Family supplemented patient monitoring after surgery (SMARTER): a pilot stepped-wedge cluster-randomised trial.

BACKGROUND: Mortality after surgery in Africa is twice that in high-income countries. Most deaths occur on wards after patients develop postoperative complications. Family members might contribute meaningfully and safely to early recognition of deteriorating patients. METHODS: This was a stepped-wedge cluster-randomised trial of an intervention training family members to support nursing staff to take and record patient vital signs every 4 h after surgery. Adult inpatients across four surgical wards (clusters) in a Ugandan hospital were included. Clusters crossed once from routine care to the SMARTER intervention at monthly intervals. The primary outcome was frequency of vital sign measurements from arrival on the postoperative ward to the end of the third postoperative day (3 days). RESULTS: We enrolled 1395 patients between April and October 2021. Mean age was 28.2 (range 5-89) yr; 85.7% were female. The most common surgical procedure was Caesarean delivery (74.8%). Median (interquartile range) number of sets of vital signs increased from 0 (0-1) in control wards to 3 (1-8) in intervention wards (incident rate ratio 12.4, 95% confidence interval [CI] 8.8-17.5, P<0.001). Mortality was 6/718 (0.84%) patients in the usual care group vs 12/677 (1.77%) in the intervention group (odds ratio 1.32, 95% CI 0.1-14.7, P=0.821). There was no difference in length of hospital stay between groups (usual care: 2 [2-3] days vs intervention: 2 [2-4] days; hazard ratio 1.11, 95% CI 0.84-1.47, P=0.44). CONCLUSIONS: Family member supplemented vital signs monitoring substantially increased the frequency of vital signs after surgery. Care interventions involving family members have the potential to positively impact patient care. CLINICAL TRIAL REGISTRATION: NCT04341558.

Optimal content for a surgical curriculum for general practice in Rwanda: A Delphi study.

BACKGROUND: In Rwanda, a nationwide shortage of surgeons necessitates general practitioners (GPs) perform many common procedures and minor surgeries. However, GPs only receive a 1-year internship to prepare them to provide this care. We performed a Delphi survey of practicing GPs to assess essential content for a surgical curriculum for Rwandan interns to better prepare them for general practice. METHODS: We invited 56 practicing GPs to participate in a two-round anonymous electronic survey in February 2023. The first round assessed demographics and solicited free-text responses to gather knowledge and procedural content suggestions for the curriculum. The second round refined these responses into key content areas. RESULTS: Thirty-one GPs responded to both rounds of the Delphi survey. They provided insight into the most commonly performed procedures, most important technical skills, and the top areas of surgical knowledge necessary for general practice. They expressed a need for more exposure to a variety of surgical pathologies and interventions across multiple specialties, highlighting the value of foundational skills in trauma, obstetrics and gynecology, and orthopedics, both at the beginning of their internship, as well as at the beginning of their general practice. CONCLUSIONS: GPs emphasized the importance of broad exposure to common acute surgical pathology and interventions across several surgical subspecialties, as well as a need for foundational technical skills and surgical knowledge. The results of our study underscore the necessity of a surgical education providing a solid basis in the foundational knowledge and techniques of surgical care.

A qualitative study on the adaptation of community programmes for the promotion of early detection and health-seeking of perinatal depression in Nepal.

BACKGROUND: Despite the high burden of perinatal depression in Nepal, the detection rate is low. Community-based strategies such as sensitization programmes and the Community Informant Detection Tool (CIDT) have been found to be effective in raising awareness and thus promoting the identification of mental health problems. This study aims to adapt these community strategies for perinatal depression in the Nepalese context. METHODS: We followed a four-step process to adapt the existing community sensitization program manual and CIDT. Step 1 included in-depth interviews with women identified with perinatal depression (n=36), and focus group discussions were conducted with health workers trained in community mental health (n=13), female community health volunteers (FCHVs), cadre of Nepal government for the prevention and promotion of community maternal and child health (n=16), and psychosocial counsellors (n=5). We explored idioms and understanding of depression, perceived causes, and possible intervention. Step 2 included draft preparation based on the qualitative study. Step 3 included a one-day workshop with the psychosocial counsellors (n=2) and health workers (n=12) to assess the understandability and comprehensiveness of the draft and to refine the content. A review of the CIDT and community sensitization program manual by a psychiatrist was performed in Step 4. RESULTS: The first step led to the content development for the CIDT and community sensitization manual. Multiple stakeholders and experts reviewed and refined the content from the second to fourth steps. Idioms of depression and commonly cited risk factors were incorporated in the CIDT. Additionally, myths of perinatal depression and the importance of the role of family were added to the community sensitization manual. CONCLUSION: Both the CIDT and community sensitization manual are grounded in the local context and are simple, clear, and easy to understand.

The effectiveness of mental health interventions involving non-specialists and digital technology in low-and middle-income countries - a systematic review.

BACKGROUND: Combining non-specialists and digital technologies in mental health interventions could decrease the mental healthcare gap in resource scarce countries. This systematic review examined different combinations of non-specialists and digital technologies in mental health interventions and their effectiveness in reducing the mental healthcare gap in low-and middle-income countries. METHODS: Literature searches were conducted in four databases (September 2023), three trial registries (January-February 2022), and using forward and backward citation searches (May-June 2022). The review included primary studies on mental health interventions combining non-specialists and digital technologies in low-and middle-income countries. The outcomes were: (1) the mental health of intervention receivers and (2) the competencies of non-specialists to deliver mental health interventions. Data were expressed as standardised effect sizes (Cohen's d) and narratively synthesised. Risk of bias assessment was conducted using the Cochrane risk-of-bias tools for individual and cluster randomised and non-randomised controlled trials. RESULTS: Of the 28 included studies (n = 32 interventions), digital technology was mainly used in non-specialist primary-delivery treatment models for common mental disorders or subthreshold symptoms. The competencies of non-specialists were improved with digital training (d ≤ 0.8 in 4/7 outcomes, n = 4 studies, 398 participants). The mental health of receivers improved through non-specialist-delivered interventions, in which digital technologies were used to support the delivery of the intervention (d > 0.8 in 24/40 outcomes, n = 11, 2469) or to supervise the non-specialists' work (d = 0.2-0.8 in 10/17 outcomes, n = 3, 3096). Additionally, the mental health of service receivers improved through digitally delivered mental health services with non-specialist involvement (d = 0.2-0.8 in 12/27 outcomes, n = 8, 2335). However, the overall certainty of the evidence was poor. CONCLUSION: Incorporating digital technologies into non-specialist mental health interventions tended to enhance non-specialists' competencies and knowledge in intervention delivery, and had a positive influence on the severity of mental health problems, mental healthcare utilization, and psychosocial functioning outcomes of service recipients, primarily within primary-deliverer care models. More robust evidence is needed to compare the magnitude of effectiveness and identify the clinical relevance of specific digital functions. Future studies should also explore long-term and potential adverse effects and interventions targeting men and marginalised communities.

Addressing the challenges of integrating care for perinatal depression in primary care in Nigeria.

PURPOSE: This report provides the results of a task-shared approach for integrating care for perinatal depression (PND) within primary maternal and child healthcare (PMCH), including the factors that may facilitate or impede the process. METHODS: This hybrid implementation-effectiveness study guided by the Replicating Effective Programmes framework was conducted in 27 PMCH clinics in Ibadan, Nigeria. The primary implementation outcome was change in the identification rates of PND by primary health care workers (PHCW) while the primary effectiveness outcome was the difference in symptom remission (EPDS score ≤ 5) 6 months postpartum. Outcome measures were compared between two cohorts of pregnant women, one recruited before and the other after training PHCW to identify and treat PND. Barriers and facilitators were explored in qualitative interviews. RESULTS: Identification of PND improved from 1.4% before to 17.4% after training; post-training rate was significantly higher in clinics where PHCW routinely screened using the 2-item patient health questionnaire (24.8%) compared to non-screening clinics (5.6%). At 6-months postpartum, 60% of cohort one experienced remission from depression, compared to 56.5% cohort two [OR-0.9 (95%CI-0.6, 1.3) p = 0.58]. Identified facilitators for successful integration included existence of policy specifying mental health as a component of PHC, use of screening to aid identification and supportive supervision, while barriers included language and cultural attitudes towards mental health and human resource constraints. PHCW were able to make adaptations to address these barriers. CONCLUSIONS: Successful implementation of task-shared care for perinatal depression requires addressing staff shortages and adopting strategies that can improve identification by non-specialist providers. TRIAL REGISTRATION: This study was retrospectively registered 03 Dec 2019. https://doi.org/10.1186/ISRCTN94230307 .

Developing mental health curricula and a service provision model for clinical associates in South Africa: a Delphi survey of family physicians and psychiatrists.

BACKGROUND: Clinical associates are a health professional cadre that could be utilised in mental health task sharing in South Africa but this is training dependent. The objectives of the study were to identify the potential curricula content, training sites, and teaching modalities for undergraduate and potential postgraduate clinical associate mental health training and to identify the tasks that they should perform based on these curricula. METHODS: We utilised the Delphi method to reach consensus on items with the panel comprising psychiatrists and family physicians. The first round questionnaire of the Delphi survey was developed based on a literature review and the results from earlier phases of the overall study. The survey was administered electronically and consisted of three rounds. Following both the first and second rounds, an updated questionnaire was constructed omitting the items on which consensus was reached. The questionnaire consisted primarily of nine-point scales with consensus based on 70% of participants rating 1,2,3 or 7,8,9. RESULTS: There were 26 participants in the first round with this number falling to 23 in later rounds. There was strong consensus on a training attachment to a mental health clinic at a community health centre (CHC) at undergraduate (96.2%) and postgraduate level (100%). Consensus was reached on the importance of training on the management of six categories of disorders at the undergraduate level and nine categories of disorders at the postgraduate level. Clerking patients as a teaching modality reached 100% consensus at both undergraduate and postgraduate levels. PHC clinics, CHCs and district hospitals reached consensus as appropriate settings for clinical associates to provide mental health services. In addition, GP practices and secondary hospitals reached consensus for those with postgraduate training. Consensus was reached on ten of the 21 listed tasks that could be performed based on undergraduate training and 20 of the 21 tasks based on a postgraduate qualification in mental health. CONCLUSIONS: The Delphi panel's recommendations provide a clear roadmap for enhancing mental health curricula for clinical associates, enabling their utilisation in mental health service provision. A future postgraduate mental health qualification for clinical associates would allow for expanded task sharing.

Nurse and midwife involvement in task-sharing and telehealth service delivery models in primary care: A scoping review.

AIM: To synthesise and map current evidence on nurse and midwife involvement in task-sharing service delivery, including both face-to-face and telehealth models, in primary care. DESIGN: This scoping review was informed by the Joanna Briggs Institute (JBI) Methodology for Scoping Reviews. DATA SOURCE/REVIEW METHODS: Five databases (Ovid MEDLINE, Embase, PubMed, CINAHL and Cochrane Library) were searched from inception to 16 January 2024, and articles were screened for inclusion in Covidence by three authors. Findings were mapped according to the research questions and review outcomes such as characteristics of models, health and economic outcomes, and the feasibility and acceptability of nurse-led models. RESULTS: One hundred peer-reviewed articles (as 99 studies) were deemed eligible for inclusion. Task-sharing models existed for a range of conditions, particularly diabetes and hypertension. Nurse-led models allowed nurses to work to the extent of their practice scope, were acceptable to patients and providers, and improved health outcomes. Models can be cost-effective, and increase system efficiencies with supportive training, clinical set-up and regulatory systems. Some limitations to telehealth models are described, including technological issues, time burden and concerns around accessibility for patients with lower technological literacy. CONCLUSION: Nurse-led models can improve health, economic and service delivery outcomes in primary care and are acceptable to patients and providers. Appropriate training, funding and regulatory systems are essential for task-sharing models with nurses to be feasible and effective. IMPACT: Nurse-led models are one strategy to improve health equity and access; however, there is a scarcity of literature on what these models look like and how they work in the primary care setting. Evidence suggests these models can also improve health outcomes, are perceived to be feasible and acceptable, and can be cost-effective. Increased utilisation of nurse-led models should be considered to address health system challenges and improve access to essential primary healthcare services globally. REPORTING METHOD: This review is reported against the PRISMA-ScR criteria. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution. PROTOCOL REGISTRATION: The study protocol is published in BJGP Open (Moulton et al., 2022).

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.

Training non-specialists in teaching recovery techniques (TRT) to help traumatised children in humanitarian settings: a qualitative analysis of experiences gained from 20 years of practice.

BACKGROUND: Although several manuals and guidelines have been developed to enhance the quality of task-sharing interventions, it remains challenging to train non-professional personnel in mental health and psychosocial support. Practitioners must translate general recommendations into practical applications to make them relevant in demanding contexts. However, limited research exists on practical experiences with standardised programmes in the field. AIM: To explore how experiences gained from the training of first-line health providers in a low-threshold intervention for children with trauma symptoms may guide implementation of such interventions in local communities in low-income countries. METHOD: We summarise 20 years of experience in the training of first-line health providers, teachers, and school counsellors in providing a low-threshold intervention. The intervention is called teaching recovery techniques (TRT), developed by the Children and War Foundation (CAW). Field notes containing notes from trainings and oral, informal feedback from participants are analysed using thematic analysis, a method well-suited for identifying, analysing, and reporting patterns, or themes, within data in qualitative research. FINDINGS: The analysis showed three main themes/ challenges: (1) Who can conduct the TRT intervention? (2) What form and content should the training take? (3) How can the intervention be used in a responsible way to follow the 'do no harm' principle? We discuss the implications of the findings for trainings in scalable interventions and further research.

The Role of Peer Providers to Scale Up Psychological Treatments for Perinatal Populations Worldwide.

PURPOSE OF REVIEW: Psychological treatments remain largely inaccessible to perinatal populations despite their robust effectiveness. This gap is partly due to the limited number of available treatment providers. In this review, we critically evaluate recent literature on task-sharing to peer providers and propose future directions. RECENT FINDINGS: There is a growing evidence base demonstrating that peer providers can effectively deliver psychological treatments for perinatal populations, as well as engage in processes critical to quality assurance, such as measurement-based peer supervision. Findings have also highlighted some benefits of peers over licensed healthcare providers, such as enhanced collaborative relationships, reduced stigma, provision of social comparisons, and increased accessibility. Peer providers may be one solution to improve access to psychological treatments for perinatal populations. However, there is a need to address clinical, professional, and health-system level barriers to effectively leverage this cadre of treatment providers.

Participatory development of a home-based depression care model with lived experience older Nigerians and their caregivers: A theory of change.

OBJECTIVES: There is a huge treatment gap for late-life depression in sub-Saharan Africa. Building on prior work to scale-up mental healthcare with the aid of the WHO Mental Health Gap Action Programme Intervention Guide electronic version (emhGAP-IG), this study aims to involve older people in the iterative development of innovations to overcome challenges in the detection and clinical management of late-life depression by frontline non-specialist primary healthcare workers (PHCW) in Nigeria. METHODS: There were 43 participants in the study. We conducted formative qualitative research using 15 in-depth key informant interviews with persons who were 60 years or older and had a recent experience of depression. We also conducted two focus group discussions comprising 13 of their caregivers. Through a full day stakeholders workshop comprising 15 participants, we drew on the results of our qualitative explorations to identify the pathway to impact of an intervention package (emhGAP-Age) appropriate for the specific needs of persons with late-life depression in Nigeria. RESULTS: A Theory of Change (ToC) map was produced. It highlights the expected long-term outcomes of emhGAP-Age to include the potential for improvement of the mental health and wellbeing of older people living in Nigeria and the generation of interest among governmental agencies concerned with policy and planning for mental healthcare. Key resources that serve as preconditions were identified to consist of the availability of PHCW who are skilled in the identification and treatment of depression and have interest in and commitment to providing care to older people. Required community resources include support from immediate family, neighbours, and informal groups. Interventions that are appropriate for depression in old age need to incorporate these community resources and address not only the symptoms of the condition but also comorbid physical health problems. CONCLUSIONS: A participatory ToC process led to the identification of the key components of an age-appropriate version of the emhGAP-IG for delivering care to older persons with depression by PHCW in Nigeria.

Inguinal hernia surgery learning curves by associate clinicians.

BACKGROUND: Open inguinal hernia repair is the most commonly performed procedure in general surgery in sub-Saharan Africa, but data on its learning curve are lacking. This study evaluated the learning curve characteristics to improve surgical training and enable scaling up hernia surgery in low- and middle-income countries. METHODS: Logbook data of associate clinicians enrolled in a surgical training program in Sierra Leone were collected and their first 55 hernia surgeries following the Bassini technique (herniorrhaphies) were analyzed in cohorts of five cases. Studied variables were gradient of decline of operating time, variation in operating time, and length of stay (LOS). Eleven subsequent cohorts of each five herniorrhaphies were investigated. RESULTS: Seventy-five trainees enrolled in the training program between 2011 and 2020 were eligible for inclusion. Thirty-one (41.3%) performed the minimum of 55 herniorrhaphies, and had also complete personal logbook data. Mean operating times dropped from 79.6 (95% CI 75.3-84.0) to 48.6 (95% CI 44.3-52.9) minutes between the first and last cohort, while standard deviation in operating time nearly halved to 15.4 (95% CI 11.7-20.0) minutes, and LOS was shortened by 3 days (8.5 days, 95%CI 6.1-10.8 vs. 5.4 days, 95% 3.1-7.6). Operating times flattened after 31-35 cases which corresponded with 1.5 years of training. CONCLUSIONS: The learning curve of inguinal hernia surgery for associate clinicians flattens after 31-35 procedures. Training programs can be tailored based on this finding. The recorded learning curve may serve as a baseline for future training techniques.

Perspectives of Nonspecialists Delivering a Brief Depression Treatment in the United States: A Qualitative Investigation.

BACKGROUND: Task sharing is an implementation strategy which increases access to services by training and supporting treatment delivery by nonspecialists. Such an approach has demonstrated effectiveness for depression and other mental health outcomes; however, few studies in high-income countries have examined nonspecialist providers' (NSPs) perspectives of the acceptability, feasibility, and appropriateness of delivering mental health interventions. We examine qualitative reports of NSPs experiences delivering a brief structured behavioral intervention for depression (called "Do More, Feel Better" [DMFB]) to adults aged 55 and older. METHODS: All NSPs (N = 4, 100%) who delivered DMFB participated in a focus group to probe their perceptions of the acceptability, feasibility, and appropriateness of both the intervention and their delivery experience as NSPs. Two coders analyzed the qualitative data from focus groups using codebook thematic analysis. RESULTS: NSPs perceived the intervention and delivery experience to be acceptable, feasible, and appropriate. Qualitative results provided insight into specific barriers and facilitators which may be important to consider when planning to implement task sharing. Themes that emerged from qualitative data included supervision being highly acceptable and feasible, appropriateness of the intervention for NSPs, and the feasibility of tailoring the intervention to patient participants. NSPs also expressed difficulty managing emotional investment in patients' success and providing therapy during a pandemic and racial violence in the US. CONCLUSIONS: Our results can inform future implementation and sustainment of task sharing interventions to expand access to care.

Surgeons' involvement in COVID-19 treatment: a practice by a regional core hospital in Japan to avoid physician burnout.

BACKGROUND: To prevent task accumulation on certain divisions, our institution developed a unique system of allocating inpatient treatment of COVID-19 patients to doctors who were not specialized in respiratory infections. The objective of this study was to investigate whether surgeons can be involved in the COVID-19 inpatient treatment without negatively affecting patient outcome, and how such involvement can affect the wellbeing of surgeons. METHODS: There were 300 patients diagnosed with COVID-19 and hospitalized from January to June 2021, and 160 of them were treated by the redeployed doctors. They were divided into 3 groups based on the affiliation of the treating doctor. Patient characteristics and outcomes were compared between the groups. In addition, the impact of COVID-19 duty on participating surgeons was investigated from multiple perspectives, and a postduty survey was conducted. RESULTS: There were 43 patients assigned to the Department of Surgery. There were no differences in the backgrounds and outcomes of patients compared with other groups. The surgeon's overtime hours were significantly longer during the duty period, despite no change in the number of operations and the complication rate. The questionnaire revealed that there was a certain amount of mental and physical burden from the COVID-19 duty. CONCLUSION: Surgeons can take part in inpatient COVID-19 treatment without affecting patient outcome. However, as such duty could negatively affect the surgeons' physical and mental wellbeing, further effort is needed to maintain the balance of fulfilling individual and institutional needs.

Optimizing the roles of health workers to improve access to health services in Africa: an implementation framework for task shifting and sharing for policy and practice.

BACKGROUND: Globally, countries are taking actions to ensure that their population have improved access to people-centred and integrated health services. Attaining this requires improved access to health workers at all levels of health service delivery and equitably distributed by geographical location. Due to the persistent health worker shortages, countries have resorted to implementing task shifting and task sharing in various settings to optimally utilize existing health workers to improve access to health services. There are deliberations on the need for an implementation framework to guide the adoption and operationalization of task shifting and task sharing as a key strategy for optimally utilizing the existing health workforce towards the achievement of UHC. The objective of this study was to develop an implementation framework for task shifting and task sharing for policy and practice in Africa. METHODS: A sequential multimethod research design supported by scoping reviews, and qualitative descriptive study was employed in this study. The evidence generated was synthesized into an implementation framework that was evaluated for applicability in Africa by 36 subject matter experts. RESULTS: The implementation framework for task shifting and task sharing has three core components - context, implementation strategies and intended change. The implementation strategies comprise of iterative actions in the development, translation, and sustainment phases that to achieve an intended change. The implementation strategies in the framework include mapping and engagement of stakeholders, generating evidence, development, implementation and review of a road map (or action plan) and national and/or sub-national policies and strategies, education of health workers using manuals, job aids, curriculum and clinical guidelines, and monitoring, evaluation, reviews and learning. CONCLUSION: The implementation framework for task shifting and task sharing in Africa serves as a guide on actions needed to achieve national, regional and global goals based on contextual evidence. The framework illustrates the rationale and the role of a combination of factors (enablers and barriers) in influencing the implementation of task shifting and task sharing in Africa.

A low-intensity behavioral intervention for depression in older adults delivered by lay coaches: proof-of-concept trial.

OBJECTIVES: A broader workforce is necessary to expand U.S. geriatric mental health services. We examined (1) feasibility of training undergraduate students to deliver Do More, Feel Better (DMFB), an evidence-informed program for depression; and (2) feasibility, acceptability, and outcomes in a single-arm proof-of-concept trial. METHOD: In Study 1, we taught DMFB to 18 upper-level undergraduate students and assessed fidelity using role plays. In Study 2, four students delivered six weekly DMFB sessions to 12 community-dwelling older adults (M = 66.83 years old, SD = 10.39) with depression (PHQ ≥ 10). Patient outcomes were change in pre- to post-treatment depressive symptoms, disability, and the target mechanism of increased activity. RESULTS: Fidelity was high in the course (Study 1; 82.4% of role plays rated as 'passing') and the trial (Study 2; 100% of 24 sessions rated as 'passing'). The majority (83.3%) of patients were retained and evidenced statistically and clinically significant improvement in depressive symptoms (Hamilton Rating Scale for Depression [HAM-D]), disability (World Health Organization's Disability Assessment Schedule 2.0 [WHODAS 2.0], and activity (Behavioral Activation for Depression Scale [BADS]). CONCLUSION: It is feasible to train bachelor's-level students to deliver a brief, structured intervention for depression. Future research should consider implementation strategies and stakeholder feedback.

Development of a Digital Program for Training Community Health Workers in the Detection and Referral of Schizophrenia in Rural India.

This study aimed to develop and assess the acceptability of a digital program for training community health workers (CHWs) in the detection and referral of patients with schizophrenia in community settings in rural India. An iterative design process was employed. First, evidence-based content from existing community programs for schizophrenia care was incorporated into the curriculum, and reviewed by experts to ensure clinical utility and fidelity of the adapted content. Second, CHWs provided feedback on the appropriateness of language, content, and an initial prototype of the digital training program to ensure relevance for the local context. Focus group discussions were then used to understand the acceptability of the digital training prototype and to inform modifications to the design and layout. Qualitative data was analysed using a rapid thematic analysis approach based on predetermined topics pertaining to acceptability of the training content and digital platform. Development of the initial prototype involved content review by 13 subject matter experts with clinical expertise or experience accessing and receiving mental health services, and engagement of 23 CHWs, of which 11 provided feedback for contextualization of the training content and 12 participated in focus group discussions on the acceptability of the prototype. Additionally, 2 service-users with lived experience of schizophrenia contributed to initial testing of the digital training prototype and offered feedback in a focus group discussion. During contextualization of the training content, key feedback pertained to simplifying the language and presentation of the content by removing technical terms and including interactive content and images to enhance interest and engagement with the digital training. During prototype testing, CHWs shared their familiarity with similar symptoms but were unaware of schizophrenia as a treatable illness. They shared that training can help them identify symptoms of schizophrenia and connect patients with specialized care. They were also able to understand misconceptions and discrimination towards people with schizophrenia, and how to address these challenges by supporting others and spreading awareness in their communities. Participants also appreciated the digital training, as it could save them time and could be incorporated within their routine work. This study shows the acceptability of leveraging digital technology for building capacity of CHWs to support early detection and referral of schizophrenia in community settings in rural India. These findings can inform the subsequent evaluation of this digital training program to determine its impact on enhancing the knowledge and skills of CHWs.

Adaptation and translation of a scalable measure for assessing health worker competence to deliver a brief psychological intervention: A case study from central India of its comparison to a performance-based measure.

Efforts to reduce the global burden of common mental disorders have focused on scaling up evidence-based training programs for non-specialist providers to deliver brief psychological interventions. To evaluate these provider training programs, appropriate and scalable assessments of competency need to be developed alongside them. We followed a systematic approach for the cultural adaptation and translation into Hindi of a valid, English, multiple-choice applied knowledge measure to assess non-specialists' competence to deliver a brief psychological intervention for depression in rural India. We then explored the relationship between the performance of 30 non-specialist providers on the same written measure compared with a structured performance-based measure consisting of two role-plays. The results of the multiple-choice assessment had an overall mean score of 37.40 (SD = 11.31) compared to the mean scores of role-play A (the easier role-play) of 43.25 (SD = 14.50) and role-play B (the more difficult role-play) of 43.25 (SD = 13.00). Role-play performance-based measures and written applied knowledge measures represent different approaches with unique strengths and challenges to measuring competence. Scaling up training programs requires the development of scalable methods for competency assessment. Exploring the relationship between these two measures, our team found no apparent differences between the two modes of assessment. Continued comparison of these approaches is needed to determine the consistency of outcomes across the two formats and to link the scores on these measures with clinical performance as reflected by the quality of care and patient outcomes.Trial Registration: ClinicalTrials.gov Identifier: NCT04157816; 8th November 2019.

A Multi-Site Study of Mental Disorders in the Mozambican Health Care System.

In Mozambique, human and financial resources for public mental health services are extremely limited. Understanding the mental health needs of those seeking healthcare can inform efficient targeting of mental health services. We examined if the frequency of mental disorders in a health facility varied based on the level of specialization of such facility, from primary care without mental health specialists (PrCMH -), to those with mental health specialists (PrCMH +) and tertiary care (TerC), where both inpatient and outpatient mental health services are available. Participants were adults (convenience sample) seeking health or mental health services at six facilities (2 PrCMH + , 3 PrCMH -, and 1 TerC) in the cities of Maputo and Nampula in Mozambique. Mental disorders were assessed by the MINI International Neuropsychiatric Interview (MINI) 4.0.0. We compared the sociodemographic characteristics and MINI diagnoses across the three types of health facilities. Multiple logistic regression models determined the likelihood that a person seeking services at each type of facility would have any mental disorder, common mental disorders (CMD), severe mental disorders (SMD), substance use disorders (SUD), and moderate-to-high suicide risk, adjusting for sociodemographic factors. Of the 612 total participants, 52.6% (n = 322) were positive for at least one mental disorder: 37.1% were positive for CMD, 28.9% for SMD, 13.2% for SUD, and 10.5% had suicide risk. Presence of any mental disorder was highest in TerC (62.5%) and lowest in PrCMH - (48.4%). Adjusting for sociodemographic covariates, participants in PrCMH + were significantly more likely to have SMD (OR 1.85, 95%CI 1.10-3.11) and SUD (OR 2.79, 95%CI 1.31-5.94) than participants in PrCMH -; participants in TerC were more likely to have CMD (OR 1.70, 95%CI 1.01-2.87) and SUD (OR 2.57, 95%CI 1.14-5.79) than in PrCMH -. Suicide risk was the only condition that did not differ across facility types. As anticipated, people with mental disorders were more likely to be cared for at facilities with mental health specialists. However, our study detected in this convenience sample a remarkably high frequency of mental disorders across different types of facilities within the Mozambican healthcare system. These results, if confirmed in representative samples, suggest a need to increase mental health services at the primary care level.

Cooperation between health professionals in primary care for the management of musculoskeletal disorders a narrative review / Modèles de partage des tâches impliquant les kinésithérapeutes pour la prise en charge des troubles musculosquelettiques en soins primaires: une revue narrative

Introduction: The current medical shortage and increasing healthcare needs lead to the overcrowding of primary care services. In an effort to cope with this, task sharing models of care have been implemented between healthcare professionals. Varied terms are used to describe these models. In France, "cooperation protocol" pathways have been established between general practitioners and physiotherapists. Objective: The aim of this narrative review is to define the terms used to describe models of task sharing involving physiotherapists for musculoskeletal care and to describe these models and their impact in order to suggest evolution prospects of French experimentations. Results: Delegation, task shifting, substitution, supplementation and advanced practice terms were found in the literature. A clear distinction is suggested between substitution and supplementation. Advanced practice physiotherapy is internationally defined and recognized. Advanced practice physiotherapy models of care seem to improve care access and quality of care without increasing costs. In France, two cooperation protocols have been implemented between general practitioners and physiotherapists for musculoskeletal disorders. Regarding the obstacles to their deployment, these models could evolve considering the international and formally defined framework of advanced practice physiotherapy. Conclusions: Task sharing models of care involving physiotherapists could be promising strategies to improve access to care for patients with musculoskeletal disorders. Further studies are needed to better define the models, their objectives and to evaluate their impact in the French context.

Introduction: L'engorgement des services de soins primaires et l'augmentation de la demande de soins conduisent à des difficultés croissantes d'accès aux soins de premier recours pour les patients souffrant de troubles musculosquelettiques. Pour y faire face, plusieurs modèles de partage de tâches entre les professionnels de santé sont mis en place. Dans la littérature, différentes notions sont employées pour décrire ces modèles. En France, ces expérimentations peuvent prendre la forme de « protocoles de coopération ¼ établis entre les médecins généralistes et les kinésithérapeutes. Objectif: Cette revue narrative vise à définir les notions employées pour décrire les modèles de partage de tâches impliquant les kinésithérapeutes dans la prise en charge des troubles musculosquelettiques à l'international, puis à décrire ces modèles et leur impact pour aboutir à des perspectives d'évolution des expérimentations françaises. Résultats: Les notions de « délégation ¼, de « transfert ¼, de « substitution ¼, de « supplémentation ¼ et de « pratique avancée ¼ sont employées dans la littérature. À la différence des termes « délégation ¼ et « transfert ¼, une distinction claire est retrouvée entre la substitution et la supplémentation. La pratique avancée en kinésithérapie est quant à elle, définie et reconnue à l'international. Elle permettrait d'améliorer l'accès et la qualité des soins, sans augmentation des coûts. En France, deux protocoles nationaux de coopération entre les médecins généralistes et les kinésithérapeutes existent pour les troubles musculo-squelettiques. En tenant compte des freins à leur déploiement rencontrés sur le terrain, ces modèles gagneraient à être repensés en s'inspirant du cadre international de la pratique avancée en kinésithérapie. Conclusions: Les modèles de partage de tâches impliquant les kinésithérapeutes en soins primaires semblent être des leviers d'amélioration de l'accès aux soins pour les patients souffrant de troubles musculosquelettiques. Davantage d'études permettant de mieux définir les modèles, leurs objectifs et d'en évaluer l'efficacité dans le contexte français restent nécessaires.