Brain Vitality Enhancement (BRAVE) program to promote brain health among persons with mild cognitive impairment: A study protocol.

AIM: This study aims to evaluate the effects of a community-based program entitled 'Brain Vitality Enhancement (BRAVE)' on the cognitive function, physical and mental well-being of persons with mild cognitive impairment. STUDY DESIGN: This is a parallel wait list randomized controlled trial. METHODS: The BRAVE program consists of two phases. Phase 1 is an empowerment workshop for training 50 peer mentors to be the exercise ambassadors, while Phase 2 is a supervised exercise program for 250 persons with mild cognitive impairment. They will be randomly allocated to intervention or wait list control groups. For the intervention group, the peer mentors and mentees will be matched according to gender and residential areas to form mentor-mentee groups to attend an 8-week supervised exercise training. The mentor-mentee groups will continue to participate mentor-directed exercise sessions in the community thereafter. A mobile application will be developed for self-directed learning. We hypothesize that persons with mild cognitive impairment receiving the BRAVE program will demonstrate better cognitive function and health-related quality of life than the control group who receive usual care. This study is funded by a grant from the Food and Health Bureau of the Government of Hong Kong Special Administrative Region in April 2018. DISCUSSION: This study will empower a group of golden-aged adults to be the ambassadors to promote brain health in the community and persons with mild cognitive impairment to integrate moderate-intensity exercise into their lifestyle to achieve long-term beneficial effects on their cognition and well-being. IMPACT: Given the population with mild cognitive impairment is growing rapidly and expected to keep escalating in coming decades and limited treatment options for cognitive decline and its significant burden on the health and social care system, this study is timely to promote active ageing in the society and reduce the burden associated with cognitive decline.

Effective training practices for non-specialist providers to promote high-quality mental health intervention delivery: A narrative review with four case studies from Kenya, Ethiopia, and the United States.

Mental health needs and disparities are widespread and have been exacerbated by the COVID-19 pandemic, with the greatest burden being on marginalized individuals worldwide. The World Health Organization developed the Mental Health Gap Action Programme to address growing global mental health needs by promoting task sharing in the delivery of psychosocial and psychological interventions. However, little is known about the training needed for non-specialists to deliver these interventions with high levels of competence and fidelity. This article provides a brief conceptual overview of the evidence concerning the training of non-specialists carrying out task-sharing psychosocial and psychological interventions while utilizing illustrative case studies from Kenya, Ethiopia, and the United States to highlight findings from the literature. In this article, the authors discuss the importance of tailoring training to the skills and needs of the non-specialist providers and their roles in the delivery of an intervention. This narrative review with four case studies advocates for training that recognizes the expertise that non-specialist providers bring to intervention delivery, including how they promote culturally responsive care within their communities.

A peer-volunteer led active ageing programme to prevent decline in physical function in older people at risk of mobility disability (Active, Connected, Engaged [ACE]): study protocol for a randomised controlled trial.

BACKGROUND: The Active Connected Engaged [ACE] study is a multi-centre, pragmatic, two-arm, parallel-group randomised controlled trial [RCT] with an internal pilot phase. The ACE study incorporates a multi-level mixed methods process evaluation including a systems mapping approach and an economic evaluation. ACE aims to test the effectiveness and cost-effectiveness of a peer-volunteer led active ageing intervention designed to support older adults at risk of mobility disability to become more physically and socially active within their communities and to reduce or reverse, the progression of functional limitations associated with ageing. METHODS/DESIGN: Community-dwelling, older adults aged 65 years and older (n = 515), at risk of mobility disability due to reduced lower limb physical functioning (Short Physical Performance Battery (SPPB) score of 4-9 inclusive) will be recruited. Participants will be randomised to receive either a minimal control intervention or ACE, a 6-month programme underpinned by behaviour change theory, whereby peer volunteers are paired with participants and offer them individually tailored support to engage them in local physical and social activities to improve lower limb mobility and increase their physical activity. Outcome data will be collected at baseline, 6, 12 and 18 months. The primary outcome analysis (difference in SPPB score at 18 months) will be undertaken blinded to group allocation. Primary comparative analyses will be on an intention-to-treat (ITT) basis with due emphasis placed on confidence intervals. DISCUSSION: ACE is the largest, pragmatic, community-based randomised controlled trial in the UK to target this high-risk segment of the older population by mobilising community resources (peer volunteers). A programme that can successfully engage this population in sufficient activity to improve strength, coordination, balance and social connections would have a major impact on sustaining health and independence. ACE is also the first study of its kind to conduct a full economic and comprehensive process evaluation of this type of community-based intervention. If effective and cost-effective, the ACE intervention has strong potential to be implemented widely in the UK and elsewhere. TRIAL REGISTRATION: ISRCTN, ISRCTN17660493. Registered on 30 September 2021. Trial Sponsor: University of Birmingham, Contact: Dr Birgit Whitman, Head of Research Governance and Integrity; Email: researchgovernance@contacts.bham.ac.uk. Protocol Version 5 22/07/22.

Measuring the implementation strength of a perinatal mental health intervention delivered by peer volunteers in rural Pakistan.

The South Asian region, including Pakistan, reports one of the highest rates of perinatal depression. Effective task-shifting perinatal mental health interventions exist and are gaining attention of policy makers, as a potential solution to bridge the existing treatment gap. However, no specific indicators are available to gauge the level of implementation for such interventions in the South Asian region. The Thinking Healthy Programme Peer-delivered (THPP) is a perinatal mental health intervention delivered, at scale, by peer volunteers (PVs). An effectiveness trial for THPP based on 570 depressed pregnant women was conducted in rural Rawalpindi, Pakistan. In addition, we also examined the implementation processes of THPP in order to develop an index to gauge implementation strength of this intervention. The key components of this index are based on four important intervention processes related to service provision which include; i) the competence of PVs, ii) supervisions attended by PVs and iii) number and iv) duration of THPP sessions. We attempt to inform an implementation strength index which best correlates with reduced perinatal depression and disability at 6 months post childbirth. Knowledge of such an implementation strength index for a task-shifted perinatal depression intervention carries implications for scale up strategies.

Scaling-up psychological interventions in resource-poor settings: training and supervising peer volunteers to deliver the 'Thinking Healthy Programme' for perinatal depression in rural Pakistan.

BACKGROUND: There is a scarcity of specialist trainers and supervisors for psychosocial interventions in low- and middle-income countries. A cascaded model of training and supervision was developed to sustain delivery of an evidence-based peer-delivered intervention for perinatal depression (the Thinking Healthy Programme) in rural Pakistan. The study aimed to evaluate the model. METHODS: Mixed methods were employed as part of a randomised controlled trial of the intervention. Quantitative data consisted of the peers' competencies assessed during field training and over the implementation phase of the intervention, using a specially developed checklist. Qualitative data were collected from peers and their trainers through 11 focus groups during the second and third year of intervention rollout. RESULTS: Following training, 43 peers out of 45 (95%) achieved at least a 'satisfactory' level of competency (scores of ⩾70% on the Quality and Competency Checklist). Of the cohort of 45 peers initially recruited 34 (75%) were retained over 3 years and showed sustained or improved competencies over time. Qualitatively, the key factors contributing to peers' competency were use of interactive training and supervision techniques, the trainer-peer relationship, and their cultural similarity. The partnership with community health workers and use of primary health care facilities for training and supervision gave credibility to the peers in the community. CONCLUSION: The study demonstrates that lay-workers such as peers can be trained and supervised to deliver a psychological intervention using a cascaded model, thus addressing the barrier of scarcity of specialist trainers and supervisors.

Delivering maternal mental health through peer volunteers: a 5-year report.

BACKGROUND: Maternal depression affects one in five women in low-and middle income countries (LMIC) and has significant economic and social impacts. Evidence-based psychosocial interventions delivered by non-specialist health workers are recommended as first-line management of the condition, and recent studies on such interventions from LMIC show promising results. However, lack of human resource to deliver the interventions is a major bottle-neck to scale-up, and much research attention has been devoted to 'task-sharing' initiatives. A peer-delivered version of the World Health Organization's Thinking Healthy Programme for perinatal depression in Pakistan and India showed clinical, functional and social benefits to women at 3 months postpartum. The programme has been iteratively adapted and continually delivered for 5 years in Pakistan. In this report, we describe the extended intervention and factors contributing to the peers' continued motivation and retention, and suggest future directions to address scale-up challenges. METHODS: The study was conducted in rural Rawalpindi. We used mixed methods to evaluate the programme 5 years since its initiation. The competency of the peers in delivering the intervention was evaluated using a specially developed Quality and Competency Checklist, an observational tool used by trainers to rate a group session on key areas of competencies. In-depth interviews explored factors contributing to the peer volunteers' continued motivation and retention, as well as the key challenges faced. RESULTS: Our key findings are that about 70% of the peer volunteers inducted 5 years ago continued to be part of the programme, retaining their competency in delivering the intervention, with only token financial incentives. Factors contributing to sustained motivation included altruistic aspirations, enhanced social standing in the community, personal benefits to their own mental health, and the possibility for other avenues of employment. Long-term challenges included demotivation due to lack of certainty about the programme's future, increased requirement for financial incentivisation, the logistics of organising groups in the community, and resistance from some families to the need for ongoing care. CONCLUSIONS: The programme, given the sustained motivation and competence of peer volunteers in delivering the intervention, has the potential for long-term sustainability in under-resourced settings and a candidate for scale-up.

Barefoot therapists: barriers and facilitators to delivering maternal mental health care through peer volunteers in Pakistan: a qualitative study.

BACKGROUND: Perinatal depression is a public health problem in low and middle income countries. Although effective psychosocial interventions exist, a major limitation to their scale up is the scarcity of mental health professionals. The aim of this study was to explore the facilitators and barriers to the acceptability of peer volunteers (PVs)-volunteer lay women from the community with shared socio-demographic and life experiences with the target population-as delivery agents of a psychosocial intervention for perinatal depression in a rural area of Pakistan. METHODS: This qualitative study was embedded in the pilot phase of a larger peer-delivered mental health programme. Forty nine participants were included: depressed mothers (n = 21), PVs (n = 8), primary health care staff (n = 5), husbands (n = 5) and mothers-in-law (n = 10). Data were collected through in-depth interviews and focus groups and analysed using the Framework Analysis approach. RESULTS: The PVs were accepted as delivery agents by all key stakeholders. Facilitators included the PVs' personal attributes such as being local, trustworthy, empathetic, and having similar experiences of motherhood. The perceived usefulness and cultural appropriateness of the intervention and linkages with the primary health care (PHC) system was vital to their legitimacy and credibility. The PVs' motivation was important, and factors influencing this were: appropriate selection; effective training and supervision; community endorsement of their role, and appropriate incentivisation. Barriers included women's lack of autonomy, certain cultural beliefs, stigma associated with depression, lack of some mothers' engagement and resistance from some families. CONCLUSION: PVs are a potential human resource for the delivery of a psychosocial intervention for perinatal depression in this rural area of Pakistan. The use of such delivery agents could be considered for other under-resourced settings globally.

The effectiveness of the peer delivered Thinking Healthy Plus (THPP+) Programme for maternal depression and child socio-emotional development in Pakistan: study protocol for a three-year cluster randomized controlled trial.

BACKGROUND: The negative effects of perinatal depression on the mother and child start early and persist throughout the lifecourse (Lancet 369(9556):145-57, 2007; Am J Psychiatry 159(1):43-7, 2002; Arch Dis Child 77(2):99-101, 1997; J Pak Med Assoc 60(4):329; J Psychosoma Res 49(3):207-16, 2000; Clin Child Fam Psychol Rev 14(1):1-27, 2011). Given that 10-35 % of children worldwide are exposed to perinatal depression in their first year of life (Int Rev Psychiatry 8(1):37-54, 1996), mitigating this intergenerational risk is a global public health priority (Perspect Public Health 129(5):221-7, 2009; Trop Med Int Health 13(4):579-83, 2008; Br Med Bull 101(1):57-79, 2012). However, it is not clear whether intervention with depressed women can have long-term benefits for the mother and/or her child. We describe a study of the effectiveness of a peer-delivered depression intervention delivered through 36 postnatal months, the Thinking Healthy Program Peer-delivered PLUS (THPP+) for women and their children in rural Pakistan. METHODS/DESIGN: The THPP+ study aims are: (1) to evaluate the effects of an extended 36-month perinatal depression intervention on maternal and index child outcomes using a cluster randomized controlled trial (c-RCT) and (2) to determine whether outcomes among index children of perinatally depressed women in the intervention arm converge with those of index children born to perinatally nondepressed women. The trial is designed to recruit 560 pregnant women who screened positive for perinatal depression (PHQ-9 score ≥10) from 40 village clusters, of which 20 receive the THPP+ intervention. An additional reference group consists of 560 perinatally nondepressed women from the same 40 clusters as the THPP+ trial. The women in the nondepressed group are not targeted to receive the THPP+ intervention; but, by recruiting pregnant women from both intervention and control clusters, we are able to evaluate any carryover effects of the THPP+ intervention on the women and their children. Perinatally depressed women in the THPP+ intervention arm receive bimonthly group-based sessions. Primary outcomes are 3-year maternal depression and 3-year child development indicators. Analyses are intention-to-treat and account for the clustered design. DISCUSSION: This trial, together with the reference group, has the potential to further our understanding of the early developmental lifecourse of children of both perinatally depressed and perinatally nondepressed women in rural Pakistan and to determine whether intervening with women's depression in the perinatal period can mitigate the negative effects of maternal depression on 36-month child development. TRIAL REGISTRATION: THPP-P ClinicalTrials.gov Identifier: NCT02111915 (registered on 9 April 2014). THPP+ ClinicalTrials.gov Identifier: NCT02658994 (registered on 21 January 2016). SPONSOR: Human Development Research Foundation (HDRF).