Burden of disease among the world's poorest billion people: An expert-informed secondary analysis of Global Burden of Disease estimates.

BACKGROUND: The health of populations living in extreme poverty has been a long-standing focus of global development efforts, and continues to be a priority during the Sustainable Development Goal era. However, there has not been a systematic attempt to quantify the magnitude and causes of the burden in this specific population for almost two decades. We estimated disease rates by cause for the world's poorest billion and compared these rates to those in high-income populations. METHODS: We defined the population in extreme poverty using a multidimensional poverty index. We used national-level disease burden estimates from the 2017 Global Burden of Disease Study and adjusted these to account for within-country variation in rates. To adjust for within-country variation, we looked to the relationship between rates of extreme poverty and disease rates across countries. In our main modeling approach, we used these relationships when there was consistency with expert opinion from a survey we conducted of disease experts regarding the associations between household poverty and the incidence and fatality of conditions. Otherwise, no within-country variation was assumed. We compared results across multiple approaches for estimating the burden in the poorest billion, including aggregating national-level burden from the countries with the highest poverty rates. We examined the composition of the estimated disease burden among the poorest billion and made comparisons with estimates for high-income countries. RESULTS: The composition of disease burden among the poorest billion, as measured by disability-adjusted life years (DALYs), was 65% communicable, maternal, neonatal, and nutritional (CMNN) diseases, 29% non-communicable diseases (NCDs), and 6% injuries. Age-standardized DALY rates from NCDs were 44% higher in the poorest billion (23,583 DALYs per 100,000) compared to high-income regions (16,344 DALYs per 100,000). Age-standardized DALY rates were 2,147% higher for CMNN conditions (32,334 DALYs per 100,000) and 86% higher for injuries (4,182 DALYs per 100,000) in the poorest billion, compared to high-income regions. CONCLUSION: The disease burden among the poorest people globally compared to that in high income countries is highly influenced by demographics as well as large disparities in burden from many conditions. The comparisons show that the largest disparities remain in communicable, maternal, neonatal, and nutritional diseases, though NCDs and injuries are an important part of the "unfinished agenda" of poor health among those living in extreme poverty.

Building Emotional Resilience in Youth in Lebanon: a School-Based Randomized Controlled Trial of the FRIENDS Intervention.

In Lebanon, approximately one in four adolescents suffers from a psychiatric disorder. Alarmingly, 94% of adolescents with a mental disorder have not sought any treatment. This study assessed the effectiveness of an evidence-based school-based universal mental health intervention (the FRIENDS program) in reducing depression and anxiety symptoms in middle school students in Lebanon. A total of 280 6th graders aged 11-13 years were recruited from 10 schools in Beirut. Schools were matched on size and tuition and randomly assigned to intervention or control groups. The FRIENDS program was translated into Arabic, adapted, and then implemented by trained mental health professionals during 10 classroom sessions over 3 months. We assessed sociodemographic and relevant psychological symptoms by self-report, using the Scale for Childhood Anxiety and Related Disorders (SCARED), Mood and Feelings Questionnaire (MFQ), and Strengths and Difficulties Questionnaire (SDQ), at baseline. We re-administered these scales at 3 months post-intervention. There was a significant time × group interaction for the SDQ emotional score (p = 0.011) and total MFQ score (p = 0.039) indicating significant improvement in depressive and emotional symptoms in the intervention group. Subgroup analysis by gender showed a significant time × group interaction for the total SCARED score (p = 0.025) in females but not in males (p = 0.137), consistent with a reduction of anxiety symptoms in this stratum of the intervention group as compared with the control group. The FRIENDS program was effective in reducing general emotional and depressive symptoms among middle school students in this Lebanese study population. This intervention provides an opportunity for promoting mental health in Lebanese schools and reducing the treatment gap in mental health care.

High burden of mental illness and low utilization of care among school-going youth in Central Haiti: A window into the youth mental health treatment gap in a low-income country.

BACKGROUND: The mental health treatment gap for youth in low- and middle-income countries (LMICs) is substantial; strategies for redress are urgently needed to mitigate the serious health and social consequences of untreated mental illness in youth. AIMS: To estimate the burden of major depressive episode (MDE) and posttraumatic stress disorder (PTSD) as well as utilization of care among Haitian youth in order to describe the mental health treatment gap in a LMIC setting. METHODS: We estimated the point prevalence of MDE, PTSD, and subthreshold variants in a school-based sample of youth ( n = 120, ages 18-22 years) using a modified Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID)-based interview and examined treatment utilization among those receiving one of these diagnoses. We assessed additional psychopathology with self-report measures to examine validity of study diagnostic assignments. RESULTS: The combined prevalence of full-syndrome or subthreshold MDE or PTSD was high (36.7%). A large majority of affected individuals (88.6%) had accessed no mental health services in the health sector, and 36.4% had accessed no care of any kind in either the health or folk sectors in the past year. CONCLUSION: Findings demonstrate a high mental health burden among Haiti's youth and that many youth with MDE and PTSD are not accessing mental health care.

GAP-REACH: a checklist to assess comprehensive reporting of race, ethnicity, and culture in psychiatric publications.

Growing awareness of health and health care disparities highlights the importance of including information about race, ethnicity, and culture (REC) in health research. Reporting of REC factors in research publications, however, is notoriously imprecise and unsystematic. This article describes the development of a checklist to assess the comprehensiveness and the applicability of REC factor reporting in psychiatric research publications. The 16-item GAP-REACH checklist was developed through a rigorous process of expert consensus, empirical content analysis in a sample of publications (N = 1205), and interrater reliability (IRR) assessment (N = 30). The items assess each section in the conventional structure of a health research article. Data from the assessment may be considered on an item-by-item basis or as a total score ranging from 0% to 100%. The final checklist has excellent IRR (κ = 0.91). The GAP-REACH may be used by multiple research stakeholders to assess the scope of REC reporting in a research article.

Motivation to change among residential treatment patients with an eating disorder: assessment of the multidimensionality of motivation and its relation to treatment outcome.

OBJECTIVE: To examine the multidimensional nature of motivation to change in an adolescent sample in residential eating disorder (ED) treatment and relate it to outcome. METHOD: To determine whether different dimensions of motivation (benefits, burdens, and functional avoidance) are differentially associated with symptom severity and outcome, we assessed eating pathology and motivation to change in consecutively admitted female patients (n = 67) with AN, BN, and EDNOS in a residential ED program with the Eating Disorder Examination Questionnaire (EDE-Q) and the Decisional Balance Scale (DB). RESULTS: Pretreatment DB benefits and functional avoidance subscales were correlated with ED and comorbid psychopathology. Admission to discharge change in DB benefits-but not other measured dimensions of motivation was significantly associated with post-treatment EDE-Q global scores. DISCUSSION: Our findings support that motivation to change is a multidimensional construct among ED patients. A reduction in perceived benefits of illness is associated with less severe post-treatment eating pathology.

Youth health-risk behavior assessment in Fiji: the reliability of Global School-based Student Health Survey content adapted for ethnic Fijian girls.

OBJECTIVE: The Global School-based Student Health Survey (GSHS) is an assessment for adolescent health-risk behaviors and exposures, supported by the World Health Organization. Although already widely implemented - and intended for youth assessment across diverse ethnic and national contexts - no reliability data have yet been reported for GSHS-based assessment in any ethnicity or country-specific population. This study reports test-retest reliability for GSHS content adapted for a female adolescent ethnic Fijian study sample in Fiji. DESIGN: We adapted and translated GSHS content to assess health-risk behaviors as part of a larger study investigating the impact of social transition on ethnic Fijian secondary schoolgirls in Fiji. In order to evaluate the performance of this measure for our ethnic Fijian study sample (n=523), we examined its test-retest reliability with kappa coefficients, % agreement, and prevalence estimates in a sub-sample (n=81). Reliability among strata defined by topic, age, and language was also examined. RESULTS: Average agreement between test and retest was 77%, and average Cohen's kappa was 0.47. Mean kappas for questions from core modules about alcohol use, tobacco use, and sexual behavior were substantial, and higher than those for modules relating to other risk behaviors. CONCLUSIONS: Although test-retest reliability of responses within this country-specific version of GSHS content was substantial in several topical domains for this ethnic Fijian sample, only fair reliability for the module assessing dietary behaviors and other individual items suggests that population-specific psychometric evaluation is essential to interpreting language and country-specific GSHS data.

Adaptation and evaluation of the Clinical Impairment Assessment to assess disordered eating related distress in an adolescent female ethnic Fijian population.

OBJECTIVE: Measurement of disease-related impairment and distress is central to diagnostic, therapeutic, and health policy considerations for eating disorders across diverse populations. This study evaluates psychometric properties of a translated and adapted version of the Clinical Impairment Assessment (CIA) in an ethnic Fijian population. METHOD: The adapted CIA was administered to ethnic Fijian adolescent schoolgirls (N = 215). We calculated Cronbach's alpha to assess the internal consistency, examined the association between indicators of eating disorder symptom severity and the CIA to assess construct and criterion validity, and compared the strength of relation between the CIA and measures of disordered eating versus with measures of generalized distress. RESULTS: The Fijian version of the CIA is feasible to administer as an investigator-based interview. It has excellent internal consistency (alpha = 0.93). Both construct and criterion validity were supported by the data, and regression models indicated that the CIA predicts eating disorder severity, even when controlling for generalized distress and psychopathology. DISCUSSION: The adapted CIA has excellent psychometric properties in this Fijian study population. Findings suggest that the CIA can be successfully adapted for use in a non-Western study population and that at least some associated distress and impairment transcends cultural differences.

Secondary prevention for eating disorders: the impact of education, screening, and referral in a college-based screening program.

OBJECTIVE: The first National Eating Disorders Screening Program (NEDSP), conducted on more than 400 college campuses in 1996, was an educational and two-stage screening program designed to detect potentially clinically significant disordered eating attitudes and behaviors and offer referrals for further evaluation when warranted. The current study assessed the impact of the NEDSP on participants. METHOD: A randomly selected subset of this sample (n = 289) was contacted approximately 2 years after the NEDSP to assess the impact of the program on knowledge and treatment-seeking behaviors for eating disorders. RESULTS: For greater than 80% of the participants, the program made participants aware of the danger of eating disorders and the availability of treatment. Of those who received a recommendation for further clinical evaluation of disordered eating (n = 109), nearly one half (47.7%) followed up on this recommendation and kept at least a first appointment and 39.4% actually sought treatment subsequent to the NEDSP. DISCUSSION: The results of the current study suggest that educational and screening programs may be a promising strategy for secondary prevention of eating disorders. They also suggest that awareness of the risks of disordered eating and available treatment may not be sufficient to motivate individuals to adhere to recommendations to seek treatment. Clinicians should, therefore, be vigilant for nonadherence to treatment recommendations and proactive in facilitating treatment.