Ethnic density and first episode psychosis in the British Pakistani population: findings from the East Lancashire Early Intervention Service.

BACKGROUND: Elevated risk of psychosis for ethnic minority groups has generally been shown to be mitigated by high ethnic density. However, past survey studies examining UK Pakistani populations have shown an absence of protective ethnic density effects, which is not observed in other South Asian groups. AIMS: To assess the ethnic density effect at a local neighbourhood level, in the UK Pakistani population in East Lancashire. METHOD: Data was collected by the East Lancashire Early Intervention Service, identifying all cases of first episode psychosis (FEP) within their catchment area between 2012 and 2020. Multilevel Poisson regression analyses were used to compare incidence rates between Pakistani and White majority groups, while controlling for age, gender and area-level deprivation. The ethnic density effect was also examined by comparing incidence rates across high and low density areas. RESULTS: A total of 455 cases of FEP (364 White, 91 Pakistani) were identified. The Pakistani group had a higher incidence of FEP compared to the White majority population. A clear effect of ethnic density on rates of FEP was shown, with those in low density areas having higher incidence rates compared to the White majority, whereas incidence rates in high density areas did not significantly differ. Within the Pakistani group, a dose-response effect was also observed, with risk of FEP increasing incrementally as ethnic density decreased. CONCLUSIONS: Higher ethnic density related to lower risk of FEP within the Pakistani population in East Lancashire, highlighting the impact of local social context on psychosis incidence.

Community-based mental health interventions in low- and middle-income countries: a qualitative study with international experts.

BACKGROUND: Mental health services are scarce in low- and middle-income countries (LMICs), and designing and implementing effective interventions can be difficult. The aim of this international study was to explore the key lessons for developing, implementing, and evaluating community-based mental health and well-being interventions in LMICs, with an additional focus on older adults. METHODS: Research and clinical experts in developing and implementing psychosocial community-based interventions in LMICs were interviewed remotely between October 2021 and January 2022. Participants were recruited via existing global health networks and via published literature searches. Participants were asked about their experiences of developing and implementing interventions, and about key barriers and facilitators during the process. Interviews lasted up to 45 min, and data were analysed using combined inductive and deductive thematic analysis. RESULTS: Sixteen global mental health experts participated. Five themes with different sub-themes were generated: Mechanisms and contexts; Barriers; Facilitators; Public and stakeholder involvement; Looking through an ageing lens. The development and delivery of mental health interventions in LMICs are facilitated through integration into existing health infrastructures and working with existing job roles as delivery agents. Public and stakeholder involvement are crucial at all stages of development through to implementation to focus on meeting local needs and sustaining participant motivation. Logistical barriers of transport, resources, and location need to be addressed, emphasising local sustainability. CONCLUSIONS: This study provides important insights for how the development, implementation, and evaluation of community-based mental health and well-being interventions in LMICs can be optimised, and can complement general guidance into complex interventions developments.

A longitudinal study of capability-based quality of life and mental health in the first 5-months of lockdown restrictions in the UK.

BACKGROUND: COVID19, and associated lockdown restrictions, have impacted on people's daily lives. Understanding the mental health and wellbeing implications of these impacts has been identified as a public health research priority. AIMS: Building on an earlier cross-sectional study, the current study sought to investigate whether capability-based quality of life changed during the first 5-months of lock-down restrictions in the UK, and whether capability-based quality of life was predictive of future levels of depression and anxiety. METHODS: An initial convenience sample of 594 participants were followed up at three different timepoints spanning a 20-week time-period between March 2020 and August 2020. Participants provided demographic information and completed the Oxford Capabilities Questionnaire - Mental Health (OxCAP-MH), and the Hospital Anxiety and Depression Scale (HADS). RESULTS: The mean scores indicated that levels of both depression and anxiety decreased across the three timepoints, whereas capability-based QoL (as assessed by the OxCAP-MH) decreased over time. Capability-based QoL predicted additional levels of variance in both depression and anxiety levels when time and sociodemographic factors were controlled for. Cross-lagged panel model analyses indicated that capability-based QoL over a month into lockdown restrictions predicted levels of depression and anxiety 5 months into the restrictions. CONCLUSIONS: The study findings suggest that the capability-limiting impact of public health emergencies and related lockdown restrictions are important for understanding peoples' levels of depression and anxiety. The implications that the findings have for the provision of support in the context of public health emergencies and associated restrictions are discussed.

Manumycin polyketides act as molecular glues between UBR7 and P53.

Molecular glues are an intriguing therapeutic modality that harness small molecules to induce interactions between proteins that typically do not interact. However, such molecules are rare and have been discovered fortuitously, thus limiting their potential as a general strategy for therapeutic intervention. We postulated that natural products bearing one or more electrophilic sites may be an unexplored source of new molecular glues, potentially acting through multicovalent attachment. Using chemoproteomic platforms, we show that members of the manumycin family of polyketides, which bear multiple potentially reactive sites, target C374 of the putative E3 ligase UBR7 in breast cancer cells, and engage in molecular glue interactions with the neosubstrate tumor-suppressor TP53, leading to p53 transcriptional activation and cell death. Our results reveal an anticancer mechanism of this natural product family, and highlight the potential for combining chemoproteomics and multicovalent natural products for the discovery of new molecular glues.

Symptoms of Paranoia Experienced by Students of Pakistani Heritage in England: The Role of Explicit and Implicit Identities and Perceived Discrimination.

ABSTRACT: Individuals belonging to ethnic minority groups are less likely to experience symptoms of psychosis, such as paranoia, if they live in areas with high proportions of people from the same ethnic background. This effect may be due to processes associated with group belonging (social identification). We examined whether the relationship between perceived discrimination and paranoia was moderated by explicit and implicit Pakistani/English identification among students of Pakistani heritage (N = 119). Participants completed measures of explicit and implicit Pakistani and English identity, a measure of perceived discrimination, and a measure of paranoia. Perceived discrimination was the strongest predictor of paranoia (0.31). Implicit identities moderated the relationship between perceived discrimination and paranoia (-0.17). The findings suggest that higher levels of implicit Pakistani identity were most protective against high levels of paranoia (0.26, with low implicit English identity; 0.78, with medium English identity; 1.46, with high English identity). Overall, a complex relationship between identity and paranoia was apparent.

Community-based mental health and well-being interventions for older adults in low- and middle-income countries: a systematic review and meta-analysis.

BACKGROUND: Mental health support is often scarce in low- and middle-income countries (LMIC), with mental health stigmatised. Older adults are some of the most vulnerable members of society and may require specific types of mental health support. The aim of this mixed-methods systematic review and meta-analysis was to explore the types, components, and efficacy of psychosocial community-based mental health interventions for older adults (aged 60 + years) residing in LMIC. METHODS: Six databases were searched in August 2021. Studies published since 2000 were included if they collected primary quantitative or qualitative data on community-based interventions for improving mental health for older adults residing in LMICs, focusing on improving mental health and well-being outcomes. Full texts were screened by two researchers. RESULTS: From 24,378 citations identified, 40 studies met eligibility criteria. Across 12 countries, interventions were categorised into those focusing on (1) Established forms of psychological therapy; (2) Exercise; (3) Education; (4) Social engagement; (5) Multi-component. Most interventions were effective in reducing levels of depression, anxiety, and improving well-being, including reminiscence therapy, different types of socialising, and breathing and laughter exercises. Some interventions reported no benefits and those that did at times failed to report continued benefits at follow-up. Given the variations in intervention type and delivery, cultures, and outcome measures used, underpinning factors of intervention success or failure were difficult to establish. CONCLUSIONS: Psychosocial interventions for older adults in LMIC need to be adapted to local contexts depending on culture and population needs. Existing interventions and their components can be used as a foundation to produce adapted and multi-component interventions, to tackle growing and inadequate mental health care provision in LMIC. TRIAL REGISTRATION: The review protocol was registered on PROSPERO [CRD42021271404].

COVID-19 and its prevention in internally displaced person (IDP) camps in Somalia: impact on livelihood, food security and mental health.

BACKGROUND: Somalia has over 2.6 million internally displaced people (IDP) that depend on daily wages and humanitarian assistance for their livelihoods. This study investigated the impact of COVID-19 on livelihoods, food security and mental health of Somalia's IDPs. METHODS: A questionnaire was conducted with "breadwinners" (n = 585) residing in 15 randomly selected IDP camps. Mental health was assessed using the 5-item World Health Organization Wellbeing Index (WHO-5) and the Patient Health Questionnaire-9 (PHQ-9). Multivariable regression was used to explore the effect of depressive symptoms on soap use and ability to pay for food/medicine/rent. RESULTS: Knowledge of COVID-19 symptoms, transmission and prevention was relatively high, however only 55% reported using soap for hand washing. Around one third perceived that prohibition of public gatherings had negatively impacted weekly earnings. Participants reported difficulty buying food (85%), medicine (82%) and paying rent (51%) because of COVID-19. The majority were assessed as having low wellbeing and high depressive symptoms (mean WHO-5 = 44.2/100; mean PHQ-9 = 18.6/27), with most (74%) indicating that they felt worse than before the pandemic. Compared to people with low depressive symptoms, people with high depressive symptoms were less likely to use soap (aOR = 0.3, 95% CI = 0.2, 0.7; P < 0.001) and more likely to report difficulty buying food (aOR = 2.2; 95% CI = 1.1, 4.3; P = 0.02). CONCLUSION: COVID-19 and associated restrictions have negatively impacted Somalia's internally displaced population. Livelihood and mental health support is urgently needed in the recovery phase of the pandemic and should be factored into future pandemic planning.

Understanding post-conflict mental health needs and co-producing a community-based mental health intervention for older adults in Colombia: a research protocol.

BACKGROUND: Older adults in Colombia have seen a number of stressful life events - including the Colombian armed conflict, forced misplacement and recently COVID-19. These events likely have had and are having a substantial impact on people's mental health and well-being, whilst mental health care provision in Colombia is not sufficient and often access is limited and unaffordable. Therefore, the aim of this study is to understand the impact of stressful life events on the mental health of older adults living in Colombia, and co-produce, pilot, and evaluate a community-based mental health intervention in Turbo. METHODS: This 3-year international mixed-methods study comprises of three phases: Phase I will explore the impact of stressful life events on the mental health of older adults living in Colombia, and their mental health needs, via quantitative needs assessments and qualitative interviews and focus groups; Phase II will involve synthesising the findings from Phase I as well as conducting a systematic review and qualitative interviews with experts into implementing mental health interventions in LMICs to co-produce a community-based mental health intervention with older adults and local community group leaders and care providers; Phase III will involve the piloting and evaluation of the mental health intervention via quantitative and qualitative assessments. Co-production and public involvement underpin each element of this project. DISCUSSION: Appropriate mental health care is as important as physical health care, but this study also looks at how we might integrate these findings into community-level public health initiatives for application both within Colombia and more widely in both LMICs and more developed countries. This study protocol will act as a guide for the development and adaptation of psychosocial mental health interventions in different cultures and contexts.

Effectiveness of Self-Help Plus in Preventing Mental Disorders in Refugees and Asylum Seekers in Western Europe: A Multinational Randomized Controlled Trial.

INTRODUCTION: Self-Help Plus (SH+) is a group-based psychological intervention developed by the World Health Organization for managing stress. OBJECTIVE: To assess the effectiveness of SH+ in preventing mental disorders in refugees and asylum seekers in Western Europe. METHODS: We conducted a randomized controlled trial in 5 European countries. Refugees and asylum seekers with psychological distress (General Health Questionnaire score ≥3), but without a Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) or ICD/10 diagnosis of mental disorder, as assessed with the Mini International Neuropsychiatric Interview (MINI), were randomized to SH+ or enhanced treatment as usual (ETAU). The primary outcome was the frequency of mental disorders with the MINI at 6 months. Secondary outcomes included the frequency of mental disorders at postintervention, self-identified problems, psychological symptoms, and other outcomes. RESULTS: Four hundred fifty-nine individuals were randomly assigned to SH+ or ETAU. For the primary outcome, we found no difference in the frequency of mental disorders at 6 months (Cramer V = 0.007, p = 0.90, RR = 0.96; 95% CI 0.52-1.78), while the difference significantly favored SH+ at after the intervention (secondary outcome, measured within 2 weeks from the last session; Cramer V = 0.13, p = 0.01, RR = 0.50; 95% CI 0.29-0.87). CONCLUSIONS: This is the first randomized indicated prevention study with the aim of preventing the onset of mental disorders in asylum seekers and refugees in Western Europe. As a prevention effect of SH+ was not observed at 6 months, but rather after the intervention only, modalities to maintain its beneficial effect in the long term need to be identified.

Mindfulness-based cognitive therapy for prevention and time to depressive relapse: Systematic review and network meta-analysis.

OBJECTIVE: To perform a network meta-analysis (NMA) to compare the long-term effectiveness of mindfulness-based cognitive therapy (MBCT) with available strategies for prevention and time to depressive relapse. METHODS: Seven electronic databases were searched up to June 2019. Studies evaluated MBCT for the management of depression-related outcomes and follow-up assessments occurred at 12 months or longer. RESULTS: Twenty-three publications were included, 17 of which were randomised controlled trials (RCTs). Data from 14 RCTs including 2077 participants contributed to meta-analysis (MA) and NMA to assess relapse of depression and 13 RCTs with 2017 participants contributed to MA and NMA for time to relapse of depression. NMAs showed statistically significant advantages for MBCT over treatment as usual (TAU) for relapse of depression (RR = 0.73, 95% CI 0.54 to 0.98) and for MBCT over TAU and placebo for time to relapse of depression (MBCT vs TAU: HR = 0.57, 95% CI 0.37 to 0.88; MBCT vs placebo: HR = 0.23, 95% CI 0.08 to 0.67). Subgroup meta-analysis of relapse of depression by previous number of depressive episodes showed similar results between subgroups. Subgroup meta-analysis by the use or not of booster sessions suggests these may lead to improved effectiveness. CONCLUSIONS: MBCT is more effective than TAU in the long-term in preventing relapse of depression and has statistically significant advantages over TAU and placebo for time to relapse of depression. No statistically significant differences were observed between MBCT and active treatment strategies for rate of relapse or time to relapse of depression.

Impacts of the Covid-19 lockdown and relevant vulnerabilities on capability well-being, mental health and social support: an Austrian survey study.

BACKGROUND: Impacts of the Covid-19 pandemic and its public health measures go beyond physical and mental health and incorporate wider well-being impacts in terms of what people are free to do or be. We explored the impacts of the Covid-19 lockdown and relevant vulnerabilities on capability well-being, mental health and social support in Austria. METHODS: Adult Austrian residents (n = 560) provided responses to a cross-sectional online survey about their experiences during Covid-19 lockdown (15 March-15 April 2020). Instruments measuring capabilities (OxCAP-MH), depression and anxiety (HADS), social support (MSPSS) and mental well-being (WHO-5) were used in association with six pre-defined vulnerabilities using multivariable linear regression. RESULTS: 31% of the participants reported low mental well-being and only 30% of those with a history of mental health treatment received treatment during lockdown. Past mental health treatment had a significant negative effect across all outcome measures with an associated capability well-being score reduction of - 6.54 (95%CI, - 9.26, - 3.82). Direct Covid-19 experience and being 'at risk' due to age and/or physical health conditions were also associated with significant capability deprivations. When adjusted for vulnerabilities, significant capability reductions were observed in association with increased levels of depression (- 1.77) and anxiety (- 1.50), and significantly higher capability levels (+ 3.75) were associated with higher levels of social support. Compared to the cohort average, individual capability impacts varied between - 9% for those reporting past mental health treatment and + 5% for those reporting one score higher on the social support scale. CONCLUSIONS: Our study is the first to assess the capability limiting aspects of lockdown and relevant vulnerabilities alongside their impacts on mental health and social support. The negative capability well-being, mental health and social support impacts of the Covid-19 lockdown were strongest for people with a history of mental health treatment. Future public health policies concerning lockdowns should pay special attention to improve social support levels in order to increase public resilience.

Are acceptance and mindfulness-based interventions 'value for money'? Evidence from a systematic literature review.

OBJECTIVES: Acceptance and mindfulness-based interventions (A/MBIs) are recommended for people with mental health conditions. Although there is a growing evidence base supporting the effectiveness of different A/MBIs for mental health conditions, the economic case for these interventions has not been fully explored. The aim of this systematic review was to identify and appraise all available economic evidence of A/MBIs for the management of mental health conditions. METHODS: Eight electronic bibliographic databases (MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Web of Science, NHS Economic Evaluation Database (EED), Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment (HTA) database, and EconLit) were searched for relevant economic evaluations published from each database's inception date until November 2017. Study selection, quality assessment, and data extraction were carried out according to published guidelines. RESULTS: Ten relevant economic evaluations presented in 11 papers were identified. Seven of the included studies were full economic evaluations (i.e., costs and effects assessed), and three studies were partial economic evaluations (i.e., only costs were considered in the analysis). The A/MBIs that had been subjected to economic evaluation were acceptance and commitment therapy (ACT), dialectical behaviour therapy (DBT), mindfulness-based cognitive therapy (MBCT), and mindfulness-based stress reduction (MBSR). In terms of clinical presentations, the evaluation of cost-effectiveness of A/MBIs has been more focused on depression and emotional unstable personality disorder with three and four economic evaluations, respectively. Three out of seven full economic evaluations observed that A/MBIs were cost-effective for the management of mental health conditions. Nevertheless, the heterogeneity of included populations, interventions, and economic evaluation study types limits the extent to which firm conclusions can currently be made. CONCLUSION: This first substantive review of economic evaluations of A/MBIs indicates that more research is needed before firm conclusions can be reached on the cost-effectiveness of A/MBIs for mental health conditions. PRACTITIONER POINTS: The findings of the review provide information that may be relevant to mental health service commissioners and decision-makers as all economic evidence available on acceptance and mindfulness-based interventions for mental health conditions is summarized. Evidence relating to the cost-effectiveness and cost-saving potential of acceptance and mindfulness-based interventions is focused mainly on depression and emotional unstable personality disorder to date. Heterogeneity in the specific forms of acceptance and mindfulness-based interventions may limit generalizability of the findings. The number of health economic evaluations relating to acceptance and mindfulness-based interventions remains relatively small. Further research in this area is required.

Using the primary process emotional-behavioural system to better meet patient needs in psychotherapy.

In order to increase therapeutic impact by enhancing awareness of clients' nonverbal communications, this article operationalizes the therapeutic alliance as a needs-satisfaction process. The client's competence as a needs seeker and the therapist assisting with the client's expression and satiation of basic social needs are proposed as being key mechanisms of change. Functional model of primary emotions derived from Panksepp's seven primary emotional systems (care seeking, caretaking, lust, fear and anxiety, anger, play, seeking, plus dominance and disgust) is integrated with Functional Analytic Psychotherapy's emphasis on in-session contingent natural reinforcement of clients' target behaviours. By identifying in-the-moment cues of underlying emotional-behavioural functions drawn from a categorization of clients' nonverbal communication can bridge the gap between client private events and therapist observables, in order to maximize therapist attunement and responsiveness to clients, and to increase the effectiveness of clinical interventions.

Global mental health in high-income countries.

Over the past decade there have been significant efforts to scale-up mental health services in resource-poor countries. A number of cost-effective innovations have emerged as a result. At the same time, there is increasing concern in resource-rich countries about efficacy, efficiency and acceptability of mental health services. We consider two specific innovations used widely in low- and middle-income countries, task-sharing and a development model of mental healthcare, that we believe have the potential to address some of the current challenges facing mental health services in high-income countries.

The Capabilities Approach: Fostering contexts for enhancing mental health and wellbeing across the globe.

Concerted efforts have been made in recent years to achieve equity and equality in mental health for all people across the globe. This has led to the emergence of Global Mental Health as an area of study and practice. The momentum that this has created has contributed to the development, implementation and evaluation of services for priority mental disorders in many low- and middle-income countries.This paper discusses two related issues that may be serving to limit the success of mental health initiatives across the globe, and proposes potential solutions to these issues. First, there has been a lack of sophistication in determining what constitutes a 'good outcome' for people experiencing mental health difficulties. Even though health is defined and understood as a state of 'wellbeing' and not merely an absence of illness, mental health interventions tend to narrowly focus on reducing symptoms of mental illness. The need to also focus more broadly on enhancing subjective wellbeing is highlighted. The second limitation relates to the lack of an overarching theoretical framework guiding efforts to reduce inequalities and inequities in mental health across the globe. This paper discusses the potential impact that the Capabilities Approach (CA) could have for addressing both of these issues. As a framework for human development, the CA places emphasis on promoting wellbeing through enabling people to realise their capabilities and engage in behaviours that they subjectively value. The utilization of the CA to guide the development and implementation of mental health interventions can help Global Mental Health initiatives to identify sources of social inequality and structural violence that may impede freedom and individuals' opportunities to realise their capabilities.

Fear of recurrence: results of a randomized trial of relapse detection in schizophrenia.

OBJECTIVE: We aimed to develop and establish the reliability and validity of a measure of Fear of Recurrence, measuring cognitive appraisals of relapse rather than standard early signs of relapse. We also aimed to establish the sensitivity and specificity to relapse. METHOD: Participants diagnosed with schizophrenia or a related disorder were randomized to one of two early signs monitoring conditions, using either the Early Signs Scale or the Fear of Recurrence Scale (FoRSe). Participants were followed up for 6-months or until relapse. RESULTS: A total of 169 participants were randomized to Standard (n = 86) or FoRSe (n = 83) monitoring. We found good evidence supporting reliability and validity of the FoRSe. In addition, a cut-off point of ≥ 5 was associated with an optimal sensitivity in both Standard (n = 26:79%, 95% CI = 62-89) and FoRSe (n = 18:72%, 95% CI = 52-86) monitoring. However, this degree of sensitivity was associated with a lower specificity in Standard (n = 30:35%, 96% CI = 23-50) and FoRSe (n = 25:46%, 95% CI = 32-60). Finally, Fear of Relapse was a significant predictor of time to relapse [Exp(ß) = 1.20, 95% CI = 1.01-1.42, p < .05]. CONCLUSION: The study provides evidence that Fear of Recurrence may be an important clinical construct linked to increased risk of relapse and poorer emotional recovery in people diagnosed with schizophrenia. PRACTITIONER POINTS: Monitoring Fear of Recurrence is as sensitive to relapse detection as monitoring early signs alone. Greater Fear of Relapse was associated with shorter duration to actual relapse. Fear of recurrence may be an important clinical feature linked to poorer emotional recovery and increased risk of relapse. Fear of Recurrence may be an important focus of psychological therapy to promote emotional recovery and prevention of relapse.

Towards a more nuanced global mental health.

The World Health Organization has made concerted efforts to scale up mental health services in low- and middle-income countries through the Mental Health Gap Action Programme (mhGAP) initiative. However, an overreliance on scaling up services based on those used in high-income countries may risk causing more harm than good.

Counterflows for mental well-being: what high-income countries can learn from low and middle-income countries.

Global mental health is a comparatively new area of study and research that is concerned with addressing inequities and inequalities in mental health provision across the globe. In recent years concerted efforts have been made to scale up mental health services in low- and middle-income countries (LMIC). As such, there has been tendency to view LMIC as recipients of mental health-related knowledge, rather than providers of knowledge. Critics have referred to the prevailing flow of information from high-income countries (HIC) to LMIC as a form of medical imperialism. To redress the apparent imbalance in knowledge exchange, this paper reflects on valuable lessons that HIC can potentially learn from LMIC in terms of supporting mental well-being. Specifically, the paper reflects on how a greater willingness to embrace pluralism in HIC may facilitate people to engage with forms of support that they believe to be appropriate for them. The paper also explores examples of what are termed 'counterflows' of knowledge; ideas that have originated from LMIC that are influencing mental health-related practice in HIC. Barriers to potential counterflows are discussed.

Identifying core global mental health professional competencies: A multi-sectoral perspective.

Concerned with sustainably alleviating mental distress and promoting the right to health worldwide, global mental health (GMH) is practised across various contexts spanning the humanitarian-development-peace nexus. The inherently intersectoral and multidisciplinary nature of GMH calls for competency frameworks and training programmes that embody diversity, decolonisation and multiprofessionalism. Existing competency frameworks have failed to capture the multi-sectoral, inter-professional nature of contemporary GMH practice. In response to these needs, a qualitative content analysis of relevant job advertisements was conducted to distil a comprehensive set of professional competencies in contemporary GMH practice. Approximately 200 distinct skills and competencies were extracted from 70 job advertisements and organised into four meta-dimensions: 'skills', 'sector', 'self' and 'subject'. The first known systematic attempt at a multi-sectoral GMH competency framework, it offers a springboard for exploring vital yet overlooked professional competencies such as resilience, self-reflection, political skills and entrepreneurialism. On this basis, recommendations for building a competent, agile and effective GMH workforce with diversified and future-proof skillsets are proposed. The framework can also inform inter-professional training and curriculum design, and capacity-building initiatives aimed at early-career professional development, particularly in low- and middle-income settings.

The Effect of a Group-Based Mindfulness and Acceptance Training on Psychological Flexibility and Adherence to Antiretroviral Therapy Among Adolescents in Uganda: An Open-Label Randomized Trial.

Adherence to antiretroviral therapy (ART) is lower in adolescents with HIV (AWH) than in any other age group, partly due to self-regulatory challenges during development. Mindfulness and acceptance training have been shown to support psychological flexibility, a self-regulatory skill that potentially improves adolescent adherence to medication. We assessed the effect of weekly group-based mindfulness and acceptance training sessions on ART adherence among older adolescents (15-19 years) in Kampala, Uganda. One hundred and twenty-two AWH (median age 17, range 15-19 years, 57% female) receiving care at a public health facility in Kampala were randomized 1:1 to receive 4 weekly 90-min group sessions facilitated by experienced trainers or standard-of-care ART services. The training involved (Session 1) clarifying values, (Session 2) skillfully relating to thoughts, (Session 3) allowing and becoming aware of experiences non-judgmentally, and (Session 4) exploring life through trial and error. At baseline, postintervention, and 3-month follow-up, psychological flexibility was measured using the Avoidance and Fusion Questionnaire for Youth (AFQ-Y8), and self-reported ART adherence was assessed using the Morisky Medication Adherence Scale (MMAS-8). At baseline, the intervention and standard-of-care arms had similar psychological flexibility (AFQ-Y8 score:15.45 ± 0.82; 15.74 ± 0.84) and ART adherence (MMAS-8 score: 5.32 ± 0.24; 5.13 ± 0.23). Retention through the study was moderate (71%). Completion of mindfulness and acceptance training was associated with a significant reduction in psychological inflexibility at the 3-month follow-up (AFQ-Y8 score: 12.63 ± 1.06; 14.05 ± 1.07, P = .006). However, no significant differences were observed in self-reported adherence to ART at the 3-month follow-up (MMAS-8 score: 5.43 ± 0.23; 4.90 ± 0.33, P = .522). Group-based mindfulness and acceptance training improved psychological flexibility in this population of adolescents on ART in Uganda but did not significantly improve ART adherence. Future research should explore integrated approaches that combine behavioral management training with other empowerment aspects to improve ART adherence among AWH.