Addressing Challenges for Psychotherapy Supervision in Global Mental Health: Experiential Learnings From Rural Nepal.

Background: As the field of global mental health grows, many psychotherapy trainees will work across cultures in low-resource settings in high-income countries or in low- and middle-income countries. Faculty members and mentors may face several challenges in providing supervision for psychologists in low-resource settings. As such, there is a need to develop best practices for psychotherapy supervision in global mental health. Methods: We describe the common challenges and potential strategies in psychotherapy supervision based on our research, clinical, and academic partnerships between academic institutions, a nonprofit organization, and the Nepali government. Results: The strategies and considerations we have found helpful include focusing on therapies with strong behavioral and interpersonal (rather than emotional or cognitive) components and using locally validated therapies or standard manuals that have been endorsed by the WHO for low-resource settings. Other strategies include providing psychotherapy training for local psychiatrists who may be in supervisory roles and gaining competence in navigating different expectations of social structures and family dynamics. Conclusion: Supervisors face many challenges while supporting trainees and early psychologists in global mental health settings. While ensuring local adaptation, key considerations can be developed into best practices to support psychiatrists, supervisors, and trainees based in low- and middle-income countries.

Cross-cultural adaptation of motivational interviewing for use in rural Nepal.

BACKGROUND: Motivational Interviewing (MI) has a robust evidence base in facilitating behavior change for several health conditions. MI focuses on the individual and assumes patient autonomy. Cross-cultural adaptation can face several challenges in settings where individualism and autonomy may not be as prominent. Sociocultural factors such as gender, class, caste hinder individual decision-making. Key informant perspectives are an essential aspect of cross-cultural adaptation of new interventions. Here, we share our experience of translating and adapting MI concepts to the local language and culture in rural Nepal, where families and communities play a central role in influencing a person's behaviors. METHODS: We developed, translated, field-tested, and adapted a Nepali MI training module with key informants to generate insights on adapting MI for the first time in this cultural setting. Key informants were five Nepali nurses who supervise community health workers. We used structured observation notes to describe challenges and experiences in cross-cultural adaptation. We conducted this study as part of a larger study on using MI to improve adherence to HIV treatment. RESULTS: Participants viewed MI as an effective intervention with the potential to assist patients poorly engaged in care. Regarding patient autonomy, they initially shared examples of family members unsuccessfully dictating patient behavior change. These discussions led to consensus that every time the family members restrict patient's autonomy, the patient complies temporarily but then resumes their unhealthy behavior. In addition, participants highlighted that even when a patient is motivated to change (e.g., return for follow-up), their family members may not "allow" it. Discussion led to suggestions that health workers may need to conduct MI separately with patients and family members to understand everyone's motivations and align those with the patient's needs. CONCLUSIONS: MI carries several cultural assumptions, particularly around individual freedom and autonomy. MI adaptation thus faces challenges in cultures where such assumptions may not hold. However, cross-cultural adaptation with key informant perspectives can lead to creative strategies that recognize both the patient's autonomy and their role as a member of a complex social fabric to facilitate behavior change.

Transition to active learning in rural Nepal: an adaptable and scalable curriculum development model.

BACKGROUND: Traditional medical education in much of the world has historically relied on passive learning. Although active learning has been in the medical education literature for decades, its incorporation into practice has been inconsistent. We describe and analyze the implementation of a multidisciplinary continuing medical education curriculum in a rural Nepali district hospital, for which a core objective was an organizational shift towards active learning. METHODS: The intervention occurred in a district hospital in remote Nepal, staffed primarily by mid-level providers. Before the intervention, education sessions included traditional didactics. We conducted a mixed-methods needs assessment to determine the content and educational strategies for a revised curriculum. Our goal was to develop an effective, relevant, and acceptable curriculum, which could facilitate active learning. As part of the intervention, physicians acted as both learners and teachers by creating and delivering lectures. Presenters used lecture templates to prioritize clarity, relevance, and audience engagement, including discussion questions and clinical cases. Two 6-month curricular cycles were completed during the study period. Daily lecture evaluations assessed ease of understanding, relevance, clinical practice change, and participation. Periodic lecture audits recorded learner talk-time, the proportion of lecture time during which learners were talking, as a surrogate for active learning. Feedback from evaluation and audit results was provided to presenters, and pre- and post-curriculum knowledge assessment exams were conducted. RESULTS: Lecture audits showed a significant increase in learner talk-time, from 14% at baseline to 30% between months 3-6, maintained at 31% through months 6-12. Lecture evaluations demonstrated satisfaction with the curriculum. Pre- and post-curriculum knowledge assessment scores improved from 50 to 64% (difference 13.3% ± 4.5%, p = 0.006). As an outcome for the measure of organizational change, the curriculum was replicated at an additional clinical site. CONCLUSION: We demonstrate that active learning can be facilitated by implementing a new educational strategy. Lecture audits proved useful for internal program improvement. The components of the intervention which are transferable to other rural settings include the use of learners as teachers, lecture templates, and provision of immediate feedback. This curricular model could be adapted to similar settings in Nepal, and globally.