Primary-level and community worker interventions for the prevention of mental disorders and the promotion of well-being in low- and middle-income countries.

BACKGROUND: There is a significant research gap in the field of universal, selective, and indicated prevention interventions for mental health promotion and the prevention of mental disorders. Barriers to closing the research gap include scarcity of skilled human resources, large inequities in resource distribution and utilization, and stigma. OBJECTIVES: To assess the effectiveness of delivery by primary workers of interventions for the promotion of mental health and universal prevention, and for the selective and indicated prevention of mental disorders or symptoms of mental illness in low- and middle-income countries (LMICs). To examine the impact of intervention delivery by primary workers on resource use and costs. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, CINAHL, Global Index Medicus, PsycInfo, WHO ICTRP, and ClinicalTrials.gov from inception to 29 November 2021. SELECTION CRITERIA: Randomized controlled trials (RCTs) of primary-level and/or community health worker interventions for promoting mental health and/or preventing mental disorders versus any control conditions in adults and children in LMICs. DATA COLLECTION AND ANALYSIS: Standardized mean differences (SMD) or mean differences (MD) were used for continuous outcomes, and risk ratios (RR) for dichotomous data, using a random-effects model. We analyzed data at 0 to 1, 1 to 6, and 7 to 24 months post-intervention. For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥ 0.80 large clinical effects. We evaluated the risk of bias (RoB) using Cochrane RoB2. MAIN RESULTS: Description of studies We identified 113 studies with 32,992 participants (97 RCTs, 19,570 participants in meta-analyses) for inclusion. Nineteen RCTs were conducted in low-income countries, 27 in low-middle-income countries, 2 in middle-income countries, 58 in upper-middle-income countries and 7 in mixed settings. Eighty-three RCTs included adults and 30 RCTs included children. Cadres of primary-level workers employed primary care health workers (38 studies), community workers (71 studies), both (2 studies), and not reported (2 studies). Interventions were universal prevention/promotion in 22 studies, selective in 36, and indicated prevention in 55 RCTs. Risk of bias The most common concerns over risk of bias were performance bias, attrition bias, and reporting bias. Intervention effects 'Probably', 'may', or 'uncertain' indicates 'moderate-', 'low-', or 'very low-'certainty evidence. *Certainty of the evidence (using GRADE) was assessed at 0 to 1 month post-intervention as specified in the review protocol. In the abstract, we did not report results for outcomes for which evidence was missing or very uncertain. Adults Promotion/universal prevention, compared to usual care: - probably slightly reduced anxiety symptoms (MD -0.14, 95% confidence interval (CI) -0.27 to -0.01; 1 trial, 158 participants) - may slightly reduce distress/PTSD symptoms (SMD -0.24, 95% CI -0.41 to -0.08; 4 trials, 722 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD -0.69, 95% CI -1.08 to -0.30; 4 trials, 223 participants) Indicated prevention, compared to usual care: - may reduce adverse events (1 trial, 547 participants) - probably slightly reduced functional impairment (SMD -0.12, 95% CI -0.39 to -0.15; 4 trials, 663 participants) Children Promotion/universal prevention, compared to usual care: - may improve the quality of life (SMD -0.25, 95% CI -0.39 to -0.11; 2 trials, 803 participants) - may reduce adverse events (1 trial, 694 participants) - may slightly reduce depressive symptoms (MD -3.04, 95% CI -6 to -0.08; 1 trial, 160 participants) - may slightly reduce anxiety symptoms (MD -2.27, 95% CI -3.13 to -1.41; 1 trial, 183 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD 0, 95% CI -0.16 to -0.15; 2 trials, 638 participants) - may slightly reduce anxiety symptoms (MD 4.50, 95% CI -12.05 to 21.05; 1 trial, 28 participants) - probably slightly reduced distress/PTSD symptoms (MD -2.14, 95% CI -3.77 to -0.51; 1 trial, 159 participants) Indicated prevention, compared to usual care: - decreased slightly functional impairment (SMD -0.29, 95% CI -0.47 to -0.10; 2 trials, 448 participants) - decreased slightly depressive symptoms (SMD -0.18, 95% CI -0.32 to -0.04; 4 trials, 771 participants) - may slightly reduce distress/PTSD symptoms (SMD 0.24, 95% CI -1.28 to 1.76; 2 trials, 448 participants). AUTHORS' CONCLUSIONS: The evidence indicated that prevention interventions delivered through primary workers - a form of task-shifting - may improve mental health outcomes. Certainty in the evidence was influenced by the risk of bias and by substantial levels of heterogeneity. A supportive network of infrastructure and research would enhance and reinforce this delivery modality across LMICs.

Common mental health problems and associated factors among medical students of University of Ibadan, Nigeria.

BACKGROUND: The burden of mental health problems among medical students is on the increase especially when compared with their counterparts in other disciplines. This has counterproductive impact on the society. Understanding the prevalence and predictors of common mental health problems can inform early intervention to curb this menace. AIMS: This study was conducted to determine the prevalence, pattern and correlates of common mental health problems (anxiety and depression) amongst medical students of the University of Ibadan, Nigeria. METHODOLOGY: A descriptive cross-sectional survey was conducted among 690 pre-clinical and clinical medical students of the University of Ibadan. Data were analyzed using descriptive statistics, Chi-square test and binary logistic regression at p < 0.05. RESULTS: The prevalence of anxiety and depression were 26.5% and 10.1%, respectively, with 6.8% having both. Perceived risk factors included overwhelming academic workload (65.2%) and failure to meet up with academic expectations (64.1%). The predictors of comorbid anxiety and depression were: polygamous family setting (OR 2.7: 95% CI: 1.156-6.536) and preclinical studentship (OR: 6.2; 95% CI: 2.282-16.868). CONCLUSION: This study shows that the prevalence of mental health problems is high among medical students.

Becoming a Xhosa traditional healer: The calling, illness, conflict and belonging.

BACKGROUND: Traditional healers (THs) are an important part of the healthcare system in sub-Saharan Africa. Understanding their training, experiences of becoming healers and their perceived roles in society is critical. AIM: This study aimed to explore the experience of becoming a TH, including accepting the calling, and sheds light on how the experience is conceptualised within the cultural and communitarian context of THs. SETTING: This study was conducted amongst Xhosa THs in the Western Cape, South Africa. METHODS: In-depth phenomenological interviews (n = 4) were conducted with Xhosa THs and analysed using Giorgi's descriptive pre-transcendental Husserlian phenomenological analysis. RESULTS: The experience of becoming a TH can be summarised in the context of three units of significance: (1) the gift of healing as an illness; (2) the experience of conflict (including with their families, the church and self-conflict); and (3) the experience of belonging. Familial conflict, specifically, was fuelled by the financial burden of becoming a TH and a lack of understanding of the process. CONCLUSION: To develop a workable model of collaboration in the future, it is crucial that mental healthcare providers develop a better understanding of the experiences of THs in becoming care providers. The findings highlight an appreciation of the challenging process of becoming a TH. Finally, further research and culturally appropriate psychoeducation can provide trainee THs and their family members with the skills and knowledge to support each other through a difficult process.

Building the capacity of policy-makers and planners to strengthen mental health systems in low- and middle-income countries: a systematic review.

BACKGROUND: Little is known about the interventions required to build the capacity of mental health policy-makers and planners in low- and middle-income countries (LMICs). We conducted a systematic review with the primary aim of identifying and synthesizing the evidence base for building the capacity of policy-makers and planners to strengthen mental health systems in LMICs. METHODS: We searched MEDLINE, Embase, PsycINFO, Web of Knowledge, Web of Science, Scopus, CINAHL, LILACS, ScieELO, Google Scholar and Cochrane databases for studies reporting evidence, experience or evaluation of capacity-building of policy-makers, service planners or managers in mental health system strengthening in LMICs. Reports in English, Spanish, Portuguese, French or German were included. Additional papers were identified by hand-searching references and contacting experts and key informants. Database searches yielded 2922 abstracts and 28 additional papers were identified. Following screening, 409 full papers were reviewed, of which 14 fulfilled inclusion criteria for the review. Data were extracted from all included papers and synthesized into a narrative review. RESULTS: Only a small number of mental health system-related capacity-building interventions for policy-makers and planners in LMICs were described. Most models of capacity-building combined brief training with longer term mentorship, dialogue and/or the establishment of networks of support. However, rigorous research and evaluation methods were largely absent, with studies being of low quality, limiting the potential to separate mental health system strengthening outcomes from the effects of associated contextual factors. CONCLUSIONS: This review demonstrates the need for partnership approaches to building the capacity of mental health policy-makers and planners in LMICs, assessed rigorously against pre-specified conceptual frameworks and hypotheses, utilising longitudinal evaluation and mixed quantitative and qualitative approaches.

Gender-Based Violence following Social Media Acquaintance in Nigeria.

In Nigeria, the growth in mobile phone use has provided the opportunity for increased access to the internet, and through this, the social media. The social media in turn offers tremendous communication benefits but also results in some undesirable consequences. One of such is the experience of Gender-Based Violence (GBV). Internet searches using Google Search and Google Scholar in addition to information available to the authors from news media is reported in this study. Five cases were selected for reporting. All cases selected had first contact with their perpetrator(s) on Facebook. The perpetrators were usually men, older than the victims (24-34 years for perpetrators compared with 17-25 years for the victims). The victims experienced physical, psychological, sexual and economic violence from their aggressors. One case resulted in the death of the victim, while two required hospitalization following severe trauma. Three of the victims were raped, while rape was attempted for the other two cases. GBV associated with acquaintances made on social media channels is emerging as a new social problem in Nigeria. Interventions to educate female social media users about this potential danger are urgently necessary.

Task-sharing psychosocial interventions for the prevention of common mental disorders in the perinatal period in low- and middle-income countries: A systematic review and meta-analysis.

AIM: to assess the efficacy of psychosocial interventions delivered through task-sharing approaches for preventing perinatal common mental disorders among women in low- and middle-income countries. METHODS: We conducted a systematic review of randomized controlled trials following a prespecified protocol registered in the Open Science Framework (osf.io/qt4y3). We searched MEDLINE, Web of Science, PsycINFO, and Cochrane Central Register of Controlled Trials (CENTRAL) through June 2022. Two reviewers independently extracted the data and evaluated the risk of bias of included studies using the Cochrane risk of bias tool. We performed random-effects meta-analyses and rated the certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. RESULTS: We included 23 studies with 24,442 participants. At post-intervention, task-shared psychosocial interventions, were effective in preventing the development of mental disorders in general (RR 0.57, 95% CI [0.35, 0.91]), and specifically depression (RR 0.51, 95% CI [0.35, 0.75]), but not anxiety disorders (RR 0.46, 95% CI [0.06, 3.33]). Similarly, psychosocial interventions reduced psychological distress (SMD -1.32, 95% CI [-2.28, -0.35]), and depressive symptoms (SMD -0.50, 95% CI [-0.80, -0.16]), and increased parenting self-efficacy (SMD -0.76, 95% CI [-1.13, -0.38]) and social support (SMD -0.72, 95% CI [-1.22, -0.22]). No effect was detected for anxiety symptoms at post-intervention. At follow-up the beneficial effects of interventions progressively decreased. CONCLUSIONS: Psychosocial interventions delivered through the task-sharing modality are effective in preventing perinatal common mental disorders and fostering positive mental health among women in low- and middle-income countries. However, our findings are tentative, due to the low number of preventative intervention strategies considering outcomes as the incidence of mental disorders, especially in the long-term. This evidence supports calls to implement and scale up psychosocial prevention interventions for perinatal common mental disorders in low- and middle-income countries.

Pathways to Psychiatric Care for Children and Adolescents at a Tertiary Facility in Northern Nigeria.

There is limited availability of mental health services in Nigeria, and indeed most of Africa. Available services are also often under-utilized because of widespread ignorance and supernatural beliefs about the etiology of mental illnesses. The consequence, therefore, is a long and tedious pathway to care for the mentally ill, especially children and adolescents. This was a study of all new patients, aged 18 years and below, presenting over a 6 month period in 2009 (January - June) at the outpatient clinic of a tertiary psychiatric facility in northern Nigeria. A socio-demographic questionnaire was utilized, along with a record of the clinician's assessment of diagnosis for 242 patients. Subjects who had been withdrawn from school, or any previously engaged-in activity for longer than 4 weeks on account of the illness, were recorded as having disability from the illness. The children were aged 1-18 years (mean=12.3; SD=5.2) with males accounting for 51.7% (125) while 14.5% of the females (n=117) were married. Two thirds (64.5%) of the patients had been ill for longer than 6 months prior to presentation. One hundred and forty four subjects (59.5%) had received no care at all, while 36.4% had received treatment from traditional/religious healers prior to presentation. The most disabling conditions were ADHD (80%), mental retardation (77.8%), epilepsy (64.1%) and psychotic disorders (50%). There is urgent need for extending mental health services into the community in order to improve access to care and increase awareness about effective and affordable treatments.

Pathways to psychiatric care for children and adolescents at tertiary facility in northern Nigeria

There is limited availability of mental health services in Nigeria; and indeed most of Africa. Available services are also often under-utilized because of widespread ignorance and supernatural beliefs about the etiology of mental illnesses. The consequence; therefore; is a long and tedious pathway to care for the mentally ill; especially children and adolescents. This was a study of all new patients; aged 18 years and below; presenting over a 6 month period in 2009 (January - June) at the outpatient clinic of a tertiary psychiatric facility in northern Nigeria. A socio-demographic questionnaire was utilized; along with a record of the clinician's assessment of diagnosis for 242 patients. Subjects who had been withdrawn from school; or any previously engaged-in activity for longer than 4 weeks on account of the illness; were recorded as having disability from the illness. The children were aged 1-18 years (mean=12.3; SD=5.2) with males accounting for 51.7 (125) while 14.5 of the females (n=117) were married. Two thirds (64.5) of the patients had been ill for longer than 6 months prior to presentation. One hundred and forty four subjects (59.5) had received no care at all; while 36.4 had received treatment from traditional/religious healers prior to presentation. The most disabling conditions were ADHD (80); mental retardation (77.8); epilepsy (64.1) and psychotic disorders (50). There is urgent need for extending mental health services into the community in order to improve access to care and increase awareness about effective and affordable treatments