Assessment of Brief Online Approaches for Teaching Neuroscience in Psychiatry.

OBJECTIVE: The goal of this study was to assess an online collection of brief educational resources (videos, case studies, articles) for teaching a broad range of concepts relating to neuroscience in psychiatry. METHODS: A national sample of 52 psychiatrists enrolled in the study. Forty (77%) completed an assessment before and after having access to the educational resources for 4 weeks. Pre- and post-assessments were compared using paired t-tests. Fifteen participants were randomly selected to participate in a semi-structured interview. RESULTS: The mean knowledge score increased on a multiple-choice quiz from 46.9 to 86.4% (p < .01). Based on a 5-point Likert rating, participants reported significant gains in self-confidence in their ability to integrate a neuroscience perspective into their clinical work (p = .03) and to discuss neuroscience with their patients (p = .008). Participants rated the extent that they applied neuroscience concepts (such as neurotransmitters, genetics, epigenetics, synaptic plasticity, and neural circuitry) to their overall case formulation and treatment plan over the past typical work week and how often they discussed these elements with patients. Significant gains were noted across all elements (p ≤ .001). Overall satisfaction with the resources were high: participants agreed that the content was useful and relevant (100%) and the teaching resources were engaging (95%). On semi-structured interviews, participants appreciated the mixed teaching approaches and the brief format. Many commented on how the resources impacted their clinical practice. CONCLUSIONS: Brief online teaching resources may be an effective approach for enhancing neuroscience education among psychiatrists and may help facilitate the integration of neuroscience into clinical practice.

Global and regional levels and trends of child and adolescent morbidity from 2000 to 2016: an analysis of years lost due to disability (YLDs).

INTRODUCTION: Non-fatal health loss makes a substantial contribution to the total disease burden among children and adolescents. An analysis of these morbidity patterns is essential to plan interventions that improve the health and well-being of children and adolescents. Our objective was to describe current levels and trends in the non-fatal disease burden from 2000 to 2016 among children and adolescents aged 0-19 years. METHODS: We used years lost due to disability (YLD) estimates in WHO's Global Health Estimates to describe the non-fatal disease burden from 2000 to 2016 for the age groups 0-27 days, 28 days-11 months, 1-4 years, 5-9 years, 10-14 years and 15-19 years globally and by modified WHO region. To describe causes of YLDs, we used 18 broad cause groups and 54 specific cause categories. RESULTS: In 2016, the total number of YLDs globally among those aged 0-19 years was about 130 million, or 51 per 1000 population, ranging from 30 among neonates aged 0-27 days to 67 among older adolescents aged 15-19 years. Global progress since 2000 in reducing the non-fatal disease burden has been limited (53 per 1000 in 2000 for children and adolescents aged 0-19 years). The most important causes of YLDs included iron-deficiency anaemia and skin diseases for both sexes, across age groups and regions. For young children under 5 years of age, congenital anomalies, protein-energy malnutrition and diarrhoeal diseases were important causes of YLDs, while childhood behavioural disorders, asthma, anxiety disorders and depressive disorders were important causes for older children and adolescents. We found important variations between sexes and between regions, particularly among adolescents, that need to be addressed context-specifically. CONCLUSION: The disappointingly slow progress in reducing the global non-fatal disease burden among children and adolescents contrasts starkly with the major reductions in mortality over the first 17 years of this century. More effective action is needed to reduce the non-fatal disease burden among children and adolescents, with interventions tailored for each age group, sex and world region.

Assessing the effectiveness of a comprehensive menstrual health intervention program in Ugandan schools (MENISCUS): process evaluation of a pilot intervention study.

BACKGROUND: Poor menstrual health and hygiene (MHH) is a globally recognised public health challenge. A pilot study of an MHH intervention was conducted in two secondary schools in Entebbe, Uganda, over 9 months. The intervention included five components delivered by the implementing partner (WoMena Uganda) and the research team: (i) training teachers to implement government guidelines for puberty education, (ii) a drama skit to reduce stigma about menstruation, (iii) training in use of a menstrual kit (including re-usable pads), (iv) guidance on pain relief methods including provision of analgesics and (v) improvements to school water, sanitation and hygiene (WASH) facilities. The aim of the process evaluation was to examine implementation, context and possible causal pathways. METHODS: We collected information on fidelity, dose, reach, acceptability, context and mechanisms of impact using (i) quantitative survey data collected from female and male students in year 2 of secondary school (ages 13-21; 450 at the baseline and 369 at endline); (ii) qualitative data from 40 in-depth interviews with parents, teachers and female students, and four focus group discussions with students, stratified by gender; (iii) data from unannounced visits checking on WASH facilities throughout the study; and (iv) routine data collected as part of the implementation. Quantitative data were used primarily to assess fidelity, dose and reach. Qualitative data were used primarily to assess acceptability, context and possible mechanisms. RESULTS: Both schools received all intervention elements that were delivered by the research team and implementing partner. The drama skit, menstrual kit and pain management intervention components were delivered with fidelity. Intervention components that relied on school ownership (puberty education training and WASH improvements) were not fully delivered. Overall, the intervention was acceptable to participants. Multilevel contextual factors including schools' social and physical environment, and family, cultural and social factors influenced the acceptability of the intervention in the school setting. The intervention components reinforced one another, as suggested in our theoretical framework. CONCLUSION: The intervention was feasible to deliver and acceptable to the schools and students. We propose a full-scale cluster-randomised trial to evaluate the intervention, adding a school-based MHH leadership group to address issues with school ownership. TRIAL REGISTRATION: ClinicalTrials.gov NCT04064736. Registered August 22, 2019, retrospectively registered.

All Other Things Being Equal: Exploring Racial and Gender Disparities in Medical School Honor Society Induction.

PURPOSE: A large body of literature has demonstrated racial and gender disparities in the physician workforce, but limited data are available regarding the potential origins of these disparities. To that end, the authors evaluated the effects of race and gender on Alpha Omega Alpha Honor Medical Society (AOA) and Gold Humanism Honor Society (GHHS) induction. METHOD: In this retrospective cohort study, the authors examined data from 11,781 Electronic Residency Application Service applications from 133 U.S. MD-granting medical schools to 12 residency programs in the 2014-2015 application cycle and to all 15 residency programs in the 2015-2016 cycle at Yale-New Haven Hospital. They estimated the odds of induction into AOA and GHHS using logistic regression models, adjusting for Step 1 score, research publications, citizenship status, training interruptions, and year of application. They used gender- and race-matched samples to account for differences in clerkship grades and to test for bias. RESULTS: Women were more likely than men to be inducted into GHHS (odds ratio 1.84, P < .001) but did not differ in their likelihood of being inducted into AOA. Black medical students were less likely to be inducted into AOA (odds ratio 0.37, P < .05) but not into GHHS. CONCLUSIONS: These findings demonstrate significant differences between groups in AOA and GHHS induction. Given the importance of honor society induction in residency applications and beyond, these differences must be explored further.

Promoting school climate and health outcomes with the SEHER multi-component secondary school intervention in Bihar, India: a cluster-randomised controlled trial.

BACKGROUND: School environments affect health and academic outcomes. With increasing secondary school retention in low-income and middle-income countries, promoting quality school social environments could offer a scalable opportunity to improve adolescent health and wellbeing. METHODS: We did a cluster-randomised trial to assess the effectiveness of a multi-component whole-school health promotion intervention (SEHER) with integrated economic and process evaluations in grade 9 students (aged 13-14 years) at government-run secondary schools in the Nalanda district of Bihar state, India. Schools were randomly assigned (1:1:1) to three groups: the SEHER intervention delivered by a lay counsellor (the SEHER Mitra [SM] group), the SEHER intervention delivered by a teacher (teacher as SEHER Mitra [TSM] group), and a control group in which only the standard government-run classroom-based life-skills Adolescence Education Program was implemented. The primary outcome was school climate measured with the Beyond Blue School Climate Questionnaire (BBSCQ). Students were assessed at the start of the academic year (June, 2015) and again 8 months later at the end of the academic year (March, 2016) via self-completed questionnaires. This study is registered with ClinicalTrials.gov, number NCT02484014. FINDINGS: Of the 112 eligible schools in the Nalanda district, 75 were randomly selected to participate in the trial. We randomly assigned 25 schools to each of the three groups. One school subsequently dropped out of the TSM group, leaving 24 schools in this group. The baseline survey included a total of 13 035 participants, and the endpoint survey included 14 414 participants. Participants in the SM-delivered intervention schools had substantially higher school climate scores at endpoint survey than those in the control group (BBSCQ baseline-adjusted mean difference [aMD] 7·57 [95% CI 6·11-9·03]; effect size 1·88 [95% CI 1·44-2·32], p<0·0001) and the TSM-delivered intervention (aMD 7·57 [95% CI 6·06-9·08]; effect size 1·88 [95% CI 1·43-2·34], p<0·0001). There was no effect of the TSM-delivered intervention compared with control (aMD -0·009 [95% CI -1·53 to 1·51], effect size 0·00 [95% CI -0·45 to 0·44], p=0·99). Compared with the control group, participants in the SM-delivered intervention schools had moderate to large improvements in the secondary outcomes of depression (aMD -1·23 [95% CI -1·89 to -0·57]), bullying (aMD -0·91 [95% CI -1·15 to -0·66]), violence victimisation (odds ratio [OR] 0·62 [95% CI 0·46-0·84]), violence perpetration (OR 0·68 [95% CI 0·48-0·96]), attitude towards gender equity (aMD 0·41 [95% CI 0·21-0·61]), and knowledge of reproductive and sexual health (aMD 0·29 [95% CI 0·06-0·53]). Similar results for these secondary outcomes were noted for the comparison between SM-delivered intervention schools and TSM-delivered intervention schools (depression: aMD -1·23 [95% CI -1·91 to -0·55]; bullying: aMD -0·83 [95% CI -1·08 to -0·57]; violence victimisation: OR 0·49 [95% CI 0·35-0·67]; violence perpetration: OR 0·49 [95% CI 0·34-0·71]; attitude towards gender equity: aMD 0·23 [95% CI 0·02-0·44]; and knowledge of reproductive and sexual health: aMD 0·22 [95% CI -0·02 to 0·47]). However, no effects on these secondary outcomes were observed for the TSM-delivered intervention schools compared with the control group (depression: aMD -0·03 [95% CI -0·70 to 0·65]; bullying: aMD -0·08 [95% CI -0·34 to 0·18]; violence victimisation: OR 1·27 [95% CI 0·93-1·73]; violence perpetration: OR 1·37 [95% CI 0·95-1·95]; attitude towards gender equity: aMD 0·17 [95% CI -0·09 to 0·38]; and knowledge of reproductive and sexual health: aMD 0·06 [95% CI -0·18 to 0·32]). INTERPRETATION: The multi-component whole-school SEHER health promotion intervention had substantial beneficial effects on school climate and health-related outcomes when delivered by lay counsellors, but no effects when delivered by teachers. Future research should focus on the evaluation of the scaling up of the SEHER intervention in diverse contexts and delivery agents. FUNDING: John D. and Catherine T. MacArthur Foundation, USA and the United Nations Population Fund India Office.

The development and pilot testing of a multicomponent health promotion intervention (SEHER) for secondary schools in Bihar, India.

BACKGROUND: Schools can play an important role in health promotion by improving students' health literacy, attitudes, health-related behaviours, social connection and self-efficacy. These interventions can be particularly valuable in low- and middle-income countries with low health literacy and high burden of disease. However, the existing literature provides poor guidance for the implementation of school-based interventions in low-resource settings. This paper describes the development and pilot testing of a multicomponent school-based health promotion intervention for adolescents in 75 government-run secondary schools in Bihar, India. METHOD: The intervention was developed in three stages: evidence review of the content and delivery of effective school health interventions; formative research to contextualize the proposed content and delivery, involving intervention development workshops with experts, teachers and students and content analysis of intervention manuals; and pilot testing in situ to optimize its feasibility and acceptability. RESULTS: The three-stage process defined the intervention elements, refining their content and format of delivery. This intervention focused on promoting social skills among adolescents, engaging adolescents in school decision making, providing factual information, and enhancing their problem-solving skills. Specific intervention strategies were delivered at three levels (whole school, student group, and individual counselling) by either a trained teacher or a lay counsellor. The pilot study, in 50 schools, demonstrated generally good acceptability and feasibility of the intervention, though the coverage of intervention activities was lower in the teacher delivery schools due to competing teaching commitments, the participation of male students was lower than that of females, and one school dropped out because of concerns regarding the reproductive and sexual health content of the intervention. CONCLUSION: This SEHER approach provides a framework for adolescent health promotion in secondary schools in low-resource settings. We are now using a cluster-randomized trial to evaluate its effectiveness and cost-effectiveness.

Process Evaluation of a Sport-Based Voluntary Medical Male Circumcision Demand-Creation Intervention in Bulawayo, Zimbabwe.

INTRODUCTION: Grassroot Soccer (GRS) developed 2 brief and scalable voluntary medical male circumcision (VMMC) promotion interventions for males in Bulawayo, Zimbabwe, consisting of a 60-minute interactive, soccer-themed educational session with follow-up behavioral and logistical reinforcement. Both interventions were led by circumcised male community leaders ("coaches") ages 18-30. "Make The Cut" (MTC) targeted adult males on soccer teams and "Make The Cut+" targeted boys in secondary schools. We conducted a process evaluation of MTC and Make The Cut+ to investigate perceptions of program impact, intervention components, and program delivery; participants' understandings of intervention content; and factors related to uptake. METHODS: We conducted 17 interviews and 2 focus group discussions with coaches and 29 interviews with circumcised (n = 13) and uncircumcised participants (n = 16). RESULTS: Findings demonstrate high program acceptability, highlighting the coach-participant relationship as a key factor associated with uptake. Specifically, participants valued the coaches' openness to discuss their personal experiences with VMMC and the accompaniment by their coaches to the VMMC clinic. CONCLUSIONS: Should the coach quality remain consistent at scale, MTC offers an effective approach toward generating VMMC demand among males.

A Sport-Based Intervention to Increase Uptake of Voluntary Medical Male Circumcision Among Adolescent Male Students: Results From the MCUTS 2 Cluster-Randomized Trial in Bulawayo, Zimbabwe.

BACKGROUND: Mathematical models suggest that 570,000 HIV infections could be averted between 2011 and 2025 in Zimbabwe if the country reaches 80% voluntary medical male circumcision (VMMC) coverage among 15- to 49-year-old male subjects. Yet national coverage remains well below this target, and there is a need to evaluate interventions to increase the uptake. METHODS: A cluster-randomized trial was conducted to assess the effectiveness of Make-The-Cut-Plus (MTC+), a single, 60-minute, sport-based intervention to increase VMMC uptake targeting secondary school boys (14-20 years). Twenty-six schools in Bulawayo, Zimbabwe, were randomized to either receive MTC+ at the start (intervention) or end (control) of a 4-month period (March to June 2014). VMMC uptake over these 4 months was measured via probabilistic matching of participants in the trial database (n = 1226 male participants; age, 14-20 years; median age, 16.2 years) and the registers in Bulawayo's 2 free VMMC clinics (n = 5713), using 8 identifying variables. RESULTS: There was strong evidence that the MTC+ intervention increased the odds of VMMC uptake by approximately 2.5 fold (odds ratio = 2.53; 95% confidence interval, 1.21 to 5.30). Restricting to participants who did not report being already circumcised at baseline, MTC+ increased VMMC uptake by 7.6% (12.2% vs 4.6%, odds ratio = 2.65; 95% confidence interval, 1.19 to 5.86). Sensitivity analyses related to the probabilistic matching did not change these findings substantively. The number of participants who would need to be exposed to the demand creation intervention to yield one additional VMMC client was 22.7 (or 13.2 reporting not already being circumcised). This translated to approximately US dollar 49 per additional VMMC client. CONCLUSIONS: The MTC+ intervention was an effective and cost-effective strategy for increasing VMMC uptake among school-going adolescent male subjects in Bulawayo.

Research Priorities for Eight Areas of Adolescent Health in Low- and Middle-Income Countries.

PURPOSE: To conduct an expert-led process for identifying research priorities for eight areas of adolescent health in low- and middle-income countries. Specific adolescent health areas included communicable diseases prevention and management, injuries and violence, mental health, noncommunicable diseases management, nutrition, physical activity, substance use, and health policy. METHODS: We used a modified version of the Child Health and Nutrition Research Initiative methodology for reaching consensus on research priorities. In a three phase process, we (1) identified research and program experts with wide-ranging backgrounds and experiences from all geographic regions through systematic searches and key informants; (2) invited these experts to propose research questions related to descriptive epidemiology, interventions (discovery, development/testing, and delivery/implementation), and health policy/systems; and (3) asked the experts to prioritize the research questions based on five criteria: clarity, answerability, importance or impact, implementation, and equity. RESULTS: A total of 142 experts submitted 512 questions which were edited and reduced to 303 for scoring. Overall, the types of the top 10 research questions in each of the eight health areas included descriptive epidemiology (26%), interventions: discovery (11%), development/testing (25%), delivery (33%), and policy, health and social systems (5%). Across health areas, the top questions highlighted integration of health services, vulnerable populations, and different health platforms (such as primary care, schools, families/parents, and interactive media). CONCLUSIONS: Priority questions have been identified for research in eight key areas of adolescent health in low- and middle-income countries. These expert-generated questions may be used by donors, program managers, and researchers to prioritize and stimulate research in adolescent health.

Feasibility and acceptability of delivering adolescent health interventions alongside HPV vaccination in Tanzania.

BACKGROUND: Human papillomavirus (HPV) vaccination offers an opportunity to strengthen provision of adolescent health interventions (AHI). We explored the feasibility of integrating other AHI with HPV vaccination in Tanzania. METHODS: A desk review of 39 policy documents was preceded by a stakeholder meeting with 38 policy makers and partners. Eighteen key informant interviews (KIIs) with health and education policy makers and district officials were conducted to further explore perceptions of current programs, priorities and AHI that might be suitable for integration with HPV vaccination. RESULTS: Fourteen school health interventions (SHI) or AHI are currently being implemented by the Government of Tanzania. Most are delivered as vertical programmes. Coverage of current programs is not universal, and is limited by financial, human resource and logistic constraints. Limited community engagement, rumours, and lack of strategic advocacy has affected uptake of some interventions, e.g. tetanus toxoid (TT) immunization. Stakeholder and KI perceptions and opinions were limited by a lack of experience with integrated delivery and AHI that were outside an individual's area of expertise and experience. Deworming and educational sessions including reproductive health education were the most frequently mentioned interventions that respondents considered suitable for integrated delivery with HPV vaccine. CONCLUSIONS: Given programme constraints, limited experience with integrated delivery and concern about real or perceived side-effects being attributed to the vaccine, it will be very important to pilot-test integration of AHI/SHI with HPV vaccination. Selected interventions will need to be simple and quick to deliver since health workers are likely to face significant logistic and time constraints during vaccination visits.