Lack of reliable and valid measures of therapist competence is a barrier to dissemination and implementation of psychological treatments in global mental health. We developed the ENhancing Assessment ...of Common Therapeutic factors (ENACT) rating scale for training and supervision across settings varied by culture and access to mental health resources. We employed a four-step process in Nepal: (1) Item generation: We extracted 1081 items (grouped into 104 domains) from 56 existing tools; role-plays with Nepali therapists generated 11 additional domains. (2) Item relevance: From the 115 domains, Nepali therapists selected 49 domains of therapeutic importance and high comprehensibility. (3) Item utility: We piloted the ENACT scale through rating role-play videotapes, patient session transcripts, and live observations of primary care workers in trainings for psychological treatments and the Mental Health Gap Action Programme (mhGAP). (4) Inter-rater reliability was acceptable for experts (intraclass correlation coefficient, ICC(2,7) = 0.88 (95% confidence interval (CI) 0.81–0.93), N = 7) and non-specialists (ICC(1,3) = 0.67 (95% CI 0.60–0.73), N = 34). In sum, the ENACT scale is an 18-item assessment for common factors in psychological treatments, including task-sharing initiatives with non-specialists across cultural settings. Further research is needed to evaluate applications for therapy quality and association with patient outcomes.
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•We review and assess cultural relevance of common factors rating tools.•We develop and pilot a novel tool to assess competence in global mental health.•The tool demonstrates good psychometric properties when used by non-specialists.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Antiretroviral therapy (ART) is efficacious in improving clinical outcomes among people living with HIV (PLWH) and reducing HIV transmission when taken regularly. Research examining modifiable ...factors associated with ART non-adherence is critical for informing novel intervention development in settings with high HIV prevalence. Alcohol use has been linked with ART non-adherence in studies in sub-Saharan Africa; however, no review has pooled estimates across studies. We reviewed studies of alcohol use and ART non-adherence conducted in sub-Saharan Africa. We searched PubMed, CINAHL, EMBASE, and PsycINFO through August 2019 with terms related to ART non-adherence, alcohol use, and sub-Saharan Africa. One author reviewed titles/abstracts (
n
= 754) and two authors reviewed full texts (
n
= 308) for inclusion. Discrepancies were resolved by group consensus. Studies were retained if they quantitatively measured associations between alcohol use and ART non-adherence or viral non-suppression. We defined ART non-adherence using the definitions from each parent study (e.g., patients with > 5% missed ART doses during the previous four, seven or 30 days were considered non-adherent). A random effects meta-analysis was conducted to pool associations and we conducted additional analyses to assess between-study heterogeneity and publication bias and sensitivity analyses to determine robustness of our results when considering only certain study designs, alcohol use or ART scales, or studies that used viral non-suppression as their primary outcome. Of 56 articles meeting our inclusion criteria, 32 articles were included in the meta-analysis. All studies measured alcohol use via self-report. ART non-adherence was assessed using self-report, pill counts, or pharmacy records and definition of non-adherence varied depending on the measure used. Individuals who used alcohol had twice the odds of ART non-adherence compared with those who did not use alcohol (34% non-adherence among alcohol users vs. 18% among non-users; pooled odds ratio: 2.25; 95% confidence interval: 1.87–2.69;
p
< 0.001). We found evidence of a high degree of heterogeneity between studies (Cochrane Q statistic: 382.84, p< 0.001;
I
2
proportion: 91.9%) and evidence of publication bias. However, the magnitude of our pooled odds ratio was consistent across a number of sensitivity analyses to account for heterogeneity and publication bias. In a secondary analysis with studies using viral non-suppression as their primary outcome, we also estimated a statistically significant pooled effect of alcohol use on viral non-suppression (pooled odds ratio: 2.47; 95% confidence interval: 1.58–3.87). Evidence suggests alcohol use is associated with ART non-adherence in Sub-Saharan Africa, potentially hindering achievement of the UNAIDS 90-90-90 HIV treatment targets.
Although 85% of HIV-positive adolescents reside in sub-Saharan Africa, little is known about the psychosocial and mental health factors affecting their daily well-being. Identifying these contextual ...variables is key to development of culturally appropriate and effective interventions for this understudied and high-risk population. The purpose of this study was to identify salient psychosocial and mental health challenges confronted by HIV-positive youth in a resource-poor Tanzanian setting. A total of 24 qualitative interviews were conducted with a convenience sample of adolescents aged 12-24 receiving outpatient HIV care at a medical center in Moshi, Tanzania. All interviews were audio-recorded, transcribed, and coded using thematic analysis. Psychosocial challenges identified included loss of one or more parents, chronic domestic abuse, financial stressors restricting access to medical care and education, and high levels of internalized and community stigma among peers and other social contacts. Over half of youth (56%) reported difficulties coming to terms with their HIV diagnosis and espoused related feelings of self-blame. These findings highlight the urgent need to develop culturally proficient programs aimed at helping adolescents cope with these manifold challenges. Results from this study guided the development of Sauti ya Vijana (The Voice of Youth), a 10-session group mental health intervention designed to address the psychosocial and mental health needs of HIV-positive Tanzanian youth.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
We examined the secondary effects of an antiretroviral therapy (ART) adherence intervention on information, motivation, and behavioral skills (IMB) and patient-provider communication (PPC). Data were ...from a sample of 116 patients enrolled in a quasi-experimental mixed-methods study at two large ART clinics in Haiti. We examined changes in IMB and PPC scores after the intervention and the association between baseline PPC and endline IMB.
The intervention was associated with increased scores in information (ß = 0.89, 95% CI 0.07, 1.70) and motivation (ß = 2.55, 95% CI 0.38, 4.72) but a decreased score in behavioral skills (ß = -2.39, 95% CI -4.29, -0.49), after controlling for demographic and clinical variables. Baseline PPC was associated with higher endline IMB total scores (ß = 0.17, 95% CI 0.02, 0.31), controlling for demographic variables, clinical variables, and baseline IMB score. At the subscale level, baseline PPC was associated with higher endline motivation score (ß = 0.09, 95% CI 0.01, 0.17), marginally associated with higher endline information score (ß = 0.04, 95% CI 0.00, 0.08), after controlling for demographic and clinical variables.
The intervention was beneficial to patients' adherence related motivation. Favorable patient-provider communication is associated with more motivation to adhere to ART.
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DOBA, IJS, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Current psychological trauma-focused interventions have left a gap for individuals who may not be ready for trauma-focused treatment and/or who present with other forms of clinically significant ...distress, such as subthreshold post-traumatic stress disorder (PTSD). Emotion regulation is a possible transdiagnostic mechanism of change that may promote and maintain some of the varied mental health problems related to trauma exposure.
This study examines the feasibility and initial impact of two brief emotion regulation skill trainings targeting different processes hypothesized to reduce trauma-related problems, compared with an active control.
Subjects (
= 156) were randomized to receive one of three brief internet-based trainings: (1) skill training on accepting emotions, (2) skill training on changing emotions, or (3) stress psychoeducation (control). Participants completed measures of emotion regulation, mindfulness, and affect intensity 24 hours pre- and immediately post-training.
Results suggested that a brief internet-based skills training programme was feasible and acceptable, with 91.9% completing the training programme to which they were randomized. Results showed that participants in all conditions demonstrated significant decreases in emotion regulation problems over time; yet these improvements did not vary by condition. Participants in the Change condition with higher PTSD symptoms were significantly more likely to have greater increases in positive affect compared with those with lower PTSD symptoms.
Although the three conditions did not show different outcomes, all three brief internet-delivered trainings were feasible. Results provide direction for future studies to evaluate the delivery of emotion regulation skills in individuals with trauma-related distress.
Growing evidence exists on the potential for adapting evidence-based interventions for low- and-middle-income countries (LMIC). One opportunity that has received limited attention is the adaptation ...of psychotherapies developed in high-income countries (HIC) based on principles from LMIC cultural groups. Dialectical behavior therapy (DBT) is one such treatment with significant potential for acceptability in South Asian settings with high suicide rates. We describe a tri-phasic approach to adapt DBT in Nepal that consists of qualitative interviews with major Nepali mental health stakeholders (Study 1), an adaptation workshop with 15 Nepali counselors (Study 2), and a small-scale treatment pilot with eligible clients in one rural district (Study 3). Due to low literacy levels, distinct conceptualizations of mind and body, and program adherence barriers, numerous adaptations were required. DBT concepts attributable to Asian belief systems were least comprehensible to clients. However, the 82% program completion rate suggests utility of a structured, skills-based treatment. This adaptation process informs future research regarding the effectiveness of culturally adapted DBT in South Asia.
•There is growing public health need to adapt therapies for global mental health settings.•Dialectical behavior therapy has strong potential for cross-cultural adaptation.•A tri-phasic, collaborative approach was used to adapt DBT for rural Nepali women.•Core components of Nepali ethnopsychology were included in the intervention.•An 82% program completion rate suggests utility of the adapted program.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Background
Suicide in low‐ and middle‐income countries (LMICs) accounts for 75% of the world's burden of suicide mortality and is the leading single cause of death among Nepali reproductive age ...women. To advance treatment for suicidal behaviors in LMICs, a single‐case experimental design (SCED) was conducted of a culturally adapted Dialectical Behavior Therapy skills intervention for Nepali populations (DBT‐N).
Method
Ten Nepali women with histories of suicidality participated in the 10‐session intervention. Outcomes of emotion regulation, suicidal ideation, depression, anxiety, resilience, and coping skills use were measured at multiple time points pre‐intervention, during, and at follow‐up. Qualitative interviewing assessed DBT‐N's feasibility and acceptability.
Results
Participants showed improvements in emotion regulation over the course of treatment, which were associated with increased skills use. Rapid, sustained reductions in suicidal ideation and improvements in resilience were observed after DBT‐N initiation.
Conclusion
This SCED supports conducting further evaluation of DBT‐N through controlled trials with emotion regulation as a target mechanism of action for reducing suicidal behaviors in LMICs.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK
Child and adolescent mental health problems are major contributors to the global burden of disease in low- and middle-income country (LMIC) settings. To advance the evidence base for adolescent ...mental health interventions in LMICs, we evaluated the feasibility and acceptability of a school-based emotion regulation prevention intervention (READY-Nepal) for adolescents who had a recent exposure to a humanitarian disaster.
A mixed-method, non-randomized controlled trial was conducted with Nepali secondary school students in one heavily affected post-earthquake district. Students (
= 102; aged 13 to 17 years) were enrolled in the intervention (
= 42) and waitlist control (
= 60) conditions. Feasibility and acceptability were examined via attendance, and by qualitative interviews with a subset of students (
= 15), teachers (
= 2), and caregivers (
= 3). Preliminary efficacy was examined on primary outcome (emotion regulation) and secondary outcomes (anxiety symptoms, posttraumatic stress symptoms, functional impairment, resilience, coping skills), which were measured at baseline and post-intervention (four weeks).
Delivering the intervention was feasible and acceptable, as demonstrated by low dropout (8%) and high program attendance (6.7 of 8 sessions). Qualitative data suggested high uptake of anger regulation skills, but lower uptake of mindfulness skills. Despite this, there were no significant differences by condition on primary or secondary outcomes at four-week follow-up. Students provided suggestions for improvement of the program.
Further research on longitudinal outcome measurement, use of alternatives to retrospective self-report data, and rigorous development of culturally grounded models of emotion regulation is necessary to explore the utility of school-based emotion regulation interventions in Nepal and other LMICs.
Two decades since the development of antiretroviral therapy (ART) for HIV, adherence remains the primary obstacle to achieving the best outcomes for patients receiving treatment.1 Indeed, despite the ...increased availability and affordability of potent once-daily regimens worldwide, the UNAIDS goal of 90% viral suppression has not been reached, partly because of poor adherence.2,3 Dedicated funding has generated a wave of rigorous research on developing and assessing interventions to promote ART adherence in both high-income and low-resource settings.4,5 Notably, a research synthesis project by the US Centers for Disease Control6 has identified 13 interventions that are supported by good evidence.7,8 In the Lancet Infectious Diseases, Marijn de Bruin and colleagues9 present the results of their multicentre randomised trial of an intervention to improve adherence to treatment for HIV-an outstanding addition to the scientific literature on adherence. Capitalising on advances in EDM technologies, novel mHealth devices, and other adherence assessment strategies (eg, pharmacy refills) might improve acceptability, feasibility, and affordability of the intervention. ...although EDM data are integrated into most key intervention components, we do not know whether the assessment of daily adherence patterns (as with EDM) and the joint review of adherence during counselling sessions are essential to the intervention's effects...
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
While Haiti has scaled up use of antiretroviral therapy (ART), current studies suggest sub-optimal adherence threatens long-term viral suppression in this understudied setting. Patient-provider ...communication (PPC) and information, motivation, and behavioral skills (IMB) have been implicated in ART adherence globally. However, no studies have examined their relevance in Haiti. The present mixed-methods study utilized cross-sectional survey data from 128 ART-initiating patients at 2 large HIV treatment sites in Haiti, as well as observational data from 12 clinic visits, to document associations between adherence-related PPC and IMB. Multivariate regression analyses suggested that PPC is associated with IMB constructs. At the bivariate level, more effective PPC was associated with higher levels of adherence-related information and motivation, but not behavioral skills. Observational findings indicate infrequent and non-collaborative adherence support. Taken together, findings lay the groundwork for additional research in the area of PPC, IMB, and ART adherence in Haiti.
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