In an analysis of data from the Creditor Reporting System, Chunling Lu and colleagues investigate the level of development assistance from high-income countries towards child and adolescent mental ...health in low- and middle-income countries.
Introduction
The COVID‐19 pandemic has brought a health care crisis of unparalleled devastation. A mental health crisis as a second wave has begun to emerge in our front‐line health care workers.
...Objective
To address these needs, The Healthcare Worker Mental Health COVID‐19 Hotline, based on crisis intervention principles, was developed and launched in 2 weeks.
Methods
Upon reflection of why this worked, we decided it might be useful to describe what we now recognize as 13‐steps which led to our success. The process included the following: (1) anticipate mental health needs; (2) use leadership capable of mobilizing the systems and resources; (3) convene a multidisciplinary team; (4) delegate tasks and set timelines; (5) choose a clinical service model; (6) motivate staff as a workforce of volunteers; (7) develop training and educational materials; (8) develop personal, local, and national resources; (9) develop marketing plans; (10) deliver the training; (11) launch a 24 hr/7days per week Healthcare Worker Mental Health COVID‐19 Hotline, and launch follow‐up sessions for staff; (12) structure data collection to determine effectiveness and outcomes; and (13) obtain funding (not required).
Discussion
We believe the process we used is specifically useful for others who may want to develop a COVID‐19 hotline services for health care workers and generally useful for the development of other mental health services.
Conclusion
We hope that this process may serve as a guide for other heath care systems.
In low-income countries, care for people with mental, neurological, and substance use (MNS) disorders is largely absent, especially in rural settings. To increase treatment coverage, integration of ...mental health services into community and primary healthcare settings is recommended. While this strategy is being rolled out globally, rigorous evaluation of outcomes at each stage of the service delivery pathway from detection to treatment initiation to individual outcomes of care has been missing.
A combination of methods were employed to evaluate the impact of a district mental healthcare plan for depression, psychosis, alcohol use disorder (AUD), and epilepsy as part of the Programme for Improving Mental Health Care (PRIME) in Chitwan District, Nepal. We evaluated 4 components of the service delivery pathway: (1) contact coverage of primary care mental health services, evaluated through a community study (N = 3,482 combined for all waves of community surveys) and through service utilisation data (N = 727); (2) detection of mental illness among participants presenting in primary care facilities, evaluated through a facility study (N = 3,627 combined for all waves of facility surveys); (3) initiation of minimally adequate treatment after diagnosis, evaluated through the same facility study; and (4) treatment outcomes of patients receiving primary-care-based mental health services, evaluated through cohort studies (total N = 449 depression, N = 137; AUD, N = 175; psychosis, N = 95; epilepsy, N = 42). The lack of structured diagnostic assessments (instead of screening tools), the relatively small sample size for some study components, and the uncontrolled nature of the study are among the limitations to be noted. All data collection took place between 15 January 2013 and 15 February 2017. Contact coverage increased 7.5% for AUD (from 0% at baseline), 12.2% for depression (from 0%), 11.7% for epilepsy (from 1.3%), and 50.2% for psychosis (from 3.2%) when using service utilisation data over 12 months; community survey results did not reveal significant changes over time. Health worker detection of depression increased by 15.7% (from 8.9% to 24.6%) 6 months after training, and 10.3% (from 8.9% to 19.2%) 24 months after training; for AUD the increase was 58.9% (from 1.1% to 60.0%) and 11.0% (from 1.1% to 12.1%) for 6 months and 24 months, respectively. Provision of minimally adequate treatment subsequent to diagnosis for depression was 93.9% at 6 months and 66.7% at 24 months; for AUD these values were 95.1% and 75.0%, respectively. Changes in treatment outcomes demonstrated small to moderate effect sizes (9.7-point reduction d = 0.34 in AUD symptoms, 6.4-point reduction d = 0.43 in psychosis symptoms, 7.2-point reduction d = 0.58 in depression symptoms) at 12 months post-treatment.
These combined results make a promising case for the feasibility and impact of community- and primary-care-based services delivered through an integrated district mental healthcare plan in reducing the treatment gap and increasing effective coverage for MNS disorders. While the integrated mental healthcare approach does lead to apparent benefits in most of the outcome metrics, there are still significant areas that require further attention (e.g., no change in community-level contact coverage, attrition in AUD detection rates over time, and relatively low detection rates for depression).
School-based mental health practice holds promise in meeting unmet mental health needs of American children by expanding access to quality mental health care for hard-to-reach populations such as ...those in rural regions. The purpose of the present study was to address four specific aims: 1) To replicate findings from prior studies regarding educators' perspectives of mental health promotion in school; 2) To extend prior research by examining specific needs for mental health training; 3) To compare the responses between the educators in rural schools and urban schools within the same geographic and political context of a large Midwestern state; and 4) To explore similarities and differences of the educators' perspectives based on participants' roles including administrators, teachers and school mental health providers.
A total of 786 educators including 127 administrators in a large Midwestern state completed a one-time, anonymous online survey. Descriptive analyses were employed to explore the perspectives of educators regarding the current status of mental health promotion in school. Additionally, independent samples t-tests were run to examine the differences in the educators' perspectives based on region (rural vs. urban). Finally, one-way analysis of variance (ANOVA) was used to examine the differences in the educators' perspectives based on participants' roles.
Results replicated previous findings, indicating a large percentage of educators reporting a high level of concerns for student mental health needs (93%) and the need for further training in mental health (85%). Mental health disorders, behavior management, and specialized skills such as social skills were identified as the top three areas of need for further training. While no differences were found between educators in urban and rural schools in other topics, significantly more respondents in rural schools (27%) reported that their schools hire mental health professionals as compared to urban schools (13%). The ANOVA results indicated that school-based mental health professionals and administrators are significantly more concerned about students' mental health needs than teachers (p=0.000).
A majority of participants take students' mental health issues seriously and many feel that current resources and training opportunities could be expanded. An area of future research could be exploring current mental health trainings provided to educators and examine how their specific training needs are addressed. An important strategy to decrease mental health care disparity by geographic region may be statewide initiatives to increase the number of mental health professionals in rural areas. The discrepancy in the level of mental health concerns expressed by teachers and administrators may suggest a need for school-wide initiatives to foster shared commitments to promoting students' mental health across various staff roles.
•Participants take students’ mental health issues seriously and feel that current mental health resources and training opportunities could be expanded.•Mental health disorders, behavior management, and specialized skills were identified as the top three areas of need for further training.•Significantly fewer educators in rural schools reported that their schools hire mental health professionals as compared to those in urban schools.•School mental health professionals and administrators were significantly more likely to express concerns about student mental health issues compared to teachers.•Administrators were significantly more likely to regard addressing students’ mental health issues as a part of their job than teachers.
Mental ill‐health represents the main threat to the health, survival and future potential of young people around the world. There are indications that this is a rising tide of vulnerability and need ...for care, a trend that has been augmented by the COVID‐19 pandemic. It represents a global public health crisis, which not only demands a deep and sophisticated understanding of possible targets for prevention, but also urgent reform and investment in the provision of developmentally appropriate clinical care. Despite having the greatest level of need, and potential to benefit, adolescents and emerging adults have the worst access to timely and quality mental health care. How is this global crisis to be addressed? Since the start of the century, a range of co‐designed youth mental health strategies and innovations have emerged. These range from digital platforms, through to new models of primary care to new services for potentially severe mental illness, which must be locally adapted according to the availability of resources, workforce, cultural factors and health financing patterns. The fulcrum of this progress is the advent of broad‐spectrum, integrated primary youth mental health care services. They represent a blueprint and beach‐head for an overdue global system reform. While resources will vary across settings, the mental health needs of young people are largely universal, and underpin a set of fundamental principles and design features. These include establishing an accessible, “soft entry” youth primary care platform with digital support, where young people are valued and essential partners in the design, operation, management and evaluation of the service. Global progress achieved to date in implementing integrated youth mental health care has highlighted that these services are being accessed by young people with genuine and substantial mental health needs, that they are benefiting from them, and that both these young people and their families are highly satisfied with the services they receive. However, we are still at base camp and these primary care platforms need to be scaled up across the globe, complemented by prevention, digital platforms and, crucially, more specialized care for complex and persistent conditions, aligned to this transitional age range (from approximately 12 to 25 years). The rising tide of mental ill‐health in young people globally demands that this focus be elevated to a top priority in global health.
The mental health of children and young people can be disproportionally affected and easily overlooked in the context of emergencies and disasters. Child and adolescent mental health services can ...contribute greatly to emergency preparedness, resilience and response and, ultimately, mitigate harmful effects on the most vulnerable members of society.
The mental health treatment gap-the difference between those with mental health need and those who receive treatment-is high in low- and middle-income countries. Task-shifting has been used to ...address the shortage of mental health professionals, with a growing body of research demonstrating the effectiveness of mental health interventions delivered through task-shifting. However, very little research has focused on how to embed, support, and sustain task-shifting in government-funded systems with potential for scale up. The goal of the Building and Sustaining Interventions for Children (BASIC) study is to examine implementation policies and practices that predict adoption, fidelity, and sustainment of a mental health intervention in the education sector via teacher delivery and the health sector via community health volunteer delivery.
BASIC is a Hybrid Type II Implementation-Effectiveness trial. The study design is a stepped wedge, cluster randomized trial involving 7 sequences of 40 schools and 40 communities surrounding the schools. Enrollment consists of 120 teachers, 120 community health volunteers, up to 80 site leaders, and up to 1280 youth and one of their primary guardians. The evidence-based mental health intervention is a locally adapted version of Trauma-focused Cognitive Behavioral Therapy, called Pamoja Tunaweza. Lay counselors are trained and supervised in Pamoja Tunaweza by local trainers who are experienced in delivering the intervention and who participated in a Train-the-Trainer model of skills transfer. After the first sequence completes implementation, in-depth interviews are conducted with initial implementing sites' counselors and leaders. Findings are used to inform delivery of implementation facilitation for subsequent sequences' sites. We use a mixed methods approach including qualitative comparative analysis to identify necessary and sufficient implementation policies and practices that predict 3 implementation outcomes of interest: adoption, fidelity, and sustainment. We also examine child mental health outcomes and cost of the intervention in both the education and health sectors.
The BASIC study will provide knowledge about how implementation of task-shifted mental health care can be supported in government systems that already serve children and adolescents. Knowledge about implementation policies and practices from BASIC can advance the science of implementation in low-resource contexts.
Trial Registration: ClinicalTrials.gov Identifier: NCT03243396. Registered 9th August 2017, https://clinicaltrials.gov/ct2/show/NCT03243396.
Adolescents living in low-resource settings lack access to adequate psychological care. The barriers to mental health care in low- and middle-income countries (LMIC) include high disease burden, low ...allocation of resources, lack of national mental health policy and child and adolescent mental health (CAMH) professionals and services, poverty, illiteracy and poor availability of adolescent friendly health services. WHO has recommended a stepped task shifting approach to mental health care in LMIC. Training of non-mental health specialists like peers, teachers, community health workers, paediatricians and primary care physicians by CAMH and framing country-specific evidence-based national mental health policies are vital in overcoming barriers to psychological care in LMIC. Digital technology and telemedicine can be used in providing economical and accessible mental health care services to adolescents.
Poor governance has been identified as a barrier to effective integration of mental health care in low- and middle-income countries. Governance includes providing the necessary policy and legislative ...framework to promote and protect the mental health of a population, as well as health system design and quality assurance to ensure optimal policy implementation. The aim of this study was to identify key governance challenges, needs and potential strategies that could facilitate adequate integration of mental health into primary health care settings in low- and middle-income countries. Key informant qualitative interviews were held with 141 participants across six countries participating in the Emerging mental health systems in low- and middle-income countries (Emerald) research program: Ethiopia, India, Nepal, Nigeria, South Africa, and Uganda. Data were transcribed (and where necessary, translated into English) and analysed thematically using frame-work analysis, first at the country level, then synthesized at a cross-country level. While all the countries fared well with respect to strategic vision in the form of the development of national mental health policies, key governance strategies identified to address challenges included: strengthening capacity of managers at sub-national levels to develop and implement integrated plans; strengthening key aspects of the essential health system building blocks to promote responsiveness, efficiency and effectiveness; developing workable mechanisms for inter-sectoral collaboration, as well as community and service user engagement; and developing innovative approaches to improving mental health literacy and stigma reduction. Inadequate financing emerged as the biggest challenge for good governance. In addition to the need for overall good governance of a health care system, this study identifies a number of specific strategies to improve governance for integrated mental health care in low- and middle-income countries.
La mauvaise gouvernance a été identifiée comme un obstacle à l’intégration effective des soins de santé mentale dans les pays à revenu faible ou à revenu intermédiaire. La gouvernance comprend le cadre politique et législatif nécessaire pour promouvoir et protéger la santé mentale d’une population, ainsi que l’élaboration d’un système de santé et d’assurance de qualité afin d’assurer une mise en œuvre optimale des politiques. L’objectif de la présente étude est d’identifier les principaux défis, les besoins et les stratégies potentielles de gouvernance qui peuvent faciliter une intégration adéquate de la santé mentale dans les établissements de soins de santé primaires des pays à revenu faible ou à revenu intermédiaire. Des entrevues qualitatives avec des témoins privilégiés ont été réalisées avec 141 personnes dans six pays protagonistes du programme de recherche sur les systèmes émergents de santé mentale dans les pays à revenu faible ou intermédiaire (Emerald): l’ Éthiopie, l’Inde, le Népal, le Nigeria, l’Afrique du Sud et l’Ouganda. Les données ont été transcrites (et, le cas échéant, traduites en anglais) et analysées thématiquement à l’aide de l’analyse du cadre, d’abord au niveau des pays, puis synthétisées au niveau transfrontalier. Si tous les pays ont obtenu des résultats positifs en ce qui concerne la vision stratégique sous forme de mise œuvre de politiques nationales de santé mentale, les principales stratégies de gouvernance identifiées pour relever les défis sont les suivantes: renforcement des capacités des gestionnaires aux niveaux infranationaux afin d’élaborer et de mettre en œuvre des plans intégrés; consolidation des aspects clés des blocs essentiels du système de santé pour promouvoir la réactivité, l’efficacité et la productivité; développement de mécanismes efficaces de collaboration intersectorielle, ainsi que l’engagement de la communauté et des utilisateurs des services; et développement de modèles d’approches novatrices pour mieux se familiariser à la santé mentale et réduire la stigmatisation. L’insuffisance des financements constitue le plus grand défi à la bonne gouvernance. Outre la nécessité d’une bonne gouvernance globale du système de soins de santé, la présente étude identifie un certain nombre de stratégies spécifiques permettant d’améliorer la gouvernance des soins intégrés de santé mentale dans les pays à revenu faible ou à revenu intermédiaire.
治理不善是中低收入国家实现精神卫生保健有效整合的障 碍。治理包括提供必要的政策和法律框架来促进和保护人群 精神卫生, 以及通过卫生体系设计和质量保证来确保最佳政策 实施。本研究目的是辨明关键的治理挑战、需求和潜在策略, 有助于中低收入国家将精神卫生整合至初级保健中。关键知 情人定性访谈的对象共141名, 均参与了中低收入国家新兴精 神卫生体系 （Emerald） 研究项目。这些访谈对象来自六个 国家：埃塞俄比亚、印度、尼泊尔、尼日利亚、南非和乌干 达。转录访谈数据 （必要时翻译成英文）, 采用框架分析方法 分析主题, 首先进行国家层面分析, 然后整合至跨国家分析。 在战略方面, 所有国家均表现良好, 制定了全国精神卫生政策, 关键的治理策略解决以下问题：加强地方管理者制定和实施 整合规划的能力；强化基本卫生体系模块的关键部分, 以提高 反应性、效率和有效性；建立可操作的部门间合作机制, 提高 社区和服务使用者参与度；形成创新方法, 提高精神卫生知识 水平, 减少污名化。研究显示筹资不足是治理的最大挑战。除 卫生保健体系整体治理良好外, 本研究还明确了一些中低收入 国家改善治理、整合精神卫生保健的具体策略。
La mala gobernanza ha sido identificada como una barrera para la integración efectiva de la atención de salud mental en los países de ingresos bajos y medios. La gobernanza incluye proporcionar el marco político y legislativo necesario para promover y proteger la salud mental de una población, así como el diseño del sistema de salud y la garantía de la calidad para asegurar una implementación óptima de políticas. El objetivo de este estudio fue identificar los desafíos, necesidades y estrategias claves de la gobernanza, que podrían facilitar la integración adecuada de la salud mental en la atención primaria en los países de ingresos bajos y medios. Se realizaron entrevistas cualitativas con 141 informantes claves de seis países participantes en el programa de investigación de los sistemas emergentes de salud mental en países de bajos y medios ingresos (‘Emerald’): Etiopía, India, Nepal, Nigeria, Sudáfrica y Uganda. Los datos se transcribieron (y donde fue necesario, traducidos al inglés) y se analizaron temáticamente usando el análisis del marco, primero a nivel de país, luego se sintetizaron entre países. Si bien todos los países obtuvieron buenos resultados con respecto a la visión estratégica en la forma de desarrollo de las políticas nacionales de salud mental, las estrategias claves de gobernanza identificadas para abordar los desafíos incluyeron: el fortalecimiento de la capacidad de los gerentes a niveles subnacionales para desarrollar e implementar los planes integrados; el fortalecimiento de los aspectos claves de los elementos esenciales del sistema de salud para promover la capacidad de respuesta, la eficiencia y la eficacia; el desarrollo de mecanismos viables para la colaboración intersectorial, así como el compromiso de los usuarios en la comunidad y los servicios; y el desarrollo de enfoques innovadores para mejorar la alfabetización en salud mental y la reducción del estigma. Una financiación inadecuada surgió como el mayor desafío para la buena gobernanza. Además de la necesidad general de una buena gobernanza de un sistema de salud, este estudio identifica una serie de estrategias específicas para mejorar la gobernanza de la atención integral de salud mental en los países de ingresos bajos y medios.
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