Impacts of the COVID-19 pandemic on access to healthcare among people with disabilities: evidence from six low- and middle-income countries.

BACKGROUND: The pandemic has placed considerable strain on health systems, especially in low- and middle-income countries (LMICs), leading to reductions in the availability of routine health services. Emerging evidence suggests that people with disabilities have encountered marked challenges in accessing healthcare services and supports in the context of the pandemic. Further research is needed to explore specific barriers to accessing healthcare during the pandemic, and any strategies that promoted continued access to health services in LMICs where the vast majority of people with disabilities live. METHODS: Qualitative in-depth interviews were conducted with persons with disabilities in Ghana, Zimbabwe, Viet Nam, Türkiye (Syrian refugees), Bangladesh, and India as part of a larger project exploring the experiences of people with disabilities during the COVID-19 pandemic and their inclusion in government response activities. Data were analysed using thematic analysis. RESULTS: This research found that people with disabilities in six countries - representing a diverse geographic spread, with different health systems and COVID-19 responses - all experienced additional difficulties accessing healthcare during the pandemic. Key barriers to accessing healthcare during the pandemic included changes in availability of services due to systems restructuring, difficulty affording care due to the economic impacts of the pandemic, fear of contracting coronavirus, and a lack of human support to enable care-seeking. CONCLUSION: These barriers ultimately led to decreased utilisation of services which, in turn, negatively impacted their health and wellbeing. However, we also found that certain factors, including active and engaged Organisations of Persons with Disabilities (OPDs) and Non-Governmental Organizations (NGOs) played a role in reducing some of the impact of pandemic-related healthcare access barriers.

"If you work alone on this project, you can't reach your target": unpacking the leader's role in well-performing teams in a maternal and neonatal quality improvement programme in South Africa, before and during COVID-19.

The South African National Department of Health developed a quality improvement (QI) programme to reduce maternal and neonatal mortality and still births. The programme was implemented between 2018 and 2022 in 21 purposively selected public health facilities. We conducted a process evaluation to describe the characteristics and skills of the QI team leaders of well-performing teams. The evaluation was conducted in 15 of the 21 facilities. Facilities were purposively selected and comprised semi-structured interviews with leaders at three time points; reviewing of QI documentation; and 37 intermittently conducted semi-structured interviews with the QI advisors, being QI technical experts who supported the teams. These interviews focused on participants' experiences and perceptions of how the teams performed, and performance barriers and enablers. Thematic data analysis was conducted using Atlas.ti. Variation in team performance was associated with leaders' attributes and skills. However, the COVID-19 pandemic also affected team functioning. Well-performing teams had leaders who effectively navigated COVID-19 and other challenges, who embraced QI and had sound QI skills. These leaders cultivated trust by taking responsibility for failures, correcting members' mistakes in encouraging ways, and setting high standards of care. Moreover, they promoted programme ownership among members by delegating tasks. Given the critical role leaders play in team performance and thus in the outcomes of QI programmes, efforts should focus on leader selection, training, and support.

From purists to pragmatists: a qualitative evaluation of how implementation processes and contexts shaped the uptake and methodological adaptations of a maternal and neonatal quality improvement programme in South Africa prior to, and during COVID-19.

BACKGROUND: Despite progress, maternal and neonatal mortality and still births remain high in South Africa. The South African National Department of Health implemented a quality improvement (QI) programme, called Mphatlalatsane, to reduce maternal and neonatal mortality and still births. It was implemented in 21 public health facilities, seven per participating province, between 2018 and 2022. METHODS: We conducted a qualitative process evaluation of the contextual and implementation process factors' influence on implementation uptake amongst the QI teams in 15 purposively selected facilities. Data collection included three interview rounds with the leaders and members of the QI teams in each facility; intermittent interviews with the QI advisors; programme documentation review; observation of programme management meetings; and keeping a fieldwork journal. All data were thematically analysed in Atlas.ti. Implementation uptake varied across the three provinces and between facilities within provinces. RESULTS: Between March and August 2020, the COVID-19 pandemic disrupted uptake in all provinces but affected QI teams in one province more severely than others, because they received limited pre-pandemic training. Better uptake among other sites was attributed to receiving more QI training pre-COVID-19, having an experienced QI advisor, and good teamwork. Uptake was more challenging amongst hospital teams which had more staff and more complicated MNH services, versus the primary healthcare facilities. We also attributed better uptake to greater district management support. A key factor shaping uptake was leaders' intrinsic motivation to apply QI methodology. We found that, across sites, organic adaptations to the QI methodology were made by teams, started during COVID-19. Teams did away with rapid testing of change ideas and keeping a paper trail of the steps followed. Though still using data to identify service problems, they used self-developed audit tools to record intervention effectiveness, and not the prescribed tools. CONCLUSIONS: Our study underscores the critical role of intrinsic motivation of team leaders, support from experienced technical QI advisors, and context-sensitive adaptations to maximise QI uptake when traditionally recognised QI steps cannot be followed.

First 1,000 days: enough for mothers but not for children? Long-term outcomes of an early intervention on maternal depressed mood and child cognitive development: follow-up of a randomised controlled trial.

BACKGROUND: Child cognitive development is often compromised in contexts of poverty and adversity, and these deficits tend to endure and affect the child across the life course. In the conditions of poverty and violence that characterise many low- and middle-income countries (LMIC), the capacity of parents to provide the kind of care that promotes good child development may be severely compromised, especially where caregivers suffer from depression. One avenue of early intervention focuses on the quality of the early mother-infant relationship. The aim of this study was to examine the long-term impact of an early intervention to improve the mother-infant relationship quality on child cognitive outcomes at 13 years of age. We also estimated the current costs to replicate the intervention. METHOD: We re-recruited 333 children from an early childhood maternal-infant attachment intervention, 'Thula Sana', when the children were 13 years old, to assess whether there were impacts of the intervention on child cognitive outcomes, and maternal mood. We used the Kaufman Assessment Battery to assess the child cognitive development and the Patient Health Questionnaire (PHQ-9) and the Self-Reporting Questionnaire (SRQ-20) to assess maternal mental health. RESULTS: Effect estimates indicated a pattern of null findings for the impact of the intervention on child cognitive development. However, the intervention had an effect on caregiver psychological distress (PHQ-9, ES = -0.17 [CI: -1.95, 0.05] and SRQ-20, ES = -0.30 [CI: -2.41, -0.19]), but not anxiety. The annual cost per mother-child pair to replicate the Thula Sana intervention in 2019 was estimated at ZAR13,365 ($780). CONCLUSION: In a socio-economically deprived peri-urban settlement in South Africa, a home visiting intervention, delivered by community workers to mothers in pregnancy and the first six postpartum months, had no overall effect on child cognitive development at 13 years of age. However, those caregivers who were part of the original intervention showed lasting improvements in depressed mood. Despite the fact that there was no intervention effect on long-term child outcomes, the improvements in maternal mood are important.

Public Health Approaches to Promoting University Students' Mental Health: A Global Perspective.

PURPOSE OF REVIEW: Provide a critical overview of recent global advances in student mental health from a public health perspective, highlighting key challenges and gaps in the literature. RECENT FINDINGS: Mental disorders and suicidality are common among university students globally. However, there is a significant treatment gap even though evidence-based treatments are available. To overcome barriers to treatment, public health interventions should be conceptualized within a developmental paradigm that takes cognizance of the developmental tasks of young adulthood. Traditional one-on-one treatment approaches will not be a cost-effective or sustainable way to close the treatment gap among students. A range of evidence-based interventions is available to promote students' mental health; however, novel approaches are needed to scale up services and adapt intervention delivery to suit student specific contexts. Digital interventions and peer-to-peer interventions could be a cost-effective way to scale-up and expand the range of services.

Rural-urban variation in user satisfaction with outpatient mental health services in Southern Malawi: a cross-sectional survey.

BACKGROUND: User satisfaction with outpatient mental health services is an important factor in ensuring continued engagement with mental health services for people with mental health conditions. Yet, in many low and middle-income countries, including Malawi, there is a dearth of information about user's experiences of outpatient mental health care services, and little is known about which factors might affect user satisfaction. AIM: The aim of the present work was to evaluate user satisfaction with outpatient mental health services in southern Malawi and to explore whether social demographic variables, mental health status, and treatment characteristics explain variance in user satisfaction. METHODS: This cross-sectional study was conducted in Malawi at one urban (Blantyre) and one rural (Thyolo) outpatient psychiatric clinics. Two-hundred and sixteen randomly sampled service users were enrolled into the study and completed the Charlestone Psychiatric Outpatient Satisfaction Scale (CPOSS). The unadjusted and adjusted associations between user satisfaction as the dependent variable, and participant socio-demographic characteristics as independent variables, were examined. RESULTS: Eighty percent of all participants were satisfied with the outpatient mental health services, although participants presenting to the rural clinic were less likely to be satisfied than participants presenting at the urban clinic, according to the adjusted odds ratio (AOR; AOR = 0.31; 95% confidence interval (CI): 0.13-0.76; p < 0.05). Any admission due to a mental health condition significantly explained variance in user satisfaction at the rural (Thyolo) study site; as those who had been admitted previously were less satisfied than those who had never been admitted (AOR = 0.11; 95% CI: 0.02-0.54; p < 0.05). CONCLUSION: As may be expected, these findings demonstrate that service user satisfaction is linked to service quality and past service experiences. Further research is required in order to nuance these findings in the context of Malawi's efforts to strengthen service quality. Nonetheless, rural facilities may require additional support to deliver satisfactory care.

Modelling the impact of maternal HIV on uninfected children: correcting current estimates.

A mathematical model, populated primarily with data from South Africa, was developed to model the numbers of children affected by maternal HIV, and the number who will experience long-term negative developmental consequences. A micro-simulation model generated two scenarios. The first simulated a cohort of women whose HIV status mimicked that of a target population, and mother-child dyads by way of age- and disease-specific fertility rates. Factors defining risk were used to characterize the simulated environment. The second scenario simulated mother-child dyads without maternal HIV. In the first scenario an estimated 26% of children are orphaned, compared to 10% in the absence of HIV. And a further 19% of children whose mother is alive when they turn 18 are affected by maternal HIV. School drop-out among all children increased by 4 percentage points because of maternal HIV, similarly population level estimates of abuse and negative mental health outcomes are elevated. Relative to HIV unaffected children, HIV affected have elevated risk of poor outcomes, however not all will suffer long-term negative consequences. Interventions to protect children should target the proportion of children at risk, while interventions to mitigate harm should target the smaller proportion of children who experience long-term negative outcomes..

Improving mother-infant interaction during infant feeding: A randomised controlled trial in a low-income community in South Africa.

BACKGROUND: Maternal-infant feeding interactions are a primary context for engagement between mothers and their infants, and constitute a unique space in which reciprocity, attunement and maternal sensitivity can be expressed. Increasingly, research demonstrates the importance of the psychological and social nature of the feeding context, and how it may be affected by maternal mental state, feeding skills and sensitivity. As such, feeding interactions may provide useful contexts for observations of maternal sensitivity, reflecting well on day-to-day maternal sensitivity. AIMS AND OBJECTIVES: This paper is a post hoc examination of the impact of an intervention on maternal sensitivity during a feeding interaction when the infants were 6 months old. PARTICIPANTS: A total of 449 women consented to participate in the original intervention and were randomly assigned to the intervention or control groups. Mothers and infants were assessed during pregnancy, and then at 2, 6, 12 and 18 months of infant age. At the 6 month follow-up visit, 79% (354 out of 449) of the participants were retained. Post hoc analyses were conducted on the original sample to determine breastfeeding status. Sixty-nine percent of the women completed the feeding observation at the 6 months follow-up visit, of which 47% reported exclusively breastfeeding and 22% reported bottle-feeding. RESULTS: Results demonstrated that during a feeding interaction, maternal sensitivity was significantly improved among non-breastfeeding mothers who received the intervention. Particularly, maternal responsiveness to infant cues and synchronous interactions was higher among non-breastfeeding intervention mothers compared to control group mothers. The results also show that non-breastfeeding mothers who received the intervention were significantly less intrusive in their interactions with their infants. CONCLUSION: The intervention had particular beneficial effects for mothers who were not breastfeeding and suggest that the intervention offered a protective effect for non-breastfeeding mothers.

Trasfondo: Las interacciones materno-infantiles de alimentación son un contexto primario de compromiso interactivo entre madres y sus infantes. Alimentar al infante es un proceso complejo que requiere no sólo que se provean los nutrientes, sino también una relación social entre el cuidador y el infante. Metas y Objetivos: Este artículo es un examen a posteriori del impacto de una intervención sobre la sensibilidad materna durante una interacción de alimentación cuando los infantes tenían seis meses de edad. Participantes: Un total de 449 mujeres consintieron en participar en la intervención original y fueron asignadas al azar a la propia intervención o a los grupos de control. A la visita de seguimiento de los seis meses, el 79% (354 de las 449) de las participantes aún se mantenían. Se llevaron a cabo análisis a posteriori en el grupo muestra original para determinar la condición de amamantamiento. Resultados: Durante una interacción de alimentación, la sensibilidad materna mejoró significativamente entre las madres que no amamantaban y que recibieron la intervención. La sensibilidad materna a las señales del infante y a las interacciones sincrónicas fue más alta entre madres de la intervención que no amamantaban tal como se les comparó con las madres del grupo de control. Conclusión: Estos resultados demuestran particularmente los efectos beneficiosos para las madres en el grupo de intervención que no estaban amamantando, y sugieren que la intervención ofreció un efecto de protección para las madres que no amamantaban.

Contexte: Les interactions maternelles-bébé durant l'alimentation sont un contexte primaire pour l'engagement entre les mères et leurs bébés. Nourrir son bébé est un processus complexe qui inclut non seulement le transfert d'éléments nutritifs mais également une relation sociale entre la personne prenant soin du bébé et le bébé. Buts et Objectifs: Cet article est une étude post hoc de l'impact d'une intervention sur la sensibilité maternelle durant une interaction d'alimentation lorsque les bébés avaient six mois. Participantes: Un total de 449 femmes ont consenti à participer à l'intervention originelle et ont été réparties au hasard au groupe d'intervention ou au groupe de contrôle. A la visite de suivi de six mois 79% (354 sur 449) des participantes ont été retenues. Les analyses post hoc analyses ont été faites sur l'échantillon d'origine afin de déterminer le statut d'allaitement au sein. Résultats: Durant une interaction d'alimentation, la sensibilité maternelle a été améliorée de manière importante chez les mères de donnant pas le sein qui recevaient l'intervention. La réaction maternelle aux signes du bébé et les interactions synchronisées étaient plus élevées chez les mères du groupe d'intervention de non allaitement au sein comparées au groupe de mères de contrôle. Conclusion: Ces résultats dénotent des effets particulièrement favorables pour les mères du groupe d'intervention qui n'allaitaient pas au sein, et suggèrent que l'intervention a offert un effet protecteur pour les mères n'allaitant pas leurs bébé au sein.

Mental health symptoms and disorders in Paralympic athletes: a narrative review.

OBJECTIVES: This narrative review summarises the literature on the mental health of Paralympic athletes, explores possible reasons for the paucity of research in this area and suggests directions for future research. METHODS: A systematic search of PubMed, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, SPORTDiscus, Scopus, and Cochrane databases was conducted using search terms related to disability, sport and mental health. RESULTS: The search yielded 665 publications. Of these, 129 were duplicates, resulting in 536 publications identified for initial screening. A total of 72 publications were to be relevant at initial screening. Only seven publications addressed Paralympic athletes specifically. Of these papers, three included measures of depression and three included measures of anxiety. In the studies that were not concerned with mental health symptoms or disorders, the focus of enquiry included identity and self, stress, and well-being. CONCLUSION: Most of the studies reviewed are small in scale, and there are almost no comparative data on Paralympic versus Olympic athletes. There is a paucity of data on rates of mental health symptoms and disorders in this population and the factors that might contribute to poor mental health among elite athletes with disabilities. We propose that stereotypes about people with disabilities-and the disability rights movement's rightful reaction to these stereotypes-have created barriers to mental health research among Paralympic athletes. There is a need for enquiry into the differential stressors experienced by Paralympic athletes, including trauma, transition out of sport, sport and personhood, and the potential for disability sport to promote psychological health.

Atypical maternal cradling laterality in an impoverished South African population.

Human studies consistently report a 60%-80% maternal left cradling preference. The dominant explanation points to an engagement of the emotionally more-attuned right brain. In contrast, we found equal incidences of left (31.3%), right (34.3%) and no-preference (34.3%) cradling in an impoverished South African population living under adverse conditions characterized by extreme dangers. We found striking differences on the Parenting Stress Index (PSI) between mothers with no cradling laterality preference and mothers with either a left or right preference. In several mammals a homologous left preference becomes stronger when acute threats prevail, rendering the rightwards shift we observed under dangerous conditions seemingly paradoxical. We propose this paradox can be resolved in terms of life-history strategy theory which predicts reduced parental investment in chronically dangerous environments. We interpret our high PSI score findings in no-preference cradlers as indicative of poorer, or at least ambivalent, maternal coping which many studies show is typically associated with reduced emotional sensitivity and responsiveness. We suggest that the latter may be a psychological mechanism mediating a partial withdrawal of parental investment in response to an enduringly adverse environment. To the best of our knowledge, this is the first study investigating cradling laterality preferences in an adverse socioeconomic environment.

Dating persons with physical disabilities: the perceptions of South Africans without disabilities.

There is good reason to believe that the attitudes of persons without disability towards dating a person with a physical disability might be unfavourable. However, in general, and in the Global South in particular, there is a dearth of research in this area. This study sought to take the first step in addressing this lack of enquiry, by surveying the attitudes of a general population sample in South Africa towards dating people with physical disabilities, using a vignette. Data from 1723 survey respondents were analysed thematically. Findings reveal largely negative attitudes towards people with physical disabilities. Respondents without disability perceived numerous barriers to dating a person with a physical disability, including social stigma, anxiety and concerns about the burden of care they believed such a relationship would place upon them. However, there was some evidence to suggest that some positive attitudes do exist, and a few respondents were open to dating a person with physical disabilities. Findings contribute to a nuancing and expanding of the 'myth of asexuality' among physically disabled people by showing that people with physical disabilities are actively desexualised by persons without disability. Future research is needed to explore how the inclusive attitudes, of which we did find evidence here, can be further cultivated.

The sexual and reproductive rights and benefit derived from sexual and reproductive health services of people with physical disabilities in South Africa: beliefs of non-disabled people.

There is a body of theoretical work, and some empirical research, which suggests that non-disabled people assume people with physical disabilities are not suitable romantic partners, do not have sexual drives or desires, or are not sexually active. It has also been proposed that people with physical disabilities face barriers to sexual healthcare access which are structural as well as social. The present paper explores non-disabled South Africans' beliefs concerning the degree to which non-disabled respondents enjoy sexual and reproductive rights, and benefit from sexual and reproductive healthcare, compared to people without disability. Using a survey, we asked 1989 South Africans to estimate the degree to which people with physical disabilities and people without disability have sexual rights, and benefit from sexual and reproductive healthcare services, respectively. Respondents were more likely to support the idea that the population without disability were deserving of sexual rights compared to people with physical disabilities. Respondents were more likely to rate the degree to which people with physical disability benefit from sexual and reproductive healthcare as less than that for people without physical disabilities. These findings provide some of the first empirical support that non-disabled people perceive people with physical disabilities as having fewer sexual and reproductive rights, and deriving less benefit from sexual and reproductive health services, than the population without disability. To have diminished sexual rights, and benefit less from sexual and reproductive healthcare, we suggest, evinces a negation of the sexual and reproductive needs and capacity of people with physical disabilities.

Visual Impairment, Inclusion and Citizenship in South Africa.

People with visual impairment face significant material challenges to access and inclusion in South Africa. These are in large part rooted in and supported by prejudiced assumptions about the needs, nature and capabilities of this group. The cultural and psychological face of oppression needs to be attended to. To this end, this viewpoint brings together the work of three visually impaired scholars in three key areas pertaining to the promotion of the inclusion and citizenship of visually impaired persons in South Africa. These areas are education; rehabilitation; and social inclusion and visibility. This work argues that undoing lifelong exclusion requires examining how disablism is embedded in the very fabric of our societies and operational at various levels: material, administrative, cultural and relational.

Are children with disabilities more likely to be malnourished than children without disabilities? Evidence from the Multiple Indicator Cluster Surveys in 30 countries.

Introduction: A key Sustainable Development Goal target is to eliminate all forms of malnutrition. Existing evidence suggests children with disabilities are at greater risks of malnutrition, exclusion from nutrition programmes and mortality from severe acute malnutrition than children without disabilities. However, there is limited evidence on the nutritional outcomes of children with disabilities in large-scale global health surveys. Methods: We analysed Multiple Indicator Cluster Survey data from 30 low and middle-income countries to compare nutritional outcomes for children aged 2-4 years with and without disabilities. We estimated the adjusted prevalence ratios for stunting, wasting and underweight comparing children with and without disabilities by country and sex, using quasi-Poisson models with robust SEs. We accounted for the complex survey design, wealth quintile, location and age in the analyses. We meta-analysed these results to create an overall estimate for each of these outcomes. Results: Our analyses included 229 621 children aged 2-4 across 30 countries, including 15 071 children with disabilities (6.6%). Overall, children with disabilities were more likely to be stunted (adjusted risk ratio (aRR) 1.16, 95% CI 1.11 to 1.20), wasted (aRR 1.28, 95% CI 1.18 to 1.39) and underweight (aRR 1.33, 95% CI 1.17, 1.51) than children without disabilities. These patterns were observed in both girls and boys with disabilities, compared with those without. Conclusion: Children with disabilities are significantly more likely to experience all forms of malnutrition, making it critical to accelerate efforts to improve disability inclusion within nutrition programmes. Ending all forms of malnutrition will not be achievable without a focus on disability.

Post-traumatic stress disorder symptoms following exposure to acute psychological trauma in children aged 8-16 years in South Africa: protocol for the Sinethemba longitudinal study.

INTRODUCTION: Children exposed to trauma are vulnerable to developing post-traumatic stress disorder (PTSD) and other adverse mental health outcomes. In low-and middle-income countries (LMICs), children are at increased risk of exposure to severe trauma and co-occurring adversities. However, relative to high-income countries, there is limited evidence of the factors that predict good versus poor psychological recovery following trauma exposure in LMIC children, and the role of caregiver support in these high-adversity communities. METHODS AND ANALYSIS: We will conduct a longitudinal, observational study of 250 children aged 8-16 years and their caregivers in South Africa, following child exposure to acute trauma. Dyads will be recruited from community hospitals following a potentially traumatic event, such as a motor vehicle accident or assault. Potential participants will be identified during their hospital visit, and if they agree, will subsequently be contacted by study researchers. Assessments will take place within 4 weeks of the traumatic event, with 3-month and 6-month follow-up assessments. Participants will provide a narrative description of the traumatic event and complete questionnaires designed to give information about social and psychological risk factors. Child PTSD symptoms will be the primary outcome, and wider trauma-related mental health (depression, anxiety, behavioural problems) will be secondary outcomes. Regression-based methods will be used to examine the association of psychosocial factors in the acute phase following trauma, including caregiver support and responding, with child PTSD and wider mental health outcomes. ETHICS AND DISSEMINATION: Ethical approvals have been granted by Stellenbosch University and the University of Bath, with additional approvals to recruit via hospitals and healthcare clinics being granted by the University of Cape Town, the Department of Health and the City of Cape Town. Study findings will be disseminated via publication in journals, workshops for practitioners and policy-makers, and public engagement events.

Comparative effectiveness of remote digital gamified and group CBT skills training interventions for anxiety and depression among college students: Results of a three-arm randomised controlled trial.

Digital interventions can enhance access to healthcare in under-resourced settings. However, guided digital interventions may be costly for low- and middle-income countries, despite their effectiveness. In this randomised control trial, we evaluated the effectiveness of two digital interventions designed to address this issue: (1) a Cognitive Behavioral Therapy Skills Training (CST) intervention that increased scalability by using remote online group administration; and (2) the SuperBetter gamified self-guided CBT skills training app, which uses other participants rather than paid staff as guides. The study was implemented among anxious and/or depressed South African undergraduates (n = 371) randomised with equal allocation to Remote Group CST, SuperBetter, or a MoodFlow mood monitoring control. Symptoms were assessed with the Generalized Anxiety Disorder-7 (GAD-7) and the Patient Health Questionnaire-9 (PHQ-9). Intention-to-treat analysis found effect sizes at the high end of prior digital intervention trials, including significantly higher adjusted risk differences (ARD; primary outcome) in joint anxiety/depression remission at 3-months and 6-months for Remote Group CST (ARD = 23.3-18.9%, p = 0.001-0.035) and SuperBetter (ARD = 12.7-22.2%, p = 0.047-0.006) than MoodFlow and mean combined PHQ-9/GAD-7 scores (secondary outcome) significantly lower for Remote Group CST and SuperBetter than MoodFlow. These results illustrate how innovative delivery methods can increase the scalability of standard one-on-one guided digital interventions. PREREGISTRATION INTERNATIONAL STANDARD RANDOMISED CONTROLLED TRIAL NUMBER (ISRTCN) SUBMISSION #: 47,089,643.

A community-based child health and parenting intervention to improve child HIV testing, health, and development in rural Lesotho (Early Morning Star): a cluster-randomised, controlled trial.

BACKGROUND: When caregivers live in remote settings characterised by extreme poverty, poor access to health services, and high rates of HIV/AIDS, their caregiving ability and children's development might be compromised. We aimed to test the effectiveness of a community-based child health and parenting intervention to improve child HIV testing, health, and development in rural Lesotho. METHODS: We implemented a matched cluster-randomised, controlled trial in the Mokhotlong district in northeastern Lesotho with 34 community clusters randomly assigned to intervention or wait-list control groups within a pair. Eligible clusters were villages with non-governmental organisation partner presence and an active preschool. Participants were caregiver-child dyads, where the child was 12-60 months old at baseline. The intervention consisted of eight group sessions delivered at informal preschools to all children in each village. Mobile health events were hosted for all intervention (n=17) and control (n=17) clusters, offering HIV testing and other health services to all community members. Primary outcomes were caregiver-reported child HIV testing, child language development, and child attention. Assessments were done at baseline, immediately post-intervention (3 months post-baseline), and 12 months post-intervention. We assessed child language by means of one caregiver-report measure (MacArthur-Bates Communicative Development Inventory [CDI]) and used two observational assessments of receptive language (the Mullen Scales of Early Learning receptive language subscale, and the Peabody Picture Vocabulary Test 4th edn). Child attention was assessed by means of the Early Childhood Vigilance Task. Assessors were masked to group assignment. Analysis was by intention to treat. This trial was registered with ISRCTN.com, ISRCTN16654287 and is completed. FINDINGS: Between Aug 8, 2015, and Dec 10, 2017, 1040 children (531 intervention; 509 control) and their caregivers were enrolled in 34 clusters (17 intervention; 17 control). Compared with controls, the intervention group reported significantly higher child HIV testing at the 12-month follow-up (relative risk [RR] 1·46, 95% CI 1·29 to 1·65, p<0·0001), but not immediately post-intervention. The intervention group showed significantly higher child receptive language on the caregiver report (CDI) at immediate (effect size 3·79, 95% CI 0·78 to 6·79, p=0·028) but not at 12-month follow-up (effect size 2·96, 95% CI -0·10 to 5·98, p=0·056). There were no significant group differences for the direct assessments of receptive language. Child expressive language and child attention did not differ significantly between groups. INTERPRETATION: Integrated child health and parenting interventions, delivered by trained and supervised lay health workers, can improve both child HIV testing and child development. FUNDING: United States Agency for International Development (USAID) and the President's Emergency Plan for AIDS Relief (PEPFAR).

Anxious, Depressed, and Suicidal: Crisis Narratives in University Student Mental Health and the Need for a Balanced Approach to Student Wellness.

There is growing global awareness of the poor mental health of university students, as well as the need to improve students' access to services and expand the range of available evidence-based interventions. However, a crisis narrative is emerging, particularly in the wake of the COVID-19 pandemic, that runs the risk of positioning all students as potential patients in need of formal psychiatric interventions. Our aim in this commentary is to critically present the evidence that supports increased attention to student mental health, while also raising a concern that the crisis narrative may itself have unintended harmful consequences. We highlight some of the potential dangers of overtly medicalizing and thus pathologizing students' experiences of everyday distress, inadequacies of formal diagnostic categories, limitations of focusing narrowly on psychotherapeutic and psychiatric interventions, and the short-sightedness of downplaying key social determinants of students' distress. We argue for an integrative and balanced public health approach that draws on the rigor of psychiatric epidemiology and the advances that have been made to identify evidence-based interventions for students, while simultaneously being mindful of the shortcomings and potential dangers of working narrowly within the paradigm of diagnostic labels and psychotherapeutic interventions.

Effectiveness of interventions for improving social inclusion outcomes for people with disabilities in low- and middle-income countries: A systematic review.

Background: People with disabilities-more than a billion people worldwide-are frequently excluded from social and political life, and often experience stigmatising attitudes and behaviours from people without disabilities. This stigma, coupled with inaccessible environments and systems and institutional barriers (e.g., lack of inclusive legislation), may result in discrimination against people with disabilities (and their families) to the degree that they are not able to enjoy their rights on an equal basis with others. Objectives: This review examines the effectiveness of interventions for improving social inclusion outcomes (acquisition of skills for social inclusion, broad-based social inclusion, and improved relationships) for people with disabilities in low- and middle-income countries (LMICs). Search Methods: We searched academic and online databases, carried out citation tracking of included studies, and contacted experts to ensure our search was as comprehensive as possible. We also ran the searches with search terms specific to social inclusion review using Open Alex in EPPI reviewer. Selection Criteria: We included all studies which reported on impact evaluations of interventions to improve social inclusion outcomes for people with disabilities in LMIC. Data Collection and Analysis: We used review management software EPPI Reviewer to screen the search results. Two review authors independently extracted the data from each study report, including for the confidence in study findings appraisal. Data and information were extracted regarding available characteristics of participants, intervention characteristics and control conditions, research design, sample size, risk of bias and outcomes, and results. Random-effects inverse variance weighted meta-analytic methods were used to synthesise standardised mean differences for the outcomes. Main Results: We identified 37 experimental and quasi-experimental studies. Studies were conducted in 16 countries, with the majority of the included studies (n = 13) from South Asia and nine each from East Asia, the Pacific, the Middle East, and North Africa. Most studies targeted children with disabilities (n = 23), and 12 targeted adults with disabilities. Most focused on people with intellectual disabilities (n = 20) and psychosocial disabilities (n = 13). Regarding intervention content, most (n = 17) of the included programmes aimed to improve the social and communication skills of people with disabilities through social skills training programmes. Ten studies aimed at providing personal assistance and support and evaluated the effects of a parent training programme on the interactive skills of parents of children and their children with disabilities. We calculated effect sizes from experimental and quasi-experimental studies for outcomes on skills for social inclusion, relationships of people with disabilities with family and community members, and broad-based social inclusion among people with disabilities. A meta-analysis of 16 studies indicates an overall positive, statistically significant and large effect of the interventions for skills for social inclusion with standardised mean difference (SMD) = 0.87, confidence interval (CI) = 0.57 to 1.16, k = 26, I 2 = 77%, p < 0.001). For relationships across 12 studies, we find a positive but moderate effect (SMD = 0.61, CI = 0.41 to 0.80, k = 15, I 2 = 64%, p < 0.01). As for the overall effect on broad-based social inclusion, we find the average effect size was large, and there was significant dispersion across studies (SMD = 0.72, CI = 0.33 to 1.11, k = 2, I 2 = 93%, p < 0.01). Despite the significant and large effects estimated by the studies, some limitations must be noted. Although there was a consensus on the direction of the effects, the studies presented considerable heterogeneity in the size of the effects. A majority (n = 27) of studies were assessed to be of low confidence related to methodological limitations, so the findings must be interpreted with caution. Tests for publication bias show that the effect sizes of social skills (p < 0.01) and social inclusion (p = 0.01) are all likely to be inflated by the existence of the publication bias. Authors' Conclusions: The review's findings suggest that various interventions to improve the social inclusion of people with disabilities have a significant positive effect. Interventions such as social and communication training and personal assistance led to significant improvement in the social behaviour and social skills of people with disabilities. Studies targeting broad-based social inclusion showed a large and significant positive effect. A moderate effect was reported from interventions designed to improve relationships between people with disabilities and their families and communities. However, the findings of this review must be interpreted cautiously, given the low confidence in study methods, severe heterogeneity and significant publication bias. The available evidence focused primarily on individual-level barriers such as interventions for improving social or communications skills of people with disabilities and not the systemic drivers of exclusions such as addressing societal barriers to inclusion, such as stigma reduction, and interventions to strengthen legislation, infrastructure, and institutions.

South African university students' experiences of online group cognitive behavioural therapy: Implications for delivering digital mental health interventions to young people.

Mental disorders are common among university students. In the face of a large treatment gap, resource constraints and low uptake of traditional in-person psychotherapy services by students, there has been interest in the role that digital mental health solutions could play in meeting students' mental health needs. This study is a cross-sectional, qualitative inquiry into university students' experiences of an online group cognitive behavioural therapy (GCBT) intervention. A total of 125 respondents who had participated in an online GCBT intervention completed a qualitative questionnaire, and 12 participated in in-depth interviews. The findings provide insights into how the context in which the intervention took place, students' need for and expectations about the intervention; and the online format impacted their engagement and perception of its utility. The findings of this study also suggest that, while online GCBT can capitalise on some of the strengths of both digital and in-person approaches to mental health programming, it also suffers from some of the weaknesses of both digital delivery and those associated with in-person therapies.