami); Human Development Research Foundation, Islamabad, Pakistan (Hamdani, Huma, Warraitch, Suleman, Muzzafar, Sikander); National Institute of Mental Health, Bethesda, Maryland (Pringle); Department of Psychiatry, Boston Children's Hospital and Harvard Medical School, Boston (Hamoda); Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom (Wang); Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle (Wissow)
| | - Nadia Suleman
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, United Kingdom (Hamdani, Huma, Rahman); Institute of Psychiatry, World Health Organization Collaborating Centre for Mental Health Research and Training, Rawalpindi, Pakistan (Hamdani, Minhas, Nizami); Human Development Research Foundation, Islamabad, Pakistan (Hamdani, Huma, Warraitch, Suleman, Muzzafar, Sikander); National Institute of Mental Health, Bethesda, Maryland (Pringle); Department of Psychiatry, Boston Children's Hospital and Harvard Medical School, Boston (Hamoda); Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom (Wang); Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle (Wissow)
| | - Naila Muzzafar
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, United Kingdom (Hamdani, Huma, Rahman); Institute of Psychiatry, World Health Organization Collaborating Centre for Mental Health Research and Training, Rawalpindi, Pakistan (Hamdani, Minhas, Nizami); Human Development Research Foundation, Islamabad, Pakistan (Hamdani, Huma, Warraitch, Suleman, Muzzafar, Sikander); National Institute of Mental Health, Bethesda, Maryland (Pringle); Department of Psychiatry, Boston Children's Hospital and Harvard Medical School, Boston (Hamoda); Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom (Wang); Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle (Wissow)
| | - Fareed Aslam Minhas
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, United Kingdom (Hamdani, Huma, Rahman); Institute of Psychiatry, World Health Organization Collaborating Centre for Mental Health Research and Training, Rawalpindi, Pakistan (Hamdani, Minhas, Nizami); Human Development Research Foundation, Islamabad, Pakistan (Hamdani, Huma, Warraitch, Suleman, Muzzafar, Sikander); National Institute of Mental Health, Bethesda, Maryland (Pringle); Department of Psychiatry, Boston Children's Hospital and Harvard Medical School, Boston (Hamoda); Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom (Wang); Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle (Wissow)
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- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, United Kingdom (Hamdani, Huma, Rahman); Institute of Psychiatry, World Health Organization Collaborating Centre for Mental Health Research and Training, Rawalpindi, Pakistan (Hamdani, Minhas, Nizami); Human Development Research Foundation, Islamabad, Pakistan (Hamdani, Huma, Warraitch, Suleman, Muzzafar, Sikander); National Institute of Mental Health, Bethesda, Maryland (Pringle); Department of Psychiatry, Boston Children's Hospital and Harvard Medical School, Boston (Hamoda); Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom (Wang); Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle (Wissow)
| | - Asad Tameezuddin Nizami
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, United Kingdom (Hamdani, Huma, Rahman); Institute of Psychiatry, World Health Organization Collaborating Centre for Mental Health Research and Training, Rawalpindi, Pakistan (Hamdani, Minhas, Nizami); Human Development Research Foundation, Islamabad, Pakistan (Hamdani, Huma, Warraitch, Suleman, Muzzafar, Sikander); National Institute of Mental Health, Bethesda, Maryland (Pringle); Department of Psychiatry, Boston Children's Hospital and Harvard Medical School, Boston (Hamoda); Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom (Wang); Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle (Wissow)
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- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, United Kingdom (Hamdani, Huma, Rahman); Institute of Psychiatry, World Health Organization Collaborating Centre for Mental Health Research and Training, Rawalpindi, Pakistan (Hamdani, Minhas, Nizami); Human Development Research Foundation, Islamabad, Pakistan (Hamdani, Huma, Warraitch, Suleman, Muzzafar, Sikander); National Institute of Mental Health, Bethesda, Maryland (Pringle); Department of Psychiatry, Boston Children's Hospital and Harvard Medical School, Boston (Hamoda); Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom (Wang); Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle (Wissow)
| | - Siham Sikander
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, United Kingdom (Hamdani, Huma, Rahman); Institute of Psychiatry, World Health Organization Collaborating Centre for Mental Health Research and Training, Rawalpindi, Pakistan (Hamdani, Minhas, Nizami); Human Development Research Foundation, Islamabad, Pakistan (Hamdani, Huma, Warraitch, Suleman, Muzzafar, Sikander); National Institute of Mental Health, Bethesda, Maryland (Pringle); Department of Psychiatry, Boston Children's Hospital and Harvard Medical School, Boston (Hamoda); Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom (Wang); Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle (Wissow)
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- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, United Kingdom (Hamdani, Huma, Rahman); Institute of Psychiatry, World Health Organization Collaborating Centre for Mental Health Research and Training, Rawalpindi, Pakistan (Hamdani, Minhas, Nizami); Human Development Research Foundation, Islamabad, Pakistan (Hamdani, Huma, Warraitch, Suleman, Muzzafar, Sikander); National Institute of Mental Health, Bethesda, Maryland (Pringle); Department of Psychiatry, Boston Children's Hospital and Harvard Medical School, Boston (Hamoda); Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom (Wang); Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle (Wissow)
| | - Beverly Pringle
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, United Kingdom (Hamdani, Huma, Rahman); Institute of Psychiatry, World Health Organization Collaborating Centre for Mental Health Research and Training, Rawalpindi, Pakistan (Hamdani, Minhas, Nizami); Human Development Research Foundation, Islamabad, Pakistan (Hamdani, Huma, Warraitch, Suleman, Muzzafar, Sikander); National Institute of Mental Health, Bethesda, Maryland (Pringle); Department of Psychiatry, Boston Children's Hospital and Harvard Medical School, Boston (Hamoda); Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom (Wang); Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle (Wissow)
| | - Hesham M Hamoda
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, United Kingdom (Hamdani, Huma, Rahman); Institute of Psychiatry, World Health Organization Collaborating Centre for Mental Health Research and Training, Rawalpindi, Pakistan (Hamdani, Minhas, Nizami); Human Development Research Foundation, Islamabad, Pakistan (Hamdani, Huma, Warraitch, Suleman, Muzzafar, Sikander); National Institute of Mental Health, Bethesda, Maryland (Pringle); Department of Psychiatry, Boston Children's Hospital and Harvard Medical School, Boston (Hamoda); Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom (Wang); Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle (Wissow)
| | - Duolao Wang
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, United Kingdom (Hamdani, Huma, Rahman); Institute of Psychiatry, World Health Organization Collaborating Centre for Mental Health Research and Training, Rawalpindi, Pakistan (Hamdani, Minhas, Nizami); Human Development Research Foundation, Islamabad, Pakistan (Hamdani, Huma, Warraitch, Suleman, Muzzafar, Sikander); National Institute of Mental Health, Bethesda, Maryland (Pringle); Department of Psychiatry, Boston Children's Hospital and Harvard Medical School, Boston (Hamoda); Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom (Wang); Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle (Wissow)
| | - Atif Rahman
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, United Kingdom (Hamdani, Huma, Rahman); Institute of Psychiatry, World Health Organization Collaborating Centre for Mental Health Research and Training, Rawalpindi, Pakistan (Hamdani, Minhas, Nizami); Human Development Research Foundation, Islamabad, Pakistan (Hamdani, Huma, Warraitch, Suleman, Muzzafar, Sikander); National Institute of Mental Health, Bethesda, Maryland (Pringle); Department of Psychiatry, Boston Children's Hospital and Harvard Medical School, Boston (Hamoda); Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom (Wang); Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle (Wissow)
| | - Lawrence S Wissow
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, United Kingdom (Hamdani, Huma, Rahman); Institute of Psychiatry, World Health Organization Collaborating Centre for Mental Health Research and Training, Rawalpindi, Pakistan (Hamdani, Minhas, Nizami); Human Development Research Foundation, Islamabad, Pakistan (Hamdani, Huma, Warraitch, Suleman, Muzzafar, Sikander); National Institute of Mental Health, Bethesda, Maryland (Pringle); Department of Psychiatry, Boston Children's Hospital and Harvard Medical School, Boston (Hamoda); Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom (Wang); Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle (Wissow)
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Atif N, Rahman A, Huma ZE, Hamdani SU. Preparing for parenthood: developing a life-skills and socioemotional health program for young married couples in rural Pakistan. Glob Health Action 2021; 14:1982485. [PMID: 34605368 PMCID: PMC8491718 DOI: 10.1080/16549716.2021.1982485] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Background Socioemotional life-skills to negotiate important life-transitions such as marriage and parenthood are critical for the wellbeing of young couples and their offspring, but programs addressing this issue are lacking in Low and Middle-Income Countries (LMICs). Objective This study describes the development of a ‘life-skills’ program for young married women, their husbands and families, living in rural settings in Pakistan. Methods Our methods included: a) a targeted review of relevant literature on life-skills and mental health in young people, b) a qualitative study and, c) intervention development workshops with experts and stakeholders. The review showed that common life-skills employed as part of psychosocial interventions in LMICs were communication skills, problem-solving, assessing relations, stress management, emotional regulation, identifying/eliciting affect, and self-awareness. Results The qualitative study indicated that areas of particular need included interpersonal communication skills with significant others, coping with the pressures of parenthood, and mental well-being. Existing helpful practices included social support by family members and elders. Lack of empowerment in young married women and poor engagement of husbands were identified as a barrier to accessing a potential intervention. Our proposed intervention called ‘Preparing for Parenthood’ consisted of 10 core sessions and 10 follow-up sessions designed to be delivered by lay health workers. It synergistically combined evidence-based socioemotional life-skills (awareness, communication skills, assertiveness, decision-making skills, goal-setting, critical thinking, problem-solving, and coping with stress), with cognitive behavioural strategies (gently challenging existing thoughts and attitudes, behaviour activation and problem solving). The intervention focuses on engagement of the entire family, including husbands. Conclusions The intervention can supplement existing sexual and reproductive health programs by providing skills to prospective parents to effectively negotiate stressful life-transitions and life-events. We envisage the intervention would improve mental as well as sexual and reproductive health of young couples and plan to test this in future randomised trials.
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Affiliation(s)
- Najia Atif
- Child and Adolescent Mental Health, Human Development Research Foundation, Rawalpindi, Pakistan
| | - Atif Rahman
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK
| | - Zill-E- Huma
- Child and Adolescent Mental Health, Human Development Research Foundation, Rawalpindi, Pakistan.,Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK
| | - Syed Usman Hamdani
- Child and Adolescent Mental Health, Human Development Research Foundation, Rawalpindi, Pakistan.,Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK
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Hamdani SU, Huma ZE, Rahman A, Wang D, Chen T, van Ommeren M, Chisholm D, Farooq S. Cost-effectiveness of WHO Problem Management Plus for adults with mood and anxiety disorders in a post-conflict area of Pakistan: randomised controlled trial. Br J Psychiatry 2020; 217:623-629. [PMID: 32720628 DOI: 10.1192/bjp.2020.138] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND With the development of evidence-based interventions for treatment of priority mental health conditions in humanitarian settings, it is important to establish the cost-effectiveness of such interventions to enable their scale-up. AIMS To evaluate the cost-effectiveness of the Problem Management Plus (PM+) intervention compared with enhanced usual care (EUC) for common mental disorders in primary healthcare in Peshawar, Pakistan. Trial registration ACTRN12614001235695 (anzctr.org.au). METHOD We randomly allocated 346 participants to either PM+ (n = 172) or EUC (n = 174). Effectiveness was measured using the Hospital Anxiety and Depression Scale (HADS) at 3 months post-intervention. Cost-effectiveness analysis was performed as incremental costs (measured in Pakistani rupees, PKR) per unit change in anxiety, depression and functioning scores. RESULTS The total cost of delivering PM+ per participant was estimated at PKR 16 967 (US$163.14) using an international trainer and supervisor, and PKR 3645 (US$35.04) employing a local trainer. The mean cost per unit score improvement in anxiety and depression symptoms on the HADS was PKR 2957 (95% CI 2262-4029) (US$28) with an international trainer/supervisor and PKR 588 (95% CI 434-820) (US$6) with a local trainer/supervisor. The mean incremental cost-effectiveness ratio (ICER) to successfully treat a case of depression (PHQ-9 ≥ 10) using an international supervisor was PKR 53 770 (95% CI 39 394-77 399) (US$517), compared with PKR 10 705 (95% CI 7731-15 627) (US$102.93) using a local supervisor. CONCLUSIONS The PM+ intervention was more effective but also more costly than EUC in reducing symptoms of anxiety, depression and improving functioning in adults impaired by psychological distress in a post-conflict setting of Pakistan.
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Affiliation(s)
- Syed Usman Hamdani
- Institute of Life and Human Sciences, University of Liverpool, UK; and Human Development Research Foundation, Islamabad, Pakistan
| | - Zill-E- Huma
- Human Development Research Foundation, Islamabad, Pakistan
| | - Atif Rahman
- Institute of Life and Human Sciences, University of Liverpool, UK
| | | | - Tao Chen
- Liverpool School of Tropical Medicine, UK
| | - Mark van Ommeren
- Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland
| | - Dan Chisholm
- WHO Regional Office for Europe, Copenhagen, Denmark
| | - Saeed Farooq
- Lady Reading Hospital, Peshawar, Pakistan; and School of Primary, Community and Social Care, Keele University, UK
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19
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Tol WA, Ager A, Bizouerne C, Bryant R, El Chammay R, Colebunders R, García-Moreno C, Hamdani SU, James LE, Jansen SCJ, Leku MR, Likindikoki S, Panter-Brick C, Pluess M, Robinson C, Ruttenberg L, Savage K, Welton-Mitchell C, Hall BJ, Harper Shehadeh M, Harmer A, van Ommeren M. Improving mental health and psychosocial wellbeing in humanitarian settings: reflections on research funded through R2HC. Confl Health 2020; 14:71. [PMID: 33292413 PMCID: PMC7602334 DOI: 10.1186/s13031-020-00317-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 10/16/2020] [Indexed: 01/08/2023] Open
Abstract
Major knowledge gaps remain concerning the most effective ways to address mental health and psychosocial needs of populations affected by humanitarian crises. The Research for Health in Humanitarian Crisis (R2HC) program aims to strengthen humanitarian health practice and policy through research. As a significant portion of R2HC's research has focused on mental health and psychosocial support interventions, the program has been interested in strengthening a community of practice in this field. Following a meeting between grantees, we set out to provide an overview of the R2HC portfolio, and draw lessons learned. In this paper, we discuss the mental health and psychosocial support-focused research projects funded by R2HC; review the implications of initial findings from this research portfolio; and highlight four remaining knowledge gaps in this field. Between 2014 and 2019, R2HC funded 18 academic-practitioner partnerships focused on mental health and psychosocial support, comprising 38% of the overall portfolio (18 of 48 projects) at a value of approximately 7.2 million GBP. All projects have focused on evaluating the impact of interventions. In line with consensus-based recommendations to consider a wide range of mental health and psychosocial needs in humanitarian settings, research projects have evaluated diverse interventions. Findings so far have both challenged and confirmed widely-held assumptions about the effectiveness of mental health and psychosocial interventions in humanitarian settings. They point to the importance of building effective, sustained, and diverse partnerships between scholars, humanitarian practitioners, and funders, to ensure long-term program improvements and appropriate evidence-informed decision making. Further research needs to fill knowledge gaps regarding how to: scale-up interventions that have been found to be effective (e.g., questions related to integration across sectors, adaptation of interventions across different contexts, and optimal care systems); address neglected mental health conditions and populations (e.g., elderly, people with disabilities, sexual minorities, people with severe, pre-existing mental disorders); build on available local resources and supports (e.g., how to build on traditional, religious healing and community-wide social support practices); and ensure equity, quality, fidelity, and sustainability for interventions in real-world contexts (e.g., answering questions about how interventions from controlled studies can be transferred to more representative humanitarian contexts).
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Affiliation(s)
- Wietse A Tol
- Section of Global Health, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, bg 9, DK-1014, Copenhagen, Denmark.
- Peter C. Alderman Program for Global Mental Health, HealthRight International, New York, NY, USA.
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Alastair Ager
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Cecile Bizouerne
- Mental Health, Child Care Practices, Gender and Protection, Action Contre La Faim, Paris, France
| | - Richard Bryant
- School of Psychology & Traumatic Stress Clinic, University of New South Wales, Sydney, Australia
| | - Rabih El Chammay
- National Mental Health Programme, Ministry of Public Health, Beirut, Lebanon
- Department of Psychiatry, Saint Joseph University, Beirut, Lebanon
| | | | - Claudia García-Moreno
- Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | | | - Leah E James
- Institute of Behavioral Science, University of Colorado, Boulder, CA, USA
| | - Stefan C J Jansen
- Center for Mental Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | | | - Samuel Likindikoki
- Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Catherine Panter-Brick
- Jackson Institute of Global Affairs, Yale University, New Haven, CT, USA
- Department of Anthropology, Yale University, New Haven, CT, USA
| | - Michael Pluess
- Department of Biological and Experimental Psychology, Queen Mary University of London, London, UK
| | - Courtland Robinson
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, London, UK
| | - Leontien Ruttenberg
- International Medical Relief Services (IMRES), Prior association: Arq International, Europe, Netherlands
| | - Kevin Savage
- Evidence Building, World Vision International, Geneva, Switzerland
| | - Courtney Welton-Mitchell
- Institute of Behavioral Science and Colorado School of Public Health, University of Colorado, Boulder, Denver, USA
| | - Brian J Hall
- Global and Community Mental Health Research Group, New York University (Shanghai), Shanghai, People's Republic of China
| | | | | | - Mark van Ommeren
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Rahman A, Naslund JA, Betancourt TS, Black CJ, Bhan A, Byansi W, Chen H, Gaynes BN, Restrepo CG, Gouveia L, Hamdani SU, Marsch LA, Petersen I, Bahar OS, Shields-Zeeman L, Ssewamala F, Wainberg ML. The NIMH global mental health research community and COVID-19. Lancet Psychiatry 2020; 7:834-836. [PMID: 32846142 PMCID: PMC7443356 DOI: 10.1016/s2215-0366(20)30347-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 07/11/2020] [Accepted: 07/13/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Atif Rahman
- Institute of Population Health Sciences, University of Liverpool, Liverpool L69 3BX, UK.
| | - John A Naslund
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | | | | | | | - William Byansi
- Brown School, Washington University in St Louis, St Louis, MO, USA
| | - Hongtu Chen
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA
| | - Bradley N Gaynes
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | | | - Lídia Gouveia
- Department of Mental Health, Ministry of Health, Maputo, Mozambique
| | - Syed Usman Hamdani
- Institute of Population Health Sciences, University of Liverpool, Liverpool L69 3BX, UK
| | - Lisa A Marsch
- Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
| | - Inge Petersen
- Centre for Rural Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | | | - Laura Shields-Zeeman
- Netherlands Institute for Mental Health and Addiction (Trimbos Institute), Utrecht, Netherlands
| | - Fred Ssewamala
- Brown School, Washington University in St Louis, St Louis, MO, USA
| | - Milton L Wainberg
- Department of Psychiatry, New York State, Columbia University, New York, NY, USA
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Hamdani SU, Huma ZE, Wissow L, Rahman A, Gladstone M. Erratum: Measuring functional disability in children with developmental disorders in low-resource settings: validation of Developmental Disorders-Children Disability Assessment Schedule (DD-CDAS) in rural Pakistan. Glob Ment Health (Camb) 2020; 7:e20. [PMID: 32915171 PMCID: PMC7443606 DOI: 10.1017/gmh.2020.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
[This corrects the article DOI: 10.1017/gmh.2020.10.].
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Hamdani SU, Huma ZE, Wissow L, Rahman A, Gladstone M. Measuring functional disability in children with developmental disorders in low-resource settings: validation of Developmental Disorders-Children Disability Assessment Schedule (DD-CDAS) in rural Pakistan. Glob Ment Health (Camb) 2020; 7:e17. [PMID: 32913656 PMCID: PMC7443609 DOI: 10.1017/gmh.2020.10] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 05/12/2020] [Accepted: 05/22/2020] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Developmental disorders (DDs) in children are a priority condition and guidelines have been developed for their management within low-resource community settings. However, a key obstacle is lack of open access, reliable and valid tools that lay health workers can use to evaluate the impact of such programmes on child outcomes. We adapted and validated the World Health Organization's Disability Assessment Schedule for children (WHODAS-Child), a lay health worker-administered functioning-related tool, for children with DDs in Pakistan. METHODS Lay health workers administered a version of the WHODAS-Child to parents of children with DDs (N = 400) and without DDs (N = 400), aged 2-12 years, after it was adapted using qualitative study. Factor analysis, validity, reliability and sensitivity to change analyses were conducted to evaluate the psychometric properties of the adapted outcome measure. RESULTS Among 800 children, 58% of children were male [mean (s.d.) age 6.68 (s.d. = 2.89)]. Confirmatory Factor Analysis showed a robust factor structure [χ2/df 2.86, RMSEA 0.068 (90% CI 0.064-0.073); Tucker-Lewis Index (TLI) 0.92; Comparative Fit Index (CFI) 0.93; Incremental Fit Index (IFI) 0.93]. The tool demonstrated high internal consistency (α 0.82-0.94), test-retest [Intra-class Correlation Coefficient (ICC) 0.71-0.98] and inter-data collector (ICC 0.97-0.99) reliabilities; good criterion (r -0.71), convergent (r -0.35 to 0.71) and discriminative [M (s.d.) 52.00 (s.d. = 21.97) v. 2.14 (s.d. = 4.00); 95% CI -52.05 to -47.67] validities; and adequate sensitivity to change over time (ES 0.19-0.23). CONCLUSIONS The lay health worker administrated version of adapted WHODAS-Child is a reliable, valid and sensitive-to-change measure of functional disability in children aged 2-12 years with DDs in rural community settings of Pakistan.
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Key Words
- AMOS, Analysis of Moment Structure
- Autism
- CFA, Confirmatory Factor Analysis
- CFI, Comparative Fit Index
- CGAS, Children-Global Assessment of Functioning
- DD-CDAS, Developmental Disorders-Children Disability Assessment Schedule
- DD-CGAS, Developmental Disorders Children-Global Assessment of Functioning
- Developmental Disabilities Children's Global Assessment Scale (DD-CGAS)
- Developmental Disorders-Children Disability Assessment Schedule (DD-CDAS)
- ICC, Interclass Correlation
- ICF, International Classification of Functioning
- ICF-CY, International Classification of Functioning-Children and Youth
- IFI, Incremental Fit Index
- International Classification of Functioning-Children and Youth (ICF-CY)
- LHWs, Lady Health Workers.
- RMSEA, Root Mean Square Error of Approximation
- SDGs, Sustainable Development Goals
- TLI, Tucker–Lewis Index
- TQS, Ten Questions Screen
- VABS, Vineland Adaptive Behavior Scales
- WHO Disability Assessment Schedule (WHODAS 2.0)
- WHO mhGAP, World Health Organization Mental Health Gap Action Programme
- childhood disability
- developmental disorders/disabilities
- functional disability
- intellectual disability
- low-resource settings
- non-specialists
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Affiliation(s)
- Syed Usman Hamdani
- University of Liverpool, Liverpool, UK
- Human Development Research Foundation, Islamabad, Pakistan
| | - Zill-e Huma
- University of Liverpool, Liverpool, UK
- Human Development Research Foundation, Islamabad, Pakistan
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Surkan PJ, Hamdani SU, Huma ZE, Nazir H, Atif N, Rowther AA, Chaudhri R, Zafar S, Mullany LC, Malik A, Rahman A. Cognitive-behavioral therapy-based intervention to treat symptoms of anxiety in pregnancy in a prenatal clinic using non-specialist providers in Pakistan: design of a randomised trial. BMJ Open 2020; 10:e037590. [PMID: 32300002 PMCID: PMC7200036 DOI: 10.1136/bmjopen-2020-037590] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Prenatal anxiety is a prevalent condition that is harmful for women and a strong predictor of postpartum depression. This trial assesses an intervention initiated in early pregnancy to mid pregnancy among women with clinical or subclinical symptoms of anxiety in Pakistan. METHODS AND ANALYSIS: Happy Mother, Healthy Baby (HMHB) is a phase three, two-arm, single-blind, individual randomised clinical trial conducted in the outpatient department of Holy Family Hospital, a large public tertiary care facility affiliated with Rawalpindi Medical University (RMU). Pregnant women (enrolled at ≤22 weeks of gestation) receive six individual HMHB sessions based on cognitive-behavioral therapy (CBT) and relaxation techniques that are administered by non-specialist providers and tailored to address anxiety symptoms. Two to six booster sessions are given between the fifth consecutive weekly core session and the sixth core session that occurs in the third trimester. Apart from baseline data, data are collected in the third trimester, at birth and at 6-weeks postpartum. Primary outcomes include diagnoses of postpartum common mental disorders. Secondary outcomes include symptoms of anxiety and of depression, and birth outcomes including small-for-gestational age, low birth weight and preterm birth. An economic analysis will determine the cost effectiveness of the intervention. ETHICS Ethics approval was obtained from the Johns Hopkins Bloomberg School of Health Institutional Review Board (Baltimore, USA), the Human Development Research Foundation Ethics Committee (Islamabad, Pakistan), the RMU Institutional Research Forum (Rawalpindi, Pakistan) and the National Institute of Mental Health-appointed Global Mental Health Data Safety and Monitoring Board. DISSEMINATION Results from this trial will build evidence for the efficacy of a CBT-based intervention for pregnant women delivered by non-specialised providers. Identification of an evidence-based intervention for anxiety starting in early pregnancy to mid pregnancy may be transferable for use and scale-up in other low-income and middle-income countries. TRIAL REGISTRATION NUMBER NCT03880032.
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Affiliation(s)
- Pamela J Surkan
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Syed Usman Hamdani
- Human Development Research Foundation, Rawalpindi, Pakistan
- Institute of Psychiatry, Rawalpindi Medical University, Rawalpindi, Pakistan
| | - Zill-E Huma
- Human Development Research Foundation, Rawalpindi, Pakistan
| | - Huma Nazir
- Human Development Research Foundation, Rawalpindi, Pakistan
| | - Najia Atif
- Human Development Research Foundation, Rawalpindi, Pakistan
| | - Armaan A Rowther
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Rizwana Chaudhri
- Department of Gynaecology and Obstetrics, Holy Family Hospital, Rawalpindi Medical University, Rawalpindi, Pakistan
| | - Shamsa Zafar
- Human Development Research Foundation, Rawalpindi, Pakistan
- Department of Obstetrics and Gynaecology, Air University, Islamabad, Pakistan
| | - Luke C Mullany
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Abid Malik
- Human Development Research Foundation, Rawalpindi, Pakistan
- Institute of Psychiatry, Rawalpindi Medical University, Rawalpindi, Pakistan
| | - Atif Rahman
- Department of Psychological Sciences, University of Liverpool, Liverpool, UK
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Harper Shehadeh M, Van't Hof E, Schafer A, van Ommeren M, Farooq S, Hamdani SU, Koyiet P, Akhtar P, Masood A, Nazir H, Dawson K, Albanese E. Using a person-generated mental health outcome measure in large clinical trials in Kenya and Pakistan: Self-perceived problem responses in diverse communities. Transcult Psychiatry 2020; 57:108-123. [PMID: 31237805 DOI: 10.1177/1363461519854831] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Health care should be informed by the physical, socioeconomic, mental, and emotional well-being of the person, and account for social circumstances and culture. Patient-generated outcome measures can contribute positively to mental health research in culturally diverse populations. In this study, we analysed qualitative responses to the Psychological Outcome Profiles (PSYCHLOPS) Questionnaire-a patient-generated outcome measure based on open-ended questions, and compared the qualitative responses gathered to conventional, nomothetic measures used alongside the PSYCHLOPS in two studies. Data were collected as part of outcome research on a psychological intervention in Pakistan (N = 346) and Kenya (N = 521). Two researchers coded the qualitative responses to the PSYCHLOPS and identified overarching themes. We compared the overarching themes identified to the items in the conventional, nomothetic outcome measures to investigate conceptual equivalence. Using the PSYCHLOPS, the most frequently reported problems in Kenya were financial constraints, poor health, and unemployment. In Pakistan, the most frequent problems were poor health and emotional problems. Most of the person-generated problem concepts were covered also in nomothetic measures that were part of the same study. However, there was no item equivalence in the nomothetic measures for the most frequent PSYCHLOPS problem cited in both countries. Response bias and measurement bias may not be excluded. More research on the use of PSYCHLOPS alongside conventional outcome measures is needed to further explore the extent to which it may bring added value. Use of a PSYCHLOPS semistructured interview schedule and efforts to minimise response biases should be considered.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Aqsa Masood
- Human Development Research Foundation, Pakistan
| | - Huma Nazir
- Human Development Research Foundation, Pakistan
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Volpe U, Amin H, Ayinde OO, Burns A, Chan WC, David R, Dejanovic SD, Djokic G, Eraslan D, Fischer GAL, Gracia-García P, Hamdani SU, Han C, Jafri H, Kallivayalil RA, Kriekaart RL, Kua EH, Lam LCW, Lecic-Tosevski D, Leroi I, Lobo A, Mihai A, Minhas FA, Mistry H, Ogundele AT, Olde Rikkert MGM, Olivera J, Palumbo C, Parker A, Pejuskovic B, Riese F, Robert P, Semrau M, Stoppe G, Sudhakar S, Tirintica AR, Tofique S, Tsoi C, Wolski L, Yalug I, Wang H, Yu X, Sartorius N. Pathways to care for people with dementia: An international multicentre study. Int J Geriatr Psychiatry 2020; 35:163-173. [PMID: 31657091 DOI: 10.1002/gps.5223] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 09/24/2019] [Indexed: 11/07/2022]
Abstract
OBJECTIVE The aim of the present study was to characterize the clinical pathways that people with dementia (PwD) in different countries follow to reach specialized dementia care. METHODS We recruited 548 consecutive clinical attendees with a standardized diagnosis of dementia, in 19 specialized public centres for dementia care in 15 countries. The WHO "encounter form," a standardized schedule that enables data concerning basic socio-demographic, clinical, and pathways data to be gathered, was completed for each participant. RESULTS The median time from the appearance of the first symptoms to the first contact with specialist dementia care was 56 weeks. The primary point of access to care was the general practitioners (55.8%). Psychiatrists, geriatricians, and neurologists represented the most important second point of access. In about a third of cases, PwD were prescribed psychotropic drugs (mostly antidepressants and tranquillizers). Psychosocial interventions (such as psychological counselling, psychotherapy, and practical advice) were delivered in less than 3% of situations. The analyses of the "pathways diagram" revealed that the path of PwD to receiving care is complex and diverse across countries and that there are important barriers to clinical care. CONCLUSIONS The study of pathways followed by PwD to reach specialized care has implications for the subsequent course and the outcome of dementia. Insights into local differences in the clinical presentations and the implementation of currently available dementia care are essential to develop more tailored strategies for these patients, locally, nationally, and internationally.
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Affiliation(s)
- Umberto Volpe
- Department of Neuroscience/DIMSC, Università Politecnica delle Marche, Ancona, Italy
| | - Hania Amin
- WHO Collaborating Centre for Mental Health Research and Training, Institute of Psychiatry, Rawalpindi, Pakistan
| | - Olatunde O Ayinde
- WHO Collaborating Centre for Research and Training in Mental Health, Neurosciences and Drug and Alcohol abuse, Department of Psychiatry, College of Medicine, University of Ibadan, Nigeria
| | - Alistair Burns
- Greater Manchester NIHR Clinical Research Network, University of Manchester, UK, Manchester, UK
| | - Wai Chi Chan
- Department of Psychiatry, The University of Hong Kong, Hong Kong, China
| | - Renaud David
- CoBTEK lab, Research Memory center, University Côte d'Azur, Nice, France
| | | | | | | | - Giulia A L Fischer
- Division of Old Age Psychiatry, Psychiatric University Hospital Zurich, Zurich, Switzerland
| | - Patricia Gracia-García
- Department of Medicine and Psychiatry, University of Zaragoza; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain
| | - Syed Usman Hamdani
- WHO Collaborating Centre for Mental Health Research and Training, Institute of Psychiatry, Rawalpindi, Pakistan
- Human Development Research Foundation, Islamabad, Pakistan
| | - Changsu Han
- Department of Psychiatry, Mind-Medical Research Lab, Korea University, Seoul, Korea
| | | | - Roy A Kallivayalil
- Department of Psychiatry, Pushpagiri Institute of Medical Sciences, Thiruvalla, Kerala, India
| | - Roderick Leonard Kriekaart
- Department of Geriatrics, Radboud Alzheimer Centre, Donders Institute for Brain Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ee Heok Kua
- Department of Psychological Medicine, National University Hospital, Singapore
| | - Linda C W Lam
- Department of Psychiatry, The University of Hong Kong, Hong Kong, China
| | | | - Iracema Leroi
- Global Brain Health Institute, Department of Psychiatry, School of Medicine, Trinity College, Dublin, Ireland
| | - Antonio Lobo
- Department of Medicine and Psychiatry, University of Zaragoza; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain
| | | | | | - Heena Mistry
- Greater Manchester NIHR Clinical Research Network, University of Manchester, UK, Manchester, UK
| | | | - Marcel G M Olde Rikkert
- Department of Geriatrics, Radboud Alzheimer Centre, Donders Institute for Brain Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | | | - Angela Parker
- Greater Manchester NIHR Clinical Research Network, University of Manchester, UK, Manchester, UK
| | - Bojana Pejuskovic
- Institute of Mental Health, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Florian Riese
- Division of Old Age Psychiatry, Psychiatric University Hospital Zurich, Zurich, Switzerland
| | - Philippe Robert
- CoBTEK lab, Research Memory center, University Côte d'Azur, Nice, France
| | - Maya Semrau
- Global Health and Infection Department, Brighton and Sussex Medical School, Brighton; and King's College, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | | | - Sanu Sudhakar
- Department of Psychiatry, Pushpagiri Institute of Medical Sciences, Thiruvalla, Kerala, India
| | - Andreea Raluca Tirintica
- Global Brain Health Institute, Department of Psychiatry, School of Medicine, Trinity College, Dublin, Ireland
| | - Sehrish Tofique
- Pakistan Institute of Living and Learning, Karachi, Pakistan
| | - Chris Tsoi
- Department of Psychological Medicine, National University Hospital, Singapore
| | | | - Irem Yalug
- Pakistan Institute of Living and Learning, Karachi, Pakistan
| | - Huali Wang
- Dementia Care and Research Center, Peking University Institute of Mental Health (Sixth Hospital), Beijing Dementia Key Lab, Beijing, 100191, China
| | - Xin Yu
- Dementia Care and Research Center, Peking University Institute of Mental Health (Sixth Hospital), Beijing Dementia Key Lab, Beijing, 100191, China
| | - Norman Sartorius
- Association for the Improvement of Mental Health Programmes (AMH), Geneva, Switzerland
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Rahman A, Khan MN, Hamdani SU, Chiumento A, Akhtar P, Nazir H, Nisar A, Masood A, Din IU, Khan NA, Bryant RA, Dawson KS, Sijbrandij M, Wang D, van Ommeren M. Effectiveness of a brief group psychological intervention for women in a post-conflict setting in Pakistan: a single-blind, cluster, randomised controlled trial. Lancet 2019; 393:1733-1744. [PMID: 30948286 DOI: 10.1016/s0140-6736(18)32343-2] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 09/13/2018] [Accepted: 09/18/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Many women are affected by anxiety and depression after armed conflict in low-income and middle-income countries, yet few scalable options for their mental health care exist. We aimed to establish the effectiveness of a brief group psychological intervention for women in a conflict-affected setting in rural Swat, Pakistan. METHODS In a single-blind, cluster, randomised, controlled trial, 34 community clusters in two union councils of rural Swat, Pakistan, were randomised using block permutation at a 1:1 ratio to intervention (group intervention with five sessions incorporating behavioural strategies facilitated by non-specialists) or control (enhanced usual care) groups. Researchers responsible for identifying participants, obtaining consent, enrolment, and outcome assessments were masked to allocation. A community cluster was defined as neighbourhood of about 150 households covered by a lady health worker. Women aged 18-60 years who provided written informed consent, resided in the participating cluster catchment areas, scored at least 3 on the General Health Questionnaire-12, and at least 17 on the WHO Disability Assessment Schedule were recruited. The primary outcome, combined anxiety and depression symptoms, was measured 3 months after the intervention with the Hospital Anxiety and Depression Scale (HADS). Modified intention-to-treat analyses were done using mixed models adjusted for covariates and clusters defined a priori. The trial is registered with the Australian New Zealand Clinical Trials Registry, number 12616000037404, and is now closed to new participants. FINDINGS From 34 eligible community clusters, 306 women in the intervention group and 306 women in the enhanced usual care (EUC) group were enrolled between Jan 11, 2016, and Aug 21, 2016, and the results of 288 (94%) of 306 women in the intervention group and 290 (95%) of 306 women in the EUC group were included in the primary endpoint analysis. At 3 months, women in the intervention group had significantly lower mean total scores on the HADS than women in the control group (10·01 [SD 7·54] vs 14·75 [8·11]; adjusted mean difference [AMD] -4·53, 95% CI -7·13 to -1·92; p=0·0007). Individual HADS anxiety scores were also significantly lower in the intervention group than in the control group (5·43 [SD 4·18] vs 8·02 [4·69]; AMD -2·52, 95% CI -4·04 to -1·01), as were depression scores (4·59 [3·87] vs 6·73 [3·91]; AMD -2·04, -3·19 to -0·88). No adverse events were reported in either group. INTERPRETATION Our group psychological intervention resulted in clinically significant reductions in anxiety and depressive symptoms at 3 months, and might be a feasible and effective option for women with psychological distress in rural post-conflict settings. FUNDING WHO through a grant from the Office for Foreign Disaster Assistance.
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Affiliation(s)
- Atif Rahman
- Institute of Life and Human Sciences, University of Liverpool, Liverpool, UK.
| | | | | | - Anna Chiumento
- Institute of Life and Human Sciences, University of Liverpool, Liverpool, UK
| | - Parveen Akhtar
- Human Development Research Foundation, Islamabad, Pakistan
| | - Huma Nazir
- Human Development Research Foundation, Islamabad, Pakistan
| | - Anum Nisar
- Human Development Research Foundation, Islamabad, Pakistan
| | - Aqsa Masood
- Human Development Research Foundation, Islamabad, Pakistan
| | | | - Nasir Ali Khan
- Human Development Research Foundation, Islamabad, Pakistan
| | | | | | | | - Duolao Wang
- Liverpool School of Tropical Medicine, Liverpool, UK
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Sijbrandij M, Farooq S, Bryant RA, Dawson K, Hamdani SU, Chiumento A, Minhas F, Saeed K, Rahman A, van Ommeren M. Correction to: Problem management plus (PM+) for common mental disorders in a humanitarian setting in Pakistan; study protocol for a randomised controlled trial (RCT). BMC Psychiatry 2018; 18:331. [PMID: 30322401 PMCID: PMC6191994 DOI: 10.1186/s12888-018-1922-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 10/04/2018] [Indexed: 11/28/2022] Open
Abstract
Following publication of the original article [1], the first author reported an error in referring his paper.
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Affiliation(s)
- Marit Sijbrandij
- 0000 0001 0686 3219grid.466632.3Department of Clinical Psychology, VU University Amsterdam and EMGO Institute for Health and Care Research, Amsterdam, The Netherlands
| | - Saeed Farooq
- 0000 0004 0481 4343grid.415726.3Post Graduate Medical Institute, Lady Reading Hospital, Peshawar, Pakistan
| | - Richard A Bryant
- 0000 0004 4902 0432grid.1005.4School of Psychology, University of New South Wales, Sydney, Australia
| | - Katie Dawson
- 0000 0004 4902 0432grid.1005.4School of Psychology, University of New South Wales, Sydney, Australia
| | - Syed Usman Hamdani
- grid.490844.5University of Liverpool and Human Development Research Foundation, Islamabad, Pakistan
| | - Anna Chiumento
- grid.490844.5University of Liverpool and Human Development Research Foundation, Islamabad, Pakistan
| | - Fareed Minhas
- grid.412956.dWHO Collaborating Centre for Mental Health Research, Training and Substance Abuse and Institute of Psychiatry, Rawalpindi Medical College, University of Health Sciences, Rawalpindi, Pakistan
| | - Khalid Saeed
- 0000 0001 1942 4602grid.483405.eWHO Regional Office for the Eastern Mediterranean, Cairo, Egypt
| | - Atif Rahman
- University of Liverpool and Human Development Research Foundation, Islamabad, Pakistan.
| | - Mark van Ommeren
- 0000000121633745grid.3575.4Department of Mental Health and Substance Abuse, World Health Organization (WHO), Geneva, Switzerland
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Sijbrandij M, Bryant RA, Schafer A, Dawson KS, Anjuri D, Ndogoni L, Ulate J, Hamdani SU, van Ommeren M. Correction to: Problem Management Plus (PM+) in the treatment of common mental disorders in women affected by gender-based violence and urban adversity in Kenya; study protocol for a randomized controlled trial. Int J Ment Health Syst 2018; 12:55. [PMID: 30337952 PMCID: PMC6182821 DOI: 10.1186/s13033-018-0236-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Marit Sijbrandij
- 1Department of Clinical Neuro- and Developmental Psychology, VU University Amsterdam and EMGO Institute for Health and Care Research, Van der Boechorststraat 1, 1081 BT Amsterdam, The Netherlands
| | - Richard A Bryant
- 2School of Psychology, University of New South Wales, Sydney, Australia
| | - Alison Schafer
- 3World Vision International and World Vision Australia, Burwood East, Australia
| | - Katie S Dawson
- 2School of Psychology, University of New South Wales, Sydney, Australia
| | | | | | | | - Syed Usman Hamdani
- 6University of Liverpool, Liverpool, UK.,7Human Development Research Foundation, Islamabad, Pakistan
| | - Mark van Ommeren
- 8Department of Mental Health and Substance Abuse, World Health Organization (WHO), Geneva, Switzerland
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Hamdani SU, Ahmed Z, Sijbrandij M, Nazir H, Masood A, Akhtar P, Amin H, Bryant RA, Dawson K, van Ommeren M, Rahman A, Minhas FA. Correction to: Problem Management Plus (PM+) in the management of common mental disorders in a specialized mental healthcare facility in Pakistan; study protocol for a randomized controlled trial. Int J Ment Health Syst 2018; 12:53. [PMID: 30275875 PMCID: PMC6158843 DOI: 10.1186/s13033-018-0231-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
[This corrects the article DOI: 10.1186/s13033-017-0147-1.].
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Affiliation(s)
- Syed Usman Hamdani
- 1Institute of Psychiatry, WHO Collaborating Centre for Mental Health Research and Training, Benazir Bhutto Hospital, Rawalpindi, Pakistan
| | - Zainab Ahmed
- 2Human Development Research Foundation, Islamabad, Pakistan
| | - Marit Sijbrandij
- 3Department of Clinical Psychology, VU University, Amsterdam, The Netherlands
| | - Huma Nazir
- 2Human Development Research Foundation, Islamabad, Pakistan
| | - Aqsa Masood
- 2Human Development Research Foundation, Islamabad, Pakistan
| | - Parveen Akhtar
- 2Human Development Research Foundation, Islamabad, Pakistan
| | - Hania Amin
- 1Institute of Psychiatry, WHO Collaborating Centre for Mental Health Research and Training, Benazir Bhutto Hospital, Rawalpindi, Pakistan
| | - Richard A Bryant
- 4School of Psychology, University of New South Wales, Sydney, Australia
| | - Katie Dawson
- 4School of Psychology, University of New South Wales, Sydney, Australia
| | - Mark van Ommeren
- 5World Health Organization (WHO), Department of Mental Health and Substance Abuse, Geneva, Switzerland
| | | | - Fareed Aslam Minhas
- 1Institute of Psychiatry, WHO Collaborating Centre for Mental Health Research and Training, Benazir Bhutto Hospital, Rawalpindi, Pakistan
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30
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Hamdani SU, Ahmed Z, Sijbrandij M, Nazir H, Masood A, Akhtar P, Amin H, Bryant RA, Dawson K, van Ommeren M, Rahman A, Minhas FA. Problem Management Plus (PM+) in the management of common mental disorders in a specialized mental healthcare facility in Pakistan; study protocol for a randomized controlled trial. Int J Ment Health Syst 2017; 11:40. [PMID: 28603552 PMCID: PMC5465445 DOI: 10.1186/s13033-017-0147-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 05/27/2017] [Indexed: 12/23/2022] Open
Abstract
Background The World Health Organization (WHO) has developed Problem Management Plus (PM+), a 5-session, psychological intervention program delivered by trained non-specialist that addresses common mental disorders. The objectives of this study are to evaluate effectiveness and cost-effectiveness of PM+ in a specialized mental health care facility in Pakistan. Methods A single blind individual randomized controlled trial (RCT) will be carried out in the outpatient department of a specialized mental healthcare facility in Rawalpindi, Pakistan. After informed consent, patients with high psychological distress (General Health Questionnaire-12 (score >2) and functional impairment (WHO Disability Assessment Schedule 2.0 score >16) will be randomised to PM+ plus treatment as usual (n = 96) or TAU only (n = 96). The primary outcome is the psychological distress, measured by levels of anxiety and depression on the Hospital Anxiety and Depression Scale and improvement in functioning as measured by WHODAS at 20 weeks after baseline. Secondary outcomes include improvement in symptoms of depression, post-traumatic stress disorder, levels of social support and cost effectiveness evaluation. Qualitative interviews will be conducted to evaluate the process of implementing PM+ including barriers and facilitators in implementation and possibility of integration of PM+ program in specialized mental health care facilities in Pakistan. Discussion The results of this study will be helpful in evaluating the effectiveness of the approach of training non specialists, based in the specialized mental health care facilities in delivering evidence based psychological interventions in the low resource settings. Trial registration Australian New Zealand Clinical Trials Registry, ACTRN12616000381482. Registered Retrospectively on March 23, 2016 Electronic supplementary material The online version of this article (doi:10.1186/s13033-017-0147-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Syed Usman Hamdani
- Institute of Psychiatry, WHO Collaborating Centre for Mental Health Research and Training, Benazir Bhutto Hospital, Rawalpindi, Pakistan
| | - Zainab Ahmed
- Human Development Research Foundation, Islamabad, Pakistan
| | - Marit Sijbrandij
- Department of Clinical Psychology, VU University, Amsterdam, The Netherlands
| | - Huma Nazir
- Human Development Research Foundation, Islamabad, Pakistan
| | - Aqsa Masood
- Human Development Research Foundation, Islamabad, Pakistan
| | - Parveen Akhtar
- Human Development Research Foundation, Islamabad, Pakistan
| | - Hania Amin
- Institute of Psychiatry, WHO Collaborating Centre for Mental Health Research and Training, Benazir Bhutto Hospital, Rawalpindi, Pakistan
| | - Richard A Bryant
- School of Psychology, University of New South Wales, Sydney, Australia
| | - Katie Dawson
- School of Psychology, University of New South Wales, Sydney, Australia
| | - Mark van Ommeren
- World Health Organization (WHO), Department of Mental Health and Substance Abuse, Geneva, Switzerland
| | | | - Fareed Aslam Minhas
- Institute of Psychiatry, WHO Collaborating Centre for Mental Health Research and Training, Benazir Bhutto Hospital, Rawalpindi, Pakistan
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31
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Chiumento A, Hamdani SU, Khan MN, Dawson K, Bryant RA, Sijbrandij M, Nazir H, Akhtar P, Masood A, Wang D, van Ommeren M, Rahman A. Evaluating effectiveness and cost-effectiveness of a group psychological intervention using cognitive behavioural strategies for women with common mental disorders in conflict-affected rural Pakistan: study protocol for a randomised controlled trial. Trials 2017; 18:190. [PMID: 28441974 PMCID: PMC5405533 DOI: 10.1186/s13063-017-1905-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 03/15/2017] [Indexed: 01/23/2023] Open
Abstract
Background The impact of humanitarian disasters upon mental health is well recognised. The evidence for psychological interventions for mental health is mounting, but few interventions have been rigorously tested in humanitarian settings. To be sustainable in humanitarian settings interventions need to be short, simple, deliverable by nonspecialists under supervision, and adopt a transdiagnostic approach where an array of mental health outcomes are addressed simultaneously. These elements have been incorporated into the newly developed WHO Problem Management Plus (PM+) Group intervention. The aim of this trial is to evaluate the locally adapted PM+ Group intervention for women in Swat, Pakistan. Methods This PM+ Group trial is a two-arm, single-blind, cluster randomised controlled trial conducted in a community-based setting with women in rural Pakistan. PM+ is delivered in partnership with the Lady Health Worker (LHW) Programme which provides community-based health care to women in Pakistan. Thirty-four LHW clusters will be randomised in a 1:1 allocation ratio using a permuted-block randomisation method. Participants screened and found to meet the inclusion criteria will be allocated to either the PM+ intervention group (n = 306), or the control arm (n = 306). The manualised PM+ intervention involves five sessions, each lasting 3 h, and introduces four strategies applied by participants to problems that they are facing. It is delivered by local female facilitators with a minimum of 16 years of education who are provided with targeted training and supervision. The primary outcome is individual psychological distress, measured by levels of anxiety and depression on the Hospital Anxiety and Depression Scale at 20 weeks after baseline. Secondary outcomes include major depression, post-traumatic stress disorder, levels of social support, levels of functioning, and economic effectiveness. Intervention acceptability will be explored through an embedded qualitative study. Discussion The PM+ Group trial will provide important evidence on the effectiveness of an empirically supported psychological treatment delivered by nonspecialists in a humanitarian setting. If proven effective, the qualitative component will inform strategies for PM+ Group scale-up in health systems in other humanitarian settings. Trial registration Australian New Zealand Clinical Trials Registry, identifier: ACTRN12616000037404. Registered on 19 January 2016; WHO Protocol ID RPC705, v.4, 2 November 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1905-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Syed Usman Hamdani
- University of Liverpool, Liverpool, UK.,Human Development Research Foundation, Islamabad, Pakistan
| | | | - Katie Dawson
- University of New South Wales, Sydney, NSW, Australia
| | | | | | - Huma Nazir
- Human Development Research Foundation, Islamabad, Pakistan
| | - Parveen Akhtar
- Human Development Research Foundation, Islamabad, Pakistan
| | - Aqsa Masood
- Human Development Research Foundation, Islamabad, Pakistan
| | - Duolao Wang
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Mark van Ommeren
- Department of Mental Health and Substance Abuse, World Health Organisation, Geneva, Switzerland
| | - Atif Rahman
- University of Liverpool, Liverpool, UK.,Human Development Research Foundation, Islamabad, Pakistan
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32
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Rahman A, Hamdani SU, Awan NR, Bryant RA, Dawson KS, Khan MF, Azeemi MMUH, Akhtar P, Nazir H, Chiumento A, Sijbrandij M, Wang D, Farooq S, van Ommeren M. Effect of a Multicomponent Behavioral Intervention in Adults Impaired by Psychological Distress in a Conflict-Affected Area of Pakistan: A Randomized Clinical Trial. JAMA 2016; 316:2609-2617. [PMID: 27837602 DOI: 10.1001/jama.2016.17165] [Citation(s) in RCA: 157] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The mental health consequences of conflict and violence are wide-ranging and pervasive. Scalable interventions to address a range of mental health problems are needed. OBJECTIVE To test the effectiveness of a multicomponent behavioral intervention delivered by lay health workers to adults with psychological distress in primary care settings. DESIGN, SETTING, AND PARTICIPANTS A randomized clinical trial was conducted from November 1, 2014, through January 28, 2016, in 3 primary care centers in Peshawar, Pakistan, that included 346 adult primary care attendees with high levels of both psychological distress and functional impairment according to the 12-item General Health Questionnaire and the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). INTERVENTIONS Lay health workers administered 5 weekly 90-minute individual sessions that included empirically supported strategies of problem solving, behavioral activation, strengthening social support, and stress management. The control was enhanced usual care. MAIN OUTCOMES AND MEASURES Primary outcomes, anxiety and depression symptoms, were independently measured at 3 months with the Hospital Anxiety and Depression Scale (HADS). Secondary outcomes were posttraumatic stress symptoms (Posttraumatic Stress Disorder Checklist for DSM-5), functional impairment (WHODAS 2.0), progress on problems for which the person sought help (Psychological Outcome Profiles), and symptoms of depressive disorder (9-item Patient Health Questionnaire). RESULTS Among 346 patients (mean [SD] age, 33.0 [11.8] years; 78.9% women), 172 were randomly assigned to the intervention and 174 to enhanced usual care; among them, 146 and 160 completed the study, respectively. At baseline, the intervention and control groups had similar mean (SD) HADS scores on symptoms of anxiety (14.16 [3.17] vs 13.64 [3.20]; adjusted mean difference [AMD], 0.52; 95% CI, -0.22 to 1.27) and depression (12.67 [3.27] vs 12.49 [3.34]; AMD, 0.17, 95% CI, -0.54 to 0.89). After 3 months of treatment, the intervention group had significantly lower mean (SD) HADS scores than the control group for anxiety (7.25 [3.63] vs 10.03 [3.87]; AMD, -2.77; 95% CI, -3.56 to -1.98) and depression (6.30 [3.40] vs 9.27 [3.56]; AMD, -2.98; 95% CI, -3.74 to -2.22). At 3 months, there were also significant differences in scores of posttraumatic stress (AMD, -5.86; 95% CI, -8.53 to -3.19), functional impairment (AMD, -4.17; 95% CI, -5.84 to -2.51), problems for which the person sought help (AMD, -1.58; 95% CI, -2.40 to -0.77), and symptoms of depressive disorder (AMD, -3.41; 95% CI, -4.49 to -2.34). CONCLUSIONS AND RELEVANCE Among adults impaired by psychological distress in a conflict-affected area, lay health worker administration of a brief multicomponent intervention based on established behavioral strategies, compared with enhanced usual care, resulted in clinically significant reductions in anxiety and depressive symptoms at 3 months. TRIAL REGISTRATION anzctr.org.au Identifier: ANZCTR12614001235695.
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Affiliation(s)
| | | | | | | | | | | | | | - Parveen Akhtar
- Human Development Research Foundation, Islamabad, Pakistan
| | - Huma Nazir
- Human Development Research Foundation, Islamabad, Pakistan
| | | | | | - Duolao Wang
- Liverpool School of Tropical Medicine, Liverpool, England
| | - Saeed Farooq
- Lady Reading Hospital, Peshawar, Pakistan7Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, England
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Rahman A, Riaz N, Dawson KS, Usman Hamdani S, Chiumento A, Sijbrandij M, Minhas F, Bryant RA, Saeed K, van Ommeren M, Farooq S. Problem Management Plus (PM+): pilot trial of a WHO transdiagnostic psychological intervention in conflict-affected Pakistan. World Psychiatry 2016; 15:182-3. [PMID: 27265713 PMCID: PMC4911784 DOI: 10.1002/wps.20312] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Atif Rahman
- University of LiverpoolLiverpoolUK,Human Development Research FoundationIslamabadPakistan
| | | | | | | | | | | | | | | | - Khalid Saeed
- Mental Health and Substance Abuse UnitRegional Office for the Eastern Mediterranean Region, World Health OrganizationCairoEgypt
| | - Mark van Ommeren
- Department of Mental Health and Substance AbuseWorld Health OrganizationGenevaSwitzerland
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Sijbrandij M, Bryant RA, Schafer A, Dawson KS, Anjuri D, Ndogoni L, Ulate J, Hamdani SU, van Ommeren M. Problem Management Plus (PM+) in the treatment of common mental disorders in women affected by gender-based violence and urban adversity in Kenya; study protocol for a randomized controlled trial. Int J Ment Health Syst 2016; 10:44. [PMID: 27252778 PMCID: PMC4888633 DOI: 10.1186/s13033-016-0075-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 05/12/2016] [Indexed: 11/22/2022] Open
Abstract
Background Women affected by adversity, including gender-based violence, are at increased risk for developing common mental disorders such as depression, anxiety and posttraumatic stress disorder (PTSD). The World Health Organization (WHO) has developed Problem Management Plus (PM+), a 5-session, individual psychological intervention program, that can be delivered by non-specialist counsellors that addresses common mental disorders in people affected by adversity. The objectives of this study are to evaluate effectiveness of PM+ among women who have been affected by adversity, including gender-based violence, and to perform a process evaluation. Methods Informed by community consultations, the PM+ manual has been translated and adapted to the local context. A randomized controlled trial will be carried out in the catchment areas of three local health care facilities in Dagoretti Sub County, Nairobi. After informed consent, females with high psychological distress (General Health Questionnaire-12 (score >2) and functional impairment (WHO Disability Assessment Schedule 2.0 score >16) will be randomised to PM+ (n = 247) or enhanced treatment as usual (n = 247). Post-treatment and 3-months post-treatment follow-up assessments include psychological distress, functional disability, PTSD symptoms, perceived problems for which the person seeks help, health care use and health costs. For evaluating the process of implementing PM+ within local communities in Nairobi 20 key informant interviews will be carried out in participants, PM+ providers, decision makers, clinical staff. Discussion If PM+ is proven effective, it will be rolled out to other low and middle income areas and other populations for further adaptation and testing. Trial registration Australian New Zealand Clinical Trials Registry, ACTRN12616000032459. Registered prospectively on January 18, 2016
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Affiliation(s)
- Marit Sijbrandij
- Department of Clinical, Neuro- and Developmental Psychology, VU University Amsterdam and EMGO Institute for Health and Care Research, Van der Boechorststraat 1, 1081 BT Amsterdam, The Netherlands
| | - Richard A Bryant
- School of Psychology, University of New South Wales, Sydney, Australia
| | - Alison Schafer
- World Vision International and World Vision Australia, Burwood East, Australia
| | - Katie S Dawson
- School of Psychology, University of New South Wales, Sydney, Australia
| | | | | | | | - Syed Usman Hamdani
- University of Liverpool, Liverpool, UK ; Human Development Research Foundation, Islamabad, Pakistan
| | - Mark van Ommeren
- Department of Mental Health and Substance Abuse, World Health Organization (WHO), Geneva, Switzerland
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Minhas A, Vajaratkar V, Divan G, Hamdani SU, Leadbitter K, Taylor C, Aldred C, Tariq A, Tariq M, Cardoza P, Green J, Patel V, Rahman A. Parents' perspectives on care of children with autistic spectrum disorder in South Asia - Views from Pakistan and India. Int Rev Psychiatry 2016; 27:247-56. [PMID: 26107996 DOI: 10.3109/09540261.2015.1049128] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Autism spectrum disorder (ASD) affects about 1.4% of the population in South Asia but very few have access to any form of health care service. The objective of this study was to explore the beliefs and practices related to the care of children with ASD to inform strategies for intervention. In Pakistan, primary data were collected through in-depth interviews of parents (N = 15), while in India a narrative review of existing studies was conducted. The results show that the burden of care is almost entirely on the mother, leading to high levels of stress. Poor awareness of the condition in both family members and front-line health-providers leads to delay in recognition and appropriate management. There is considerable stigma and discrimination affecting children with autism and their families. Specialist services are rare, concentrated in urban areas, and inaccessible to the majority. Strategies for intervention should include building community and family support networks to provide respite to the main carer. In the absence of specialists, community members such as community health workers, traditional practitioners and even motivated family members could be trained in recognizing and providing evidence-based interventions. Such task-shifting strategies should be accompanied by campaigns to raise awareness so greater inclusivity can be achieved.
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Zafar S, Sikander S, Hamdani SU, Atif N, Akhtar P, Nazir H, Maselko J, Rahman A. The effectiveness of Technology-assisted Cascade Training and Supervision of community health workers in delivering the Thinking Healthy Program for perinatal depression in a post-conflict area of Pakistan - study protocol for a randomized controlled trial. Trials 2016; 17:188. [PMID: 27048477 PMCID: PMC4822299 DOI: 10.1186/s13063-016-1308-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 03/22/2016] [Indexed: 11/23/2022] Open
Abstract
Background Rates of perinatal depression in low and middle income countries are reported to be very high. Perinatal depression not only has profound impact on women’s health, disability and functioning, it is associated with poor child health outcomes such as pre-term birth, under-nutrition and stunting, which ultimately have an adverse trans-generational impact. There is strong evidence in the medical literature that perinatal depression can be effectively managed with psychological treatments delivered by non-specialists. Our previous research in Pakistan led to the development of a successful perinatal depression intervention, the Thinking Healthy Program (THP). The THP is a psychological treatment delivered by community health workers. The burden of perinatal depression can be reduced through scale-up of this proven intervention; however, training of health workers at scale is a major barrier. To enhance access to such interventions there is a need to look at technological solutions to training and supervision. Methods/design This is a non-inferiority, single-blinded randomized controlled trial. Eighty community health workers called Lady Health Workers (LHWs) working in a post-conflict rural area in Pakistan (Swat) will be recruited through the LHW program. LHWs will be randomly allocated to Technology-assisted Cascade Training and Supervision (TACTS) or to specialist-delivered training (40 in each group). The TACTS group will receive training in THP through LHW supervisors using a tablet-based training package, whereas the comparison group will receive training directly from mental health specialists. Our hypothesis is that both groups will achieve equal competence. Primary outcome measure will be competence of health workers at delivering THP using a modified ENhancing Assessment of Common Therapeutic factors (ENACT) rating scale immediately post training and after 3 months of supervision. Independent assessors will be blinded to the LHW allocation status. Discussion Women living in post-conflict areas are at higher risk of depression compared to the general population. Implementation of evidence-based interventions for depression in such situations is a challenge because health systems are weak and human resources are scarce. The key innovation to be tested in this trial is a Technology-assisted Cascade Training and Supervision system to assist scale-up of the THP. Trial registration Registered with ClinicalTrials.gov as GCC-THP-TACTS-2015, Identifier: NCT02644902.
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Affiliation(s)
- Shamsa Zafar
- Human Development Research Foundation and Health Services Academy, Islamabad, Pakistan.
| | - Siham Sikander
- Human Development Research Foundation, Islamabad, Pakistan
| | | | - Najia Atif
- Human Development Research Foundation, Islamabad, Pakistan
| | - Parveen Akhtar
- Human Development Research Foundation, Islamabad, Pakistan
| | - Huma Nazir
- Human Development Research Foundation, Islamabad, Pakistan
| | | | - Atif Rahman
- Institute of Psychology, Health and Society, University of Liverpool, Manchester, UK
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Abstract
As in many low-income countries, the treatment gap for developmental disorders in rural Pakistan is near 100%. We integrated social, technological, and business innovations to develop and pilot a potentially sustainable service for children with developmental disorders in 1 rural area. Families with developmental disorders were identified through a mobile phone-based interactive voice response system, and organized into "Family Networks." "Champion" family volunteers were trained in evidence-based interventions. An Avatar-assisted Cascade Training and information system was developed to assist with training, implementation, monitoring, and supervision. In a population of ∼30,000, we successfully established 1 self-sustaining Family Network consisting of 10 trained champion family volunteers working under supervision of specialists, providing intervention to 70 families of children with developmental disorders. Each champion was responsible for training and providing ongoing support to 5 to 7 families from his or her village, and the families supported each other in management of their children. A pre-post evaluation of the program indicated that there was significant improvement in disability and socioemotional difficulties in the child, reduction in stigmatizing experiences, and greater family empowerment to seek services and community resources for the child. There was no change in caregivers' well-being. To replicate this service more widely, a social franchise model has been developed whereby the integrated intervention will be "boxed" up and passed on to others to replicate with appropriate support. Such integrated social, technological, and business innovations have the potential to be applied to other areas of health in low-income countries.
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Affiliation(s)
| | | | - Zafar Iqbal
- Human Development Research Foundation, Islamabad, Pakistan
| | - Atif Rahman
- Human Development Research Foundation, Islamabad, Pakistan; University of Liverpool, Liverpool, United Kingdom
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Sijbrandij M, Farooq S, Bryant RA, Dawson K, Hamdani SU, Chiumento A, Minhas F, Saeed K, Rahman A, van Ommeren M. Problem Management Plus (PM+) for common mental disorders in a humanitarian setting in Pakistan; study protocol for a randomised controlled trial (RCT). BMC Psychiatry 2015; 15:232. [PMID: 26428314 PMCID: PMC4591562 DOI: 10.1186/s12888-015-0602-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 09/09/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In humanitarian settings common mental disorders (depression, anxiety disorders, posttraumatic stress disorder) are highly prevalent. The World Health Organization (WHO) has developed Problem Management Plus (PM+), a 5-session, individual psychological intervention program, delivered by paraprofessionals that addresses common mental disorders in people in communities affected by adversity. The objectives of this study are to test effectiveness and cost-effectiveness of the locally adapted PM+ compared to Treatment as usual (TAU) in Peshawar District, Pakistan. METHODS A randomised controlled trial will be conducted in 346 primary care attendees in 3 health care centres in Peshawar District, Pakistan. After informed consent, primary care attendees with high levels of psychological distress according to the General Health Questionnaire-12 (GHQ-12) and functional impairment (WHO Disability Assessment Schedule 2.0 (WHODAS)) will be assigned to PM+ (n = 173) or TAU (n = 173). At baseline, 1 week and 3 months following PM+, independent assessors will assess psychological distress with the Hospital Anxiety and Depression Scale (HADS), and functional disability with the WHODAS. Secondary outcomes are posttraumatic stress disorder (PTSD) symptoms, and client-perceived priority problems. Further, cost-effectiveness will be assessed using the Service Receipt Inventory (SRI). DISCUSSION If proven effective, PM+ will be rolled out to other areas for further adaptation and testing in diverse humanitarian settings. TRIAL REGISTRATION ACTRN12614001235695. Registered 26 November 2014. Australian New Zealand Clinical Trials Registry.
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Affiliation(s)
- Marit Sijbrandij
- Department of Clinical Psychology, VU University Amsterdam and EMGO Institute for Health and Care Research, Amsterdam, The Netherlands.
| | - Saeed Farooq
- Post Graduate Medical Institute, Lady Reading Hospital, Peshawar, Pakistan.
| | - Richard A. Bryant
- School of Psychology, University of New South Wales, Sydney, Australia
| | - Katie Dawson
- School of Psychology, University of New South Wales, Sydney, Australia.
| | - Syed Usman Hamdani
- University of Liverpool and Human Development Research Foundation, Islamabad, Pakistan.
| | - Anna Chiumento
- University of Liverpool and Human Development Research Foundation, Islamabad, Pakistan.
| | - Fareed Minhas
- WHO Collaborating Centre for Mental Health Research, Training and Substance Abuse and Institute of Psychiatry, Rawalpindi Medical College, University of Health Sciences, Rawalpindi, Pakistan.
| | - Khalid Saeed
- WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt.
| | - Atif Rahman
- University of Liverpool and Human Development Research Foundation, Islamabad, Pakistan.
| | - Mark van Ommeren
- Department of Mental Health and Substance Abuse, World Health Organization (WHO), Geneva, Switzerland.
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Divan G, Hamdani SU, Vajartkar V, Minhas A, Taylor C, Aldred C, Leadbitter K, Rahman A, Green J, Patel V. Adapting an evidence-based intervention for autism spectrum disorder for scaling up in resource-constrained settings: the development of the PASS intervention in South Asia. Glob Health Action 2015; 8:27278. [PMID: 26243710 PMCID: PMC4524889 DOI: 10.3402/gha.v8.27278] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 07/02/2015] [Accepted: 07/06/2015] [Indexed: 11/14/2022] Open
Abstract
Background Evidence-based interventions for autism spectrum disorders evaluated in high-income countries typically require highly specialised manpower, which is a scarce resource in most low- and middle-income settings. This resource limitation results in most children not having access to evidence-based interventions. Objective This paper reports on the systematic adaptation of an evidence-based intervention, the Preschool Autism Communication Therapy (PACT) evaluated in a large trial in the United Kingdom for delivery in a low-resource setting through the process of task-shifting. Design The adaptation process used the Medical Research Council framework for the development and adaptation of complex interventions, focusing on qualitative methods and case series and was conducted simultaneously in India and Pakistan. Results The original intervention delivered by speech and language therapists in a high-resource setting required adaptation in some aspects of its content and delivery to enhance contextual acceptability and to enable the intervention to be delivered by non-specialists. Conclusions The resulting intervention, the Parent-mediated intervention for Autism Spectrum Disorder in South Asia (PASS), shares the core theoretical foundations of the original PACT but is adapted in several respects to enhance its acceptability, feasibility, and scalability in low-resource settings.
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Affiliation(s)
| | | | | | | | - Carol Taylor
- Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - Catherine Aldred
- Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - Kathy Leadbitter
- Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - Atif Rahman
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Jonathan Green
- Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - Vikram Patel
- Sangath, Goa, India.,Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK
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Hamdani SU, Atif N, Tariq M, Minhas FA, Iqbal Z, Rahman A. Family networks to improve outcomes in children with intellectual and developmental disorders: a qualitative study. Int J Ment Health Syst 2014; 8:7. [PMID: 24485093 PMCID: PMC3915557 DOI: 10.1186/1752-4458-8-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 01/27/2014] [Indexed: 11/21/2022] Open
Abstract
Background There are at least 50 million children with an intellectual or developmental disorder in South Asia. The vast majority of these children have no access to any service and there are no resources to develop such services. We aimed to explore a model of care-delivery for such children, whereby volunteer family members of affected individuals could be organized and trained to form an active, empowered group within the community that, a) using a task-sharing approach, are trained by specialists to provide evidence-based interventions to their children; b) support each other, with the more experienced FaNs i.e. family networks, providing peer-supervision and training to new family members who join the group; and c) works to reduce the stigma associated with the condition. Methods We used qualitative methods to explore carers’ perspectives about such a care-delivery model. Results The key findings of this research are that there is a huge gap between the needs of the carers and available services. Carers would welcome a volunteer-led service, and some community members would have time to volunteer. Raising community awareness in a culturally sensitive manner prior to launching such a service and linking it to the community health workers programme would increase the likelihood of success. Gender-matching would be important. It would be possible to form family networks around the more motivated volunteers, with support from local non-governmental organizations. The carers were receptive to the use of technology to assist the work of the volunteers as well as for networking. Conclusions We conclude that family volunteers delivering evidence-based packages of care after appropriate training is a feasible system that can help reduce the treatment gap for childhood intellectual and developmental disorders in under-served populations.
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Affiliation(s)
| | | | | | | | | | - Atif Rahman
- Human Development Research Foundation, Islamabad, Pakistan.
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