'Does it matter how old I feel?' The role of subjective age in a psychosocial intervention for improving depressive symptomatology among older adults in Brazil (PROACTIVE).

OBJECTIVES: Depression is a prevalent mental health condition that also often affects older adults. The PROACTIVE psychosocial intervention was developed to reduce depressive symptomatology among older adults within primary care settings in Brazil. An important psychological marker that affects individuals' aging experience relates to how old people feel. Known as subjective age, this marker has been shown to be a risk factor for experiencing greater depressive symptoms if individuals report feeling older than their (chronological) age. In this study, we perform secondary analyses of the PROACTIVE cluster-randomized controlled trial to examine the role of subjective age. METHOD: The sample included 715 Brazilian older adults (74% female, Mage 68.6, SD = 6.9, age range: 60-94 years) randomized to intervention (n = 360, 74% female, Mage 68.4, SD = 6.6, age range: 60-89 years) or control (n = 355, 74% female, Mage 68.9, SD = 7.2, age range: 60-94 years) arms. Here our primary outcome was depressive symptoms at the 8-month follow-up assessed with the 9-item Patient Health Questionnaire (PHQ-9) as a continuous variable. Our previous analyses demonstrated improved recovery from depression at follow-up in the intervention compared with the control arm. RESULTS: Relevant main effects and interactions in regression models for PHQ-9 presented here found that those reporting older subjective age had worse depressive symptoms at follow-up but that they benefitted more from the intervention when initial levels of depression were high. For participants who reported younger subjective ages the intervention showed positive effects that were independent of initial levels of depression. CONCLUSION: Our findings emphasize the importance of investigating possible underlying mechanisms that can help clarify the impact of mental health interventions.

Self-help mobile messaging intervention for depression among older adults in resource-limited settings: a randomized controlled trial.

Scalable solutions to treat depression in older adults in low-resourced settings are urgently needed. The PRODIGITAL-D pragmatic, single-blind, two-arm, individually randomized controlled trial assessed the effectiveness of a mobile messaging psychosocial intervention in improving depressive symptomatology among older adults in socioeconomically deprived areas of Guarulhos, Brazil. Older adults (aged 60+ years) registered with 24 primary care clinics and identified with depressive symptomatology (9-item Patient Health Questionnaire (PHQ-9) scores ≥ 10) received the 6-week Viva Vida intervention based on psychoeducation and behavioral activation (n = 298) or a single message (n = 305). No health professional support was offered. The primary outcome was improvement from depressive symptomatology (PHQ-9 < 10) at 3 months. Of the 603 participants enrolled (mean age = 65.1 years; 451 (74.8%) women), 527 (87.4%) completed the follow-up assessment. In the intervention arm, 109 of 257 (42.4%) participants had an improved depressive symptomatology, compared with 87 of 270 (32.2%) participants in the control arm (adjusted odds ratio = 1.57; 95% confidence interval = 1.07-2.29; P = 0.019). No severe adverse events related to trial participation were observed. These results demonstrate the usefulness of a digital messaging psychosocial intervention in the short-term improvement from depressive symptomatology that can potentially be integrated into primary care programs for treating older adults with depression. Brazilian Registry of Clinical Trials registration: ReBEC ( RBR-4c94dtn ).

Predictors, moderators and mediators of psychological therapies for perinatal depression in low- and middle-income countries: a systematic review.

Psychological interventions have demonstrated effectiveness in treating perinatal depression (PND), but understanding for whom, how and under what conditions they improve symptoms in low- and middle-income countries (LMICs) is largely unknown. This review aims to synthesise current knowledge about predictors, moderators and mediators of psychological therapies to treat PND in LMICs. Five databases were searched for studies quantitatively examining the effects of at least one mediator, moderator or predictor of therapies for PND in LMICs. The review sampled seven publications evaluating findings from randomised trials conducted in Asia and sub-Saharan Africa. The small number of included studies limited generalisability of findings. Analyses of trials with acceptable quality suggest that patient activation in Pakistan and social support in both India and Pakistan may mediate psychotherapy effectiveness, higher baseline depression severity may moderate treatment response in South Africa, and shorter depression duration at baseline may moderate intervention response in India. This review highlights current gaps in evidence quality and the need for future trials exploring PND psychotherapy effectiveness in LMICs to follow reporting guidelines to facilitate appropriate predictor, moderator and mediator analyses.

Do baseline characteristics affect depressive symptoms treatment success? Posthoc subgroup analysis from the CONEMO.

OBJECTIVE: As a secondary trial plan analysis, we aim to examine whether participant characteristics, measured before randomization, modified the effect of a digital intervention designed to improve depressive symptoms (CONEMO - Emotional Control) on recovery from depression that has presented a substantive impact on previous research. METHOD: Mixed logistic regression was used to explore interactions between the treatment arm and subgroups of interest, including suicidal ideation, race/color, age, gender, income, type of mobile phone, alcohol misuse, tobacco use, and diabetes/hypertension). We estimated interaction effects between the treatment group and these subgroup factors for the secondary outcomes using linear mixed regression models. RESULTS: Increased effects of the CONEMO intervention on the primary outcome (reduction of the scores of depressive symptoms in at least 50% at three-month follow-up) were observed amongst older and wealthier participants in Lima (p-values 0.030 and 0.001, respectively). At the same time, there was no evidence of such differential effects in São Paulo or any other secondary outcomes level in both countries. CONCLUSIONS: Digital intervention used in primary care settings needs to be accessible. We conclude that the technological intervention CONEMO has no heterogeneity effects on most subgroups studied, except income and age in the Lima trial.

Digital interventions for common mental disorders in low- and middle-income countries: A systematic review and meta-analysis.

Background: In low-resource settings, e-mental health may substantially increase access to evidence-based interventions for common mental disorders. We conducted a systematic literature search to identify randomised trials examining the effects of digital interventions with or without therapeutic guidance compared to control conditions in individuals with anxiety and/or depression symptoms in low- and middle-income countries (LMICs). Methods: The main outcome was the reduction in symptoms at the post-test. Secondary outcomes included improvements in quality of life and longer-term effects (≥20 weeks post-randomisation). The effect size Hedges' g was calculated using the random effects model. Results: A total of 21 studies (23 comparisons) with 5.296 participants were included. Digital interventions were more effective than controls in reducing symptoms of common mental disorders at the post-test (g = -0.89, 95% confidence interval [CI] -1.26 to -0.52, p < 0.001; NNT = 2.91). These significant effects were confirmed when examining depressive (g = -0.77, 95% CI -1.11; -0.44) and anxiety symptoms separately (g = -1.02, 95% CI -1.53 to -0.52) and across all other sensitivity analyses. Digital interventions also resulted in a small but significant effect in improving quality of life (g = 0.32, 95% CI 0.19 to 0.45) at the post-test. Over the longer term, the effects were smaller but remained significant for all examined outcomes. Heterogeneity was moderate to high in all analyses. Subgroup and meta-regression analyses did not result in significant outcomes in any of the examined variables (e.g., guided vs. unguided interventions). Conclusions: Digital interventions, with or without guidance, may effectively bridge the gap between treatment supply and demand in LMICs. Nevertheless, more studies are needed to draw firm conclusions regarding the magnitude of the effects of digital interventions.

Use of WhatsApp by older adults screened for depression in socioeconomically deprived areas of Guarulhos, São Paulo State, Brazil: challenges and possibilities for telehealth.

This study aimed to investigate the relationship between sociodemographic characteristics, depressive symptomatology, mobile phone ownership, and different uses of WhatsApp among older adults enrolled in primary care clinics in Guarulhos, São Paulo State, Brazil. This is a secondary data analysis, using data collected in the screening of participants to be included in the PROACTIVE cluster randomized trial. Individuals aged ≥ 60 years, registered in primary care clinics in Guarulhos, were assessed for sociodemographic characteristics, depressive symptoms according to the PHQ-9, mobile phone ownership, and use of WhatsApp. We performed multiple logistic regression models to investigate characteristics of the potential users of digital interventions. Of 3,356 older adults screened for depression, 45.7% said they use WhatsApp to receive/send messages. In the subsample that presented depressive symptomatology (n = 1,020), 41.9% stated using WhatsApp. Younger older adults and those with better socioeconomic status used more WhatsApp and were more likely to own a mobile phone. Participants with higher levels of symptoms of depression were less likely to use WhatsApp. Gender, age, schooling level, income, and depressive symptomatology are variables associated with the possession of a cell phone and with the use of WhatsApp by the older adults of the sample. These findings can help to implement digital health programs better suited to disadvantaged populations in Brazil and other low- and middle-income countries through mental telehealth interventions using WhatsApp and mobile health services to the older people.

Understanding the effects of a complex psychological intervention on symptoms of depression in Goa, India: findings from a causal mediation analysis.

BACKGROUND: Understanding how and under what circumstances a highly effective psychological intervention, improved symptoms of depression is important to maximise its clinical effectiveness. AIMS: To address this complexity, we estimate the indirect effects of potentially important mediators to improve symptoms of depression (measured with the Patient Health Questionnaire (PHQ-9)) in the Healthy Activity Program trial. METHOD: Interventional in(direct) effects were used to decompose the total effect of the intervention on PHQ-9 scores into the direct and indirect effects. The following indirect effects were considered: characteristics of sessions, represented by the number of sessions and homework completed; behavioural activation, according to an adapted version of the Behavioural Activation for Depression Scale - Short Form; and extra sessions offered to participants who did not respond to the intervention. RESULTS: Of the total effect of the intervention measured through the difference in PHQ-9 scores between treatment arms (mean difference: -2.1, bias-corrected 95% CI -3.2 to -1.5), 34% was mediated through improved levels of behavioural activation (mean difference: -0.7, bias-corrected 95% CI -1.2 to -0.4). There was no evidence to support the mediating role of characteristics of the sessions nor the extra sessions offered to participants who did not respond to the treatment. CONCLUSIONS: Findings from our robust mediation analyses confirmed the importance of targeting behavioural activation. Contrary to published literature, our findings suggest that neither the number of sessions nor proportion of homework completed improved outcomes. Moreover, in this context, alternative treatments other than extra sessions should be considered for patients who do not respond to the intervention.

A task-shared, collaborative care psychosocial intervention for improving depressive symptomatology among older adults in a socioeconomically deprived area of Brazil (PROACTIVE): a pragmatic, two-arm, parallel-group, cluster-randomised controlled trial.

BACKGROUND: There is an urgent need to reduce the burden of depression among older adults in low-income and middle-income countries (LMICs). We aimed to evaluate the efficacy of a task-shared, collaborative care psychosocial intervention for improving recovery from depression in older adults in Brazil. METHODS: PROACTIVE was a pragmatic, two-arm, parallel-group, cluster-randomised controlled trial conducted in Guarulhos, Brazil. Primary care clinics (clusters) were stratified by educational level and randomly allocated (1:1) to either enhanced usual care alone (control group) or to enhanced usual care plus the psychosocial intervention (intervention group), which involved a 17-week psychosocial programme based on psychoeducation and behavioural activation approaches. Individuals approached for the initial screening assessment were selected randomly from a list of individuals provided by the Health Secretariat of Guarulhos. Face-to-face baseline assessments were conducted among adults aged 60 years or older registered with one of the primary care clinics and identified with clinically significant depressive symptomatology (9-item Patient Health Questionnaire [PHQ-9] score ≥10). Community health workers delivered the programme through home sessions, supported by a dedicated tablet application. Masking of clinic staff and community health workers who delivered the intervention was not feasible; however, research assistants conducting recruitment and follow-up assessments were masked to trial allocation. The primary outcome was recovery from depression (PHQ-9 score <10) at 8-month follow-up. All primary analyses were performed by intention to treat with imputed data. Adaptations to the protocol were made due to the COVID-19 pandemic; recruitment and intervention home sessions were stopped, and follow-up assessments were conducted by telephone. This trial is registered with the ISRCTN registry, ISRCTN57805470. FINDINGS: We identified 24 primary care clinics in Guarulhos that were willing to participate, of which 20 were randomly allocated to either the control group (ten [50%] clusters) or to the intervention group (ten [50%] clusters). The four remaining eligible clusters were kept as reserves. Between May 23, 2019, and Feb 21, 2020, 8146 individuals were assessed for eligibility, of whom 715 (8·8%) participants were recruited: 355 (49·7%) in the control group and 360 (50·3%) in the intervention group. 284 (80·0%) participants in the control group and 253 (70·3%) in the intervention group completed follow-up at 8 months. At 8-month follow-up, 158 (62·5%) participants in the intervention group showed recovery from depression (PHQ-9 score <10) compared with 125 (44·0%) in the control group (adjusted odds ratio 2·16 [95% CI 1·47-3·18]; p<0·0001). These findings were maintained in the complete case analysis. No adverse events related to the intervention were observed. INTERPRETATION: Although the COVID-19 pandemic altered delivery of the intervention, the low-intensity psychosocial intervention delivered mainly by non-mental health professionals was highly efficacious in improving recovery from depression in older adults in Brazil. Our results support a low-resource intervention that could be useful to reduce the treatment gap for depression among older people in other LMICs. FUNDING: São Paulo Research Foundation and Joint Global Health Trials (UK Department for International Development, Medical Research Council, and the Wellcome Trust).

Digital psychosocial intervention for depression among older adults in socioeconomically deprived areas in Brazil (PRODIGITAL-D): protocol for an individually randomised controlled trial.

BACKGROUND: Depression in older adults is a challenge for health systems in most low- and middle-income countries (LMICs). Digital strategies for the management of this condition have been emerging worldwide, but the effectiveness of most of them is still unclear, especially among older adults. Thus, we aim to assess the effectiveness and cost-effectiveness of a digital psychosocial intervention to treat depression among older adults living in socioeconomically deprived areas in Guarulhos, Brazil. METHODS: We will conduct a two-arm individually randomised controlled trial with 1:1 allocation ratio. Five hundred older adults aged 60 years or over with depressive symptomatology (9-item Patient Health Questionnaire score, PHQ-9 ≥ 10) and registered with one of the primary care clinics will be recruited to participate in this study. A 6-week digital psychosocial programme, named Viva Vida, will be delivered via WhatsApp to participants allocated to the intervention arm. The Viva Vida will send psychoeducational and behavioural activation audio and visual messages 4 days a week for 6 weeks. The control arm will only receive a single message with general information about depression. The primary outcome will be the proportion of depression recovery (PHQ-9 < 10) assessed at 3 months. The cost-effectiveness of the intervention will be assessed at 5 months. A detailed process evaluation will be used to explore context and important implementation outcomes. DISCUSSION: This programme was based on the PROACTIVE intervention and designed to be delivered without face-to-face contact. If effective, it could be a simple treatment option, appropriate not only when social distancing is required, but it could also be included as a regular public health programme to initiate depression treatment, particularly in LMICs where resources allocated to mental health are scarce. TRIAL REGISTRATION: Registro Brasileiro de Ensaios Clínicos (ReBEC), RBR-4c94dtn. Registered on 22 October 2021 (submitted on 03 August 2021).

Implementation outcomes of a health systems strengthening intervention for perinatal women with common mental disorders and experiences of domestic violence in South Africa: Pilot feasibility and acceptability study.

BACKGROUND: South Africa has a high burden of perinatal common mental disorders (CMD), such as depression and anxiety, as well as high levels of poverty, food insecurity and domestic violence, which increases the risk of CMD. Yet public healthcare does not include routine detection and treatment for these disorders. This pilot study aims to evaluate the implementation outcomes of a health systems strengthening (HSS) intervention for improving the quality of care of perinatal women with CMD and experiences of domestic violence, attending public healthcare facilities in Cape Town. METHODS: Three antenatal care facilities were purposively selected for delivery of a HSS programme consisting of four components: (1) health promotion and awareness raising talks delivered by lay healthcare workers; (2) detection of CMD and domestic violence by nurses as part of routine care; (3) referral of women with CMD and domestic violence; and (4) delivery of structured counselling by lay healthcare workers in patients' homes. Participants included healthcare workers tasked with delivery of the HSS components, and perinatal women attending the healthcare facilities for routine antenatal care. This mixed methods study used qualitative interviews with healthcare workers and pregnant women, a patient survey, observation of health promotion and awareness raising talks, and a review of several documents, to evaluate the acceptability, appropriateness, feasibility, adoption, fidelity of delivery, and fidelity of receipt of the HSS components. Thematic analysis was used to analyse the qualitative interviews, while the quantitative findings for adoption and fidelity of receipt were reported using numbers and proportions. RESULTS: Healthcare workers found the delivery and content of the HSS components to be both acceptable and appropriate, while the feasibility, adoption and fidelity of delivery was poor. We demonstrated that the health promotion and awareness raising component improved women's attitudes towards seeking help for mental health conditions. The detection, referral and treatment components were found to improve fidelity of receipt, evidenced by an increase in the proportion of women undergoing routine detection and referral, and decreased feelings of distress in women who received counselling. However, using a task-sharing approach did not prove to be feasible, as adding additional responsibilities to already overburdened healthcare workers roles resulted in poor fidelity of delivery and adoption of all the HSS components. CONCLUSIONS: The acceptability, appropriateness and fidelity of receipt of the HSS programme components, and poor feasibility, fidelity of delivery and adoption suggest the need to appoint dedicated, lay healthcare workers to deliver key programme components, at healthcare facilities, on the same day.

Health systems strengthening interventions for perinatal common mental disorders and experiences of domestic violence in Cape Town, South Africa: protocol for a pilot implementation study.

BACKGROUND: During the perinatal period, common mental disorders (CMDs) such as depression and anxiety are highly prevalent, especially in low-resource settings, and are associated with domestic violence, poverty, and food insecurity. Perinatal CMDs have been associated with several adverse maternal and child outcomes. While the Department of Health in South Africa provides healthcare workers with the tools to detect psychological distress and experiences of domestic violence, few healthcare workers routinely screen pregnant women at clinic visits, citing discomfort with mental health issues and the lack of standardised referral pathways as the key barriers. The aim of this study is to select and evaluate a set of health systems strengthening (HSS) interventions aimed at improving the care and outcomes for perinatal women with CMDs and experiences of domestic violence, attending public healthcare facilities in Cape Town. METHODS: This study consists of a pre-implementation, development, and implementation phase. Contextual barriers identified during the pre-implementation phase included poor patient knowledge and health-seeking behaviour, high levels of stigma, and poor detection, referral, and treatment rates. Implementation science determinant frameworks were applied to findings from the pre-implementation phase to identify determinants and gaps in delivering high-quality evidence-informed care. A participatory Theory of Change workshop was used to design a HSS programme, consisting of awareness raising, detection, referral, and treatment. HSS interventions selected to support the delivery of the HSS programme includes training, health promotion, change to the healthcare environment, task-sharing, audit and feedback, and performance monitoring. The implementation phase will be used to assess several implementation and clinical outcomes associated with the delivery of the HSS programme, which will be piloted at three healthcare facilities. Qualitative and quantitative methods will be used to evaluate the implementation and clinical outcomes. DISCUSSION: This pilot implementation study will inform us about a range of implementation and clinical outcome measures that are relevant for assessing HSS interventions for perinatal women with depression, anxiety, or experiences of domestic violence in low-resource settings. Lessons learnt from the pilot study will be incorporated into the design of a cluster randomised control trial for which further funding will be sought.

HeAlth System StrEngThening in four sub-Saharan African countries (ASSET) to achieve high-quality, evidence-informed surgical, maternal and newborn, and primary care: protocol for pre-implementation phase studies.

To achieve universal health coverage, health system strengthening (HSS) is required to support the of delivery of high-quality care. The aim of the National Institute for Health Research Global Research Unit on HeAlth System StrEngThening in Sub-Saharan Africa (ASSET) is to address this need in a four-year programme, with three healthcare platforms involving eight work-packages. Key to effective health system strengthening (HSS) is the pre-implementation phase of research where efforts focus on applying participatory methods to embed the research programme within the existing health system. To conceptualise the approach, we provide an overview of the key methods applied across work-package to address this important phase of research conducted between 2017 and 2021.Work-packages are being undertaken in publicly funded health systems in rural and urban areas in Ethiopia, Sierra Leone, South Africa, and Zimbabwe. Stakeholders including patients and their caregivers, community representatives, clinicians, managers, administrators, and policymakers are the main research participants.In each work-package, initial activities engage stakeholders and build relationships to ensure co-production and ownership of HSSIs. A mixed-methods approach is then applied to understand and address determinants of high-quality care delivery. Methods such as situation analysis, cross-sectional surveys, interviews and focus group discussions are adopted to each work-package aim and context. At the end of the pre-implementation phase, findings are disseminated using focus group discussions and participatory Theory of Change workshops where stakeholders from each work package use findings to select HSSIs and develop a programme theory.ASSET places a strong emphasis of the pre-implementation phase in order to provide an in-depth and systematic diagnosis of the existing heath system functioning, needs for strengthening and stakeholder engagement. This common approach will inform the design and evaluation of the HSSIs to increase effectiveness across work packages and contexts, to better understand what works, for whom, and how.

Use of WhatsApp by older adults screened for depression in socioeconomically deprived areas of Guarulhos, São Paulo State, Brazil: challenges and possibilities for telehealth / Uso do WhatsApp por idosos depressivos em áreas socioeconomicamente carentes de Guarulhos, São Paulo, Brasil: desafios e possibilidades para a telessaúde / Uso de WhatsApp por ancianos deprimidos en áreas desfavorecidas socioeconómicamente en Guarulhos, São Paulo, Brasil: retos y posibilidades de la telesalud

This study aimed to investigate the relationship between sociodemographic characteristics, depressive symptomatology, mobile phone ownership, and different uses of WhatsApp among older adults enrolled in primary care clinics in Guarulhos, São Paulo State, Brazil. This is a secondary data analysis, using data collected in the screening of participants to be included in the PROACTIVE cluster randomized trial. Individuals aged ≥ 60 years, registered in primary care clinics in Guarulhos, were assessed for sociodemographic characteristics, depressive symptoms according to the PHQ-9, mobile phone ownership, and use of WhatsApp. We performed multiple logistic regression models to investigate characteristics of the potential users of digital interventions. Of 3,356 older adults screened for depression, 45.7% said they use WhatsApp to receive/send messages. In the subsample that presented depressive symptomatology (n = 1,020), 41.9% stated using WhatsApp. Younger older adults and those with better socioeconomic status used more WhatsApp and were more likely to own a mobile phone. Participants with higher levels of symptoms of depression were less likely to use WhatsApp. Gender, age, schooling level, income, and depressive symptomatology are variables associated with the possession of a cell phone and with the use of WhatsApp by the older adults of the sample. These findings can help to implement digital health programs better suited to disadvantaged populations in Brazil and other low- and middle-income countries through mental telehealth interventions using WhatsApp and mobile health services to the older people.

Este estudo teve como objetivo investigar a relação entre características sociodemográficas, sintomatologia depressiva, posse de telefone celular e diferentes usos do WhatsApp entre idosos cadastrados em unidades básicas de saúde de Guarulhos, São Paulo, Brasil. Trata-se de uma análise de dados secundários com informações coletadas na triagem dos participantes a serem incluídos neste estudo randomizado em cluster PROATIVO. Indivíduos com 60 anos ou mais, cadastrados em unidades básicas de saúde de Guarulhos, foram avaliados quanto a características sociodemográficas, sintomas depressivos, de acordo com o PHQ-9, posse de telefone celular e uso do WhatsApp. Foram utilizados modelos de regressão logística múltipla para investigar as características dos potenciais usuários de intervenções digitais. Dos 3.356 idosos depressivos, 45,7% usavam o WhatsApp para receber/enviar mensagens. Na subamostra que apresentou sintomatologia depressiva (n = 1.020), 41,9% disseram usar o WhatsApp. Adultos mais jovens e com melhor status socioeconômico usavam mais o WhatsApp e eram mais propensos a possuir um telefone celular. Participantes com níveis mais altos de sintomas de depressão eram menos propensos a utilizar o WhatsApp. Sexo, idade, escolaridade, renda e sintomatologia depressiva são variáveis associadas à posse de telefone celular e ao uso do WhatsApp pelos idosos da população estudada. Esses achados podem ajudar a implementar programas de saúde digital mais adequados para populações desfavorecidas no Brasil e em outros países de baixa e média renda, principalmente intervenções de telessaúde mental que utilizem o WhatsApp e serviços móveis de saúde para idosos.

Este estudio tuvo como objetivo determinar la relación entre las características sociodemográficas, los síntomas depresivos, la tenencia de teléfono celular y los diferentes usos de WhatsApp entre los ancianos inscritos en unidades básicas de salud en Guarulhos, São Paulo, Brasil. Este es un análisis de datos secundarios, que recopiló la información del triaje de los participantes a ser incluidos en este estudio aleatorio en un clúster PROACTIVO. Se evaluaron las características sociodemográficas, los síntomas depresivos según el PHQ-9, la tenencia de celular y el uso de WhatsApp de los participantes de 60 años o más, registrados en unidades básicas de salud de Guarulhos. Se utilizaron los modelos de regresión logística múltiple para identificar las características de los potenciales usuarios de las intervenciones digitales. De los 3.356 ancianos deprimidos, el 45,7% utilizaba WhatsApp para recibir/enviar mensajes. En la submuestra que presentó síntomas depresivos (n = 1.020), el 41,9% dijo usar WhatsApp. Los adultos más jóvenes con mejor nivel socioeconómico usaban más WhatsApp y tenían más probabilidades de tener un teléfono celular. Los participantes con niveles más altos de síntomas de depresión tenían menos probabilidades de usar WhatsApp. El sexo, la edad, la educación, la renta y los síntomas depresivos fueron las variables asociadas a la tenencia de celular y al uso de WhatsApp por parte de los ancianos de la población estudiada. Estos hallazgos pueden ayudar a implementar programas de salud digital que sean más adecuados para las poblaciones desfavorecidas en Brasil y en otros países de bajos y medianos ingresos, en particular las intervenciones de telesalud mental que utilizan WhatsApp y servicios de salud móviles para ancianos.

A guide to systems-level, participatory, theory-informed implementation research in global health.

Implementation research is a multidisciplinary field that addresses the complex phenomenon of how context influences our ability to deliver evidence-informed healthcare. There is increasing realisation of the importance of applying robust implementation research to scale-up life-saving interventions that meet health-related sustainable development goals. However, the lack of high-quality implementation research is impeding our ability to meet these targets, globally. Within implementation research, theory refers to the proposed hypothesis and/or explanation of how an intervention is expected to interact with the local context and actors to bring about change. Although there is increasing interest in applying theory to understand how and why implementation programmes work in real-world settings, global health actors still tend to favour impact evaluations conducted in controlled environments. This may, in part, be due to the relative novelty as well as methodological complexity of implementation research and the need to draw on divergent disciplines, including epidemiology, implementation science and social sciences. Because of this, implementation research is faced with a particular set of challenges about how to reconcile different ways of thinking and constructing knowledge about healthcare interventions. To help translate some of the ambiguity surrounding how divergent theoretical approaches and methods contribute to implementation research, we draw on our multidisciplinary expertise in the field, particularly in global health. We offer an overview of the different theoretical approaches and describe how they are applied to continuously select, monitor and evaluate implementation strategies throughout the different phases of implementation research. In doing so, we offer a relatively brief, user-focused guide to help global health actors implement and report on evaluation of evidence-based and scalable interventions, programmes and practices.

Implementation science protocol for a participatory, theory-informed implementation research programme in the context of health system strengthening in sub-Saharan Africa (ASSET-ImplementER).

OBJECTIVES: ASSET (Health System Strengthening in sub-Saharan Africa) is a health system strengthening (HSS) programme involving eight work-packages (ie, a research study that addresses a specific need for HSS) that aims to develop solutions that support high-quality care. Here we present the protocol for the implementation science (IS) theme within ASSET (ASSET-ImplmentER) that aims to understand what HSS interventions work, for whom and how, and how IS methodologies can be adapted to improve the HSS interventions within resource-poor contexts. SETTINGS: Publicly funded health facilities in rural and urban areas in in Ethiopia, South Africa, Sierra Leone, and Zimbabwe. PARTICIPANTS: Research staff including principal investigators, coinvestigators, field staff, PhD students, and research assistants. INTERVENTIONS: Work-packages use a mixed-methods effectiveness-effectiveness hybrid designs. At the end of the pre-implementation phase, a workshop is held whereby the IS theme, jointly with ASSET work-packages apply IS determinant frameworks to research findings to identify factors that influence the effectiveness of delivering evidence-informed care. Determinants are used to select a set of HSS interventions for further evaluation, where work-packages also theorise selective mechanisms.In the piloting and rolling implementation phase, work-packages pilot the HSS interventions. An iterative process then begins involving evaluation, reflection and adaptation. Throughout this phase, IS determinant frameworks are applied to monitor and identify barriers/enablers to implementation. Selective mechanisms of action are also investigated. Implementation outcomes are evaluated using qualitative and quantitative methods. The psychometric properties of outcome measures including acceptability, appropriateness and feasibility are also evaluated. In a final workshop, work-packages come together, to reflect and explore the utility of the selected IS methods and provide suggestions for future use.Structured templates are used to organise and analyse common and heterogeneous patterns across work-packages. Qualitative data are analysed using thematic analysis and quantitative data are analysed using means and proportions. CONCLUSIONS: We use a novel combination of IS methods at a programmatic level to facilitate comparisons of determinants and mechanisms that influence the effectiveness of HSS interventions in achieving implementation outcomes across different contexts. The study also contributes conceptual development and clarification at the underdeveloped interface of IS, HSS and global health.The ASSET-ImplementER theme is considered minimal risk as we only interview researchers involved in the different work-packages. To this effect we have received approval from King's College London Ethics Committee for research that is considered minimal risk (Reference number: MRA-20/21-21772).

Contextual equipoise: a novel concept to inform ethical implications for implementation research in low-income and middle-income countries.

The call for universal health coverage requires the urgent implementation and scale-up of interventions that are known to be effective, in resource-poor settings. Achieving this objective requires high-quality implementation research (IR) that evaluates the complex phenomenon of the influence of context on the ability to effectively deliver evidence-based practice. Nevertheless, IR for global health is failing to apply a robust, theoretically driven approach, leading to ethical concerns associated with research that is not methodologically sound.Inappropriate methods are often used in IR to address and report on context. This may result in a lack in understanding of how to effectively adapt the intervention to the new setting and a lack of clarity in conceptualising whether there is sufficient evidence to generalise findings from previous IR to a new setting, or if a randomised controlled trial (RCT) is needed. Some of the ethical issues arising from this shortcoming include poor-quality research that may needlessly expose vulnerable participants to research that has not been adapted to suit local needs and priorities, and the inappropriate use of RCTs that denies participants in the control arm access to treatment that is effective within the local context.To address these concerns, we propose a complementary approach to clinical equipoise for IR, known as contextual equipoise We discuss challenges in the evaluation of context and also with assessing the certainty of evidence to justify an RCT. Finally, we describe methods that can be applied to improve the evaluation and reporting of context and to help understand if contextual equipoise can be justified or if significant adaptations are required. We hope our analysis offers helpful insight to better understand and ensure that the ethical principle of beneficence is upheld in the real-world contexts of IR in low-resource settings.

Effects of women's groups practising participatory learning and action on preventive and care-seeking behaviours to reduce neonatal mortality: A meta-analysis of cluster-randomised trials.

BACKGROUND: The World Health Organization recommends participatory learning and action (PLA) in women's groups to improve maternal and newborn health, particularly in rural settings with low access to health services. There have been calls to understand the pathways through which this community intervention may affect neonatal mortality. We examined the effect of women's groups on key antenatal, delivery, and postnatal behaviours in order to understand pathways to mortality reduction. METHODS AND FINDINGS: We conducted a meta-analysis using data from 7 cluster-randomised controlled trials that took place between 2001 and 2012 in rural India (2 trials), urban India (1 trial), rural Bangladesh (2 trials), rural Nepal (1 trial), and rural Malawi (1 trial), with the number of participants ranging between 6,125 and 29,901 live births. Behavioural outcomes included appropriate antenatal care, facility delivery, use of a safe delivery kit, hand washing by the birth attendant prior to delivery, use of a sterilised instrument to cut the umbilical cord, immediate wrapping of the newborn after delivery, delayed bathing of the newborn, early initiation of breastfeeding, and exclusive breastfeeding. We used 2-stage meta-analysis techniques to estimate the effect of the women's group intervention on behavioural outcomes. In the first stage, we used random effects models with individual patient data to assess the effect of groups on outcomes separately for the different trials. In the second stage of the meta-analysis, random effects models were applied using summary-level estimates calculated in the first stage of the analysis. To determine whether behaviour change was related to group attendance, we used random effects models to assess associations between outcomes and the following categories of group attendance and allocation: women attending a group and allocated to the intervention arm; women not attending a group but allocated to the intervention arm; and women allocated to the control arm. Overall, women's groups practising PLA improved behaviours during and after home deliveries, including the use of safe delivery kits (odds ratio [OR] 2.92, 95% CI 2.02-4.22; I2 = 63.7%, 95% CI 4.4%-86.2%), use of a sterile blade to cut the umbilical cord (1.88, 1.25-2.82; 67.6%, 16.1%-87.5%), birth attendant washing hands prior to delivery (1.87, 1.19-2.95; 79%, 53.8%-90.4%), delayed bathing of the newborn for at least 24 hours (1.47, 1.09-1.99; 68.0%, 29.2%-85.6%), and wrapping the newborn within 10 minutes of delivery (1.27, 1.02-1.60; 0.0%, 0%-79.2%). Effects were partly dependent on the proportion of pregnant women attending groups. We did not find evidence of effects on uptake of antenatal care (OR 1.03, 95% CI 0.77-1.38; I2 = 86.3%, 95% CI 73.8%-92.8%), facility delivery (1.02, 0.93-1.12; 21.4%, 0%-65.8%), initiating breastfeeding within 1 hour (1.08, 0.85-1.39; 76.6%, 50.9%-88.8%), or exclusive breastfeeding for 6 weeks after delivery (1.18, 0.93-1.48; 72.9%, 37.8%-88.2%). The main limitation of our analysis is the high degree of heterogeneity for effects on most behaviours, possibly due to the limited number of trials involving women's groups and context-specific effects. CONCLUSIONS: This meta-analysis suggests that women's groups practising PLA improve key behaviours on the pathway to neonatal mortality, with the strongest evidence for home care behaviours and practices during home deliveries. A lack of consistency in improved behaviours across all trials may reflect differences in local priorities, capabilities, and the responsiveness of health services. Future research could address the mechanisms behind how PLA improves survival, in order to adapt this method to improve maternal and newborn health in different contexts, as well as improve other outcomes across the continuum of care for women, children, and adolescents.

Mortality and its risk factors in Malawian children admitted to hospital with clinical pneumonia, 2001-12: a retrospective observational study.

BACKGROUND: Few studies have reported long-term data on mortality rates for children admitted to hospital with pneumonia in Africa. We examined trends in case fatality rates for all-cause clinical pneumonia and its risk factors in Malawian children between 2001 and 2012. METHODS: Individual patient data for children (<5 years) with clinical pneumonia who were admitted to hospitals participating in Malawi's Child Lung Health Programme between 2001 and 2012 were recorded prospectively on a standardised medical form. We analysed trends in pneumonia mortality and children's clinical characteristics, and we estimated the association of risk factors with case fatality for children younger than 2 months, 2-11 months of age, and 12-59 months of age using separate multivariable mixed effects logistic regression models. FINDINGS: Between November, 2012, and May, 2013, we retrospectively collected all available hard copies of yellow forms from 40 of 41 participating hospitals. We examined 113 154 pneumonia cases, 104 932 (92·7%) of whom had mortality data and 6903 of whom died, and calculated an overall case fatality rate of 6·6% (95% CI 6·4-6·7). The case fatality rate significantly decreased between 2001 (15·2% [13·4-17·1]) and 2012 (4·5% [4·1-4·9]; ptrend<0·0001). Univariable analyses indicated that the decrease in case fatality rate was consistent across most subgroups. In multivariable analyses, the risk factors significantly associated with increased odds of mortality were female sex, young age, very severe pneumonia, clinically suspected Pneumocystis jirovecii infection, moderate or severe underweight, severe acute malnutrition, disease duration of more than 21 days, and referral from a health centre. Increasing year between 2001 and 2012 and increasing age (in months) were associated with reduced odds of mortality. Fast breathing was associated with reduced odds of mortality in children 2-11 months of age. However, case fatality rate in 2012 remained high for children with very severe pneumonia (11·8%), severe undernutrition (15·4%), severe acute malnutrition (34·8%), and symptom duration of more than 21 days (9·0%). INTERPRETATION: Pneumonia mortality and its risk factors have steadily improved in the past decade in Malawi; however, mortality remains high in specific subgroups. Improvements in hospital care may have reduced case fatality rates though a lack of sufficient data on quality of care indicators and the potential of socioeconomic and other improvements outside the hospital precludes adequate assessment of why case-fatality rates fell. Results from this study emphasise the importance of effective national systems for data collection. Further work combining this with data on trends in the incidence of pneumonia in the community are needed to estimate trends in the overall risk of mortality from pneumonia in children in Malawi. FUNDING: Bill & Melinda Gates Foundation.