Suicide is a critical global public health issue in low- and middle-income countries (LMIC) in which the majority of the world’s suicides occur. Low provider competency in managing suicide risk, ...particularly, among non-specialist or “lay” providers with minimal health or mental health training, is a theoretically critical yet poorly studied aspect of global suicide prevention that has received limited attention in the global suicide arena. The current series of four studies examined barriers (provider stigma, competency, validation, and invalidation) to competent delivery of suicide prevention services by non-specialists in Nepal (N = 205 providers) as well as their impact on patient outcomes (depressive symptoms and suicidal ideation) (N = 96 patients receiving treatment over six months). In Chapter II, pre-training competency in delivering common therapeutic factors was significantly associated with suicide-specific clinical competency (β = .48, p < .001). A small percentage of lay providers (14.2%) assessed for suicidality, and one developed a safety plan. In Chapter III, 48.7% of providers assessed for suicide and 4.9% conducted safety planning 4-months post-training. These percentages increased to 57.5% and 11.9% 16-months post-training. Pre-training common factors competency significantly predicted suicide clinical competency 4-months post-training ((β = .24, p < .05). Contrary to hypotheses, pre-training provider implicit bias (β = .30, p < .001) and mental health knowledge (β = .23, p < .05) significantly predicted suicide clinical competency 16-months post-training. In Chapter IV, lay provider validation (β = 0.63, p < .001), but not invalidation (β = 0.22, p > .05) was associated with suicide clinical competency.In Chapter V, the relationship between lay provider suicide clinical competency and patient outcomes was mixed. An increase in post-training suicide clinical competency did not predict change in depressive symptoms (β = 3.14, robust Z = 1.86). However, there were significant products between pre- and post-training suicide clinical competency (β = -5.92, robust Z = -3.51), such that for providers with low pre-training suicide clinical competency, an increase in post-training suicide clinical competency predicted a worsening of depressive symptoms, relative to a reduction in depressive symptoms for providers with high pre-training suicide clinical competency. There was also a significant product between post-training common factors competency and suicide clinical competency (β = 3.49, robust Z = 3.79), such that for providers with higher suicide clinical competency, an increase in provider common factors competency predicted a reduction in depressive symptoms.Additionally, provider post-training explicit bias predicted a greater odds of improving SI (OR = 8.15; robust Z = 4.98), and there was a significant product between post-training provider implicit bias and suicide clinical competency (OR = 2.77, robust Z = 2.97). At high provider suicide clinical competency (vs. low provider suicide clinical competency), the odds of patient suicidality improving increased an additional 17.5%. Future studies should replicate the original investigation and conduct a deeper examination of modifiable processes that explain the link between common factors competency, validation, suicide clinical competency, and patient outcomes over time. This knowledge can be used to improve training of health workers, systematic detection of suicidal behavior within healthcare settings, and suicidal patient outcomes.
Task-sharing is the involvement of non-specialist providers to deliver mental health services. A challenge for task-sharing programs is to achieve and maintain clinical competence of non-specialists, ...including primary care workers, paraprofessionals, and lay providers. We developed a tool for non-specialist peer ratings of common factors clinical competency to evaluate and optimize competence during training and supervision in global mental health task-sharing initiatives. The 18-item
hancing
ssessment of
ommon
herapeutic factors (ENACT) tool was pilot-tested with non-specialists participating in mental health Gap Action Programme trainings in Nepal. Qualitative process evaluation was used to document development of the peer rating scoring system. Qualitative data included interviews with trainers and raters as well as transcripts of pre- and post-training observed structured clinical evaluations. Five challenges for non-specialist peer ratings were identified through the process evaluation: (1) balance of training and supervision objectives with research objectives; (2) burden for peer raters due to number of scale items, number of response options, and use of behavioral counts; (3) capturing hierarchy of clinical skills; (4) objective
. subjective aspects of rating; and (5) social desirability when rating peers. The process culminated in five recommendations based on the key findings for the development of scales to be used by non-specialists for peer ratings in low-resource settings. Further research is needed to determine the ability of ENACT to capture the relationship of clinical competence with client outcomes and to explore the relevance of these recommendations for non-specialist peer ratings in high-resource settings.
Background: Child and adolescent mental health problems are major contributors to the global burden of disease, with the majority of the mental health burden concentrated in low- and middle-income ...country (LMIC) settings. To advance the evidence base for adolescent mental health interventions in LMICs, we piloted and evaluated the preliminary efficacy of a culturally adapted emotion regulation intervention (Regulating Emotions thought Adapted Dialectical behavior skills for Youth; READY-Nepal) for earthquake-exposed adolescents in Nepal. Methods: A gender-stratified, quasi-experimental design was conducted targeting Nepali secondary school students in one heavily affected post-earthquake district. A total of 102 adolescents (age 13 to 18) were enrolled in the group-based intervention. The primary outcome (emotion regulation) and secondary outcomes (coping skills, anxiety, trauma, functioning, resilience, and suicidal ideation) were measured at baseline and follow-up (four weeks). Results: Contrary to our hypotheses, we found no difference by arm either primary or secondary outcomes at four-week follow-up, with the exception of functioning (with control participants reporting greater improvement than intervention participants). Across arms, females reported greater reductions in anxiety and trauma symptoms relative to males. Conclusion: Further research, including investigation of optimal program dosage, delivery formats, and cultural models of emotion regulation, is necessary to explore the potential of school-based emotion regulation interventions in Nepal and other LMICs.
Published research on suicide and suicidal behavior has expanded rapidly in recent years and indicates the presence of a growing global public health concern. In Nepal, suicide is the number one of ...cause of mortality in women of childbearing age, accounting for 16 percent of deaths within this age group. Although treatments and therapies for suicide vary considerably, adapting existing interventions to allow them to remain culturally congruent with the worldviews of ethnic and racial minority groups is becoming an essential practice. In this study, we conducted a cultural adaptation, training, and piloting of manualized dialectical behavior therapy (DBT) in rural Nepal. DBT is a pliable, evidence-based treatment that is proven effective for risk reduction of suicidal behavior and non-suicidal self-injury (NSSI). However, its feasibility and acceptability has yet to be studied in a low-resource, international setting. In this study, the formative process used to guide modification of the standard DBT regimen is outlined. Qualitative research including focus group discussions and key informant interviews aided in incorporation of crucial elements of Nepali ethnopsychology, and a training based on the manualized adaptation with psychosocial counselors was conducted. Culturally adapted DBT (CA-DBT) was then piloted with ten women in a rural district in Northwest Nepal. Preliminary data suggests that, with additional modification and piloting, CA-DBT holds promising potential as a psychological intervention in Nepal. A number of qualitative successes and challenges in implementation are highlighted, as are suggestions for program bolstering and further testing.
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