Evaluation of Feasibility and Acceptability of a Text-Messaging Intervention for Tobacco Cessation in India.

INTRODUCTION: The aim of our study was to assess the feasibility and acceptability of a brief behavioral intervention for tobacco cessation delivered via mobile phone text messaging in India. AIMS AND METHODS: We conducted an uncontrolled intervention cohort study in adult current users of tobacco. The participants received intervention messages on their mobile phones for eight weeks. We collected qualitative data about participants' perceptions of intervention delivery and receipt, acceptability, and feasibility of the intervention. The outcomes measured at 3 months post-recruitment were self-reported 7- and 28-day point-prevalence abstinence, and Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) risk categories for tobacco-low (0-3), moderate (4-26), and high (≥27). RESULTS: We recruited 26 eligible participants, and 22 completed the outcome assessments. The participants generally perceived the intervention content to be simple to access and useful in facilitating a change in tobacco use. None of the participants indicated that they wanted to discontinue receiving the intervention messages. Some suggestions for enhancing acceptability included supplementing text messaging with more intensive counseling and the use of multimedia content. Eighteen percent of participants reported abstinence in the past 7 and 28 days. A greater proportion of those who used smokeless tobacco were abstinent at follow-up compared to those who smoked (42.9% vs. 6.7%; p = .04). CONCLUSIONS: If effective, simple and low-cost mobile phone text messaging can be used to deliver interventions for tobacco use, and has the potential to be scaled up so it can be delivered to populations of smokers interested in receiving cessation support. IMPLICATIONS: Our study is an important step towards the development of a contextually relevant intervention suited for low- and middle-income countries and which is responsive to the needs of both those who use smoked and smokeless tobacco. If found to be effective, our intervention would be a scalable solution to overcome the human resource related barrier to accessing tobacco cessation services in low resource settings.

Text message-based Cessation Intervention for People who Smoked or Used Smokeless Tobacco in India: a Feasibility Randomised Controlled Trial.

INTRODUCTION: Despite the high burden of tobacco use in India, users do not have access to adequate help. This pilot trial aimed to evaluate the feasibility and acceptability of a text messaging intervention for tobacco cessation, generate preliminary estimates of its impact, and fine-tune procedures for a definitive trial. METHODS: Parallel two-arm single blind individually randomised controlled pilot trial with nested qualitative study. Participants included adult current tobacco users (smoked and smokeless). Eligible and consenting participants were randomised to receive either (a) text messaging intervention (ToQuit) which covered specific content areas such as psychoeducation about consequences of tobacco use and benefits of quitting and tobacco avoidance strategies or (b) information about tobacco cessation helplines such as the helpline number and the languages in which tobacco cessation support was available (control). Feasibility data included screening and consent rates, treatment dropouts and outcome ascertainment. The primary abstinence outcome was self-reported abstinence from tobacco in the past seven days at three months post-randomisation. In-depth interviews were conducted with a sub-sample of participants primarily to collect acceptability data. The primary abstinence analysis used a chi-squared test and logistic regression (complete-case), and qualitative data analysed using thematic analysis. RESULTS: Ninety eight participants were randomised into the two trial arms; 77 (79%) completed outcome evaluation. No between-arm differences in abstinence were found though findings favoured the intervention (7-day abstinence: ToQuit 23%, control 19%; adjusted odds ratio 1.23, 95% confidence interval 0.38, 3.97). Participants appreciated the language, comprehensibility, and relevance of the messages; and reported overall satisfaction with and positive impact from the intervention on their lives. CONCLUSION: The findings indicate the acceptability and feasibility of ToQuit and if found effective, it could be a potentially scalable first-line response to tobacco use in low resource settings. IMPLICATIONS: Our pilot RCT provides sufficient findings supporting the acceptability and feasibility of an intervention for tobacco cessation which is suitable for a context which has a shortage of healthcare workers and for individuals who use smoked or smokeless tobacco. This is critical on a background of limited contextually relevant interventions for a problem with a high burden in low- and middle- income countries such as India.

Determinants of alcohol use among young males in two Indian states: A population-based study.

OBJECTIVES: There is insufficient evidence about the determinants of alcohol use amongst young people in India and other low-and middle-income countries, despite alcohol's high contribution to disease burden and increasing consumption in this population. We aimed to identify and estimate the determinants of alcohol use in a representative sample of 2716 young men from Bihar and Uttar Pradesh who participated in the 'Understanding the Lives of Adolescents and Young Adults' (UDAYA) study. METHODS: First, we developed an exploratory conceptual framework of potential alcohol use determinants in the study settings based on available literature. We then estimated the effects of 35 potential alcohol use determinants identified in the conceptual framework (including 14 latent factors identified through exploratory factor analysis) on any alcohol use in the past 3 years and regular alcohol use amongst past three-year drinkers, using mixed-effects logistic models. The determinants explored were operationalised using longitudinal data from the UDAYA study. RESULTS: Our adjusted models identified 18 determinants for past 3-year alcohol use and 12 determinants for regular use. Distal determinants (e.g., socioeconomic status), intermediate determinants (e.g., parental alcohol use, media use), and proximal determinants (e.g., emotional regulation, early tobacco use) were identified. Geographical variations in both outcomes indicate potential differences in unmeasured community-level determinants (e.g., alcohol availability and acceptability). CONCLUSIONS: Our findings extend the generalizability of several known determinants across settings, yet highlight the importance of addressing alcohol use in young people as a complex and context-dependent issue. Many identified determinants (e.g., education, media use, poor parental support, early tobacco use) are amenable to intervention through multi-sectoral prevention programs/policies. Such determinants should be the focus of ongoing policy/intervention development efforts in the region, and our revised conceptual framework may inform further research in India or similar South Asian settings.

Adolescent Health Series: The status of adolescent mental health research, practice and policy in sub-Saharan Africa: A narrative review.

Sub-Saharan Africa (SSA) has the fastest growing adolescent population in the world. In addition to developmental changes, adolescents in SSA face health and socioeconomic challenges that increase their vulnerability to mental ill-health. This paper is a narrative review of adolescent mental health (AMH) in SSA with a focus on past achievements, current developments, and future directions in the areas of research, practice and policy in the region. We describe the status of AMH in the region, critical factors that negatively impact AMH, and the ways in which research, practice and policy have responded to this need. Depression, anxiety and post-traumatic stress disorders are the most common mental health problems among adolescents in SSA. Intervention development has largely been focused on HIV/AIDS service delivery in school or community programs by non-specialist health workers. There is a severe shortage of specialised AMH services, poor integration of services into primary health care, lack of a coordinated inter-sectoral collaboration, and the absence of clear referral pathways. Policies for the promotion of AMH have been given less attention by policymakers, due to stigma attached to mental health problems, and an insufficient understanding of the link between mental health and social determinants, such as poverty. Given these gaps, traditional healers are the most accessible care available to help-seeking adolescents. Sustained AMH research with a focus on the socioeconomic benefits of implementing evidence-based, contextually adapted psychosocial interventions might prove useful in advocating for much needed policies to improve AMH in SSA.

Brief intervention for hazardous drinking delivered using text messaging: a pilot randomised controlled trial from Goa, India.

OBJECTIVE: To evaluate the feasibility and acceptability of a mobile-based brief intervention (BI), generate preliminary estimates of the impact of the BI and fine-tune the procedures for a definitive randomised controlled trial. DESIGN: Parallel three-arm single-blind individually randomised controlled pilot trial. Eligible and consenting participants were randomised to receive mobile-based BI, face-to-face BI and information leaflet. SETTING: Educational institutions, workplaces and primary care centres. PARTICIPANTS: Adult hazardous drinkers. RESULTS: Seventy-four participants were randomised into the three trial arms; forty-eight (64·9 %) completed outcome evaluation. There were no significant differences between the three arms on change in any of the drinking outcomes. There were however in two-way comparisons. Face-to-face BI and mobile BI were superior to active control for percent days heavy drinking at follow-up, and mobile BI was superior to active control for mean grams ethanol consumed per week at follow-up. CONCLUSION: The encouraging findings about feasibility and preliminary impact warrant a definitive trial of our intervention and if found to be effective, our intervention could be a potentially scalable first-line response to hazardous drinking in low-resource settings.

Symptoms of psychological distress reported by women from indigenous communities in South India: implications for methodology and future studies.

'Indigenous peoples' across the globe suffer a disproportionate burden of mental illness. However, this burden is not fully explored in India despite having the second largest absolute concentration of indigenous peoples in the world. We did a secondary analysis of data from a cross-sectional survey in indigenous populations from the Nilgiri Biosphere Reserve in South India. Symptoms suggestive of psychological distress were reported by 39.9% participants. Being alone, tobacco use, hypertension, hypertension in family member, and violent conflict in household were independently associated with psychological distress. More epidemiological studies need to be conducted to map the burden and elaborate the relationships between mental health problems and socio-cultural factors in indigenous populations in India.

"I will not step back": A Qualitative Study of Lay Mental Health Workers' Experiences in India.

A significant treatment gap exists for mental illnesses across the world, particularly in low- and middle-income countries (LMICs). Task-sharing, a potentially scalable strategy to bridge the treatment gap, has been shown to be feasible and effective for the treatment of a range of mental illnesses. However, there is a lack of research examining lay mental health workers' experiences in such task-sharing roles. The aim of our study was to understand the barriers and facilitators that lay health workers (LHWs) face in delivering mental healthcare. We conducted in-depth interviews with 32 lay mental health workers recruited through maximum variation sampling and 18 stakeholders leading mental health programs at a variety of non-governmental organisations across India. Interviews were semi-structured and data was analyzed using the thematic analysis approach. Results showed that LHWs perceived barriers and facilitators at three levels: individually (related to personal characteristics and family support, and in their daily work such as in relationship building and supervision), organizationally (for example, related to compensation), and societally (such as encountering gender discrimination and stigma). Each of these areas should be taken into consideration when planning and implementing task-sharing interventions for mental illnesses. As the first qualitative study to explore broad LHW experiences in mental healthcare delivery in a diverse set of programs from a LMIC, this study shows that LHW voices should be central to program design and decision-making for mental health interventions.

Temporal pathways of change in two randomized controlled trials for depression and harmful drinking in Goa, India.

BACKGROUND: The current study explored the temporal pathways of change within two treatments, the Healthy Activity Program (HAP) for depression and the Counselling for Alcohol Problems (CAP) Program for harmful drinking. METHODS: The study took place in the context of two parallel randomized controlled trials in Goa, India. N = 50 random participants who met a priori criteria were selected from each treatment trial and examined for potential direct and mediational pathways. In HAP, we examined the predictive roles of therapy quality and patient-reported activation, assessing whether activation mediated the effects of therapy quality on depression (Patient Health Questionnaire-9) outcomes. In CAP, we examined the predictive roles of therapy quality and patient change- and counter-change-talk, assessing whether change- or counter-change-talk mediated the effects of therapy quality on daily alcohol consumption. RESULTS: In HAP, therapy quality (both general and treatment-specific skills) was associated with patient activation; patient activation but not therapy quality significantly predicted depression outcomes, and patient activation mediated the effects of higher general skills on subsequent clinical outcomes [a × b = -2.555, 95% confidence interval (CI) -5.811 to -0.142]. In CAP, higher treatment-specific skills, but not general skills, were directly associated with drinking outcomes, and reduced levels of counter-change talk both independently predicted, and mediated the effects of higher general skills on, reduced alcohol consumption (a × b = -24.515, 95% CI -41.190 to -11.060). Change talk did not predict alcohol consumption and was not correlated with counter-change talk. CONCLUSION: These findings suggest that therapy quality in early sessions operated through increased patient activation and reduced counter-change talk to reduce depression and harmful drinking respectively.

The onset and progression of alcohol use disorders: A qualitative study from Goa, India.

Quantitative evidence about the burden of alcohol use disorders (AUDs) needs to be complemented with a nuanced qualitative understanding of explanatory models to help supplement public health strategies that are too often steeped uncritically in biomedical models. The aim of this study was to identify the role of various factors in the onset and persistence of AUD and recovery from AUD. This was a qualitative study nested in a population cohort from Goa, India. In-depth interviews of men with incident, recovered, and persistent AUD covered topics such as changes in drinking habits over time, perceptions and experiences about starting/stopping drinking, and so on. Data were analyzed using thematic analysis. Reasons to begin drinking included social drinking, functional use of alcohol, stress, and boredom. Progression to problematic drinking patterns was characterized by drinking alone, alternating between abstinent and heavy drinking periods, and drinking based on the availability of finances. Some enablers to reduce/stop drinking included consequences of drinking lifestyle and personal resolve; some barriers included availability of alcohol at social events and stress. Some reasons for persisting heavy use of alcohol included lack of family support, physical withdrawal symptoms, peer pressure, stress, and easy availability. This article offers a strong conceptualization and nuanced understanding of AUD across a spectrum of developmental courses. This adds to the limited literature on explanatory models of AUD in India and identifies potential targets for prevention and treatment strategies for AUD in low- and middle-income country settings.

Counselling for Alcohol Problems (CAP), a lay counsellor-delivered brief psychological treatment for harmful drinking in men, in primary care in India: a randomised controlled trial.

BACKGROUND: Although structured psychological treatments are recommended as first-line interventions for harmful drinking, only a small fraction of people globally receive these treatments because of poor access in routine primary care. We assessed the effectiveness and cost-effectiveness of Counselling for Alcohol Problems (CAP), a brief psychological treatment delivered by lay counsellors to patients with harmful drinking attending routine primary health-care settings. METHODS: In this randomised controlled trial, we recruited male harmful drinkers defined by an Alcohol Use Disorders Identification Test (AUDIT) score of 12-19 who were aged 18-65 years from ten primary health centres in Goa, India. We excluded patients who needed emergency medical treatment or inpatient admission, who were unable to communicate clearly, and who were intoxicated at the time of screening. Participants were randomly allocated (1:1) by trained health assistants based at the primary health centres to enhanced usual care (EUC) alone or EUC combined with CAP, in randomly sized blocks of four to six, stratified by primary health centre, and allocation was concealed with use of sequential numbered opaque envelopes. Physicians providing EUC and those assessing outcomes were masked. Primary outcomes were remission (AUDIT score of <8) and mean daily alcohol consumed in the past 14 days, at 3 months. Secondary outcomes were the effect of drinking, disability score, days unable to work, suicide attempts, intimate partner violence, and resource use and costs of illness. Analyses were on an intention-to-treat basis. We used logistic regression analysis for remission and zero-inflated negative binomial regression analysis for alcohol consumption. We assessed serious adverse events in the per-protocol population. This trial is registered with the ISCRTN registry, number ISRCTN76465238. FINDINGS: Between Oct 28, 2013, and July 29, 2015, we enrolled and randomly allocated 377 participants (188 [50%] to the EUC plus CAP group and 190 [50%] to the EUC alone group [one of whom was subsequently excluded because of a protocol violation]), of whom 336 (89%) completed the 3 month primary outcome assessment (164 [87%] in the EUC plus CAP group and 172 [91%] in the EUC alone group). The proportion with remission (59 [36%] of 164 in the EUC plus CAP group vs 44 [26%] of 172 in the EUC alone group; adjusted prevalence ratio 1·50 [95% CI 1·09-2·07]; p=0·01) and the proportion abstinent in the past 14 days (68 [42%] vs 31 [18%]; adjusted odds ratio 3·00 [1·76-5·13]; p<0·0001) were significantly higher in the EUC plus CAP group than in the EUC alone group, but we noted no effect on mean daily alcohol consumed in the past 14 days among those who reported drinking in this period (37·0 g [SD 44·2] vs 31·0 g [27·8]; count ratio 1·08 [0·79-1·49]; p=0·62). We noted an effect on the percentage of days abstinent in the past 14 days (adjusted mean difference [AMD] 16·0% [8·1-24·1]; p<0·0001), but no effect on the percentage of days of heavy drinking (AMD -0·4% [-5·7 to 4·9]; p=0·88), the effect of drinking (Short Inventory of Problems score AMD-0·03 [-1·93 to 1·86]; p=0.97), disability score (WHO Disability Assessment Schedule score AMD 0·62 [-0·62 to 1·87]; p=0·32), days unable to work (no days unable to work adjusted odds ratio 1·02 [0·61-1·69]; p=0.95), suicide attempts (adjusted prevalence ratio 1·8 [-2·4 to 6·0]; p=0·25), and intimate partner violence (adjusted prevalence ratio 3·0 [-10·4 to 4·4]; p=0·57). The incremental cost per additional remission was $217 (95% CI 50-1073), with an 85% chance of being cost-effective in the study setting. We noted no significant difference in the number of serious adverse events between the two groups (six [4%] in the EUC plus CAP group vs 13 [8%] in the EUC alone group; p=0·11). INTERPRETATION: CAP delivered by lay counsellors plus EUC was better than EUC alone was for harmful drinkers in routine primary health-care settings, and might be cost-effective. CAP could be a key strategy to reduce the treatment gap for alcohol use disorders, one of the leading causes of the global burden among men worldwide. FUNDING: Wellcome Trust.

Sustained effectiveness and cost-effectiveness of Counselling for Alcohol Problems, a brief psychological treatment for harmful drinking in men, delivered by lay counsellors in primary care: 12-month follow-up of a randomised controlled trial.

BACKGROUND: Counselling for Alcohol Problems (CAP), a brief intervention delivered by lay counsellors, enhanced remission and abstinence over 3 months among male primary care attendees with harmful drinking in a setting in India. We evaluated the sustainability of the effects after treatment termination, the cost-effectiveness of CAP over 12 months, and the effects of the hypothesized mediator 'readiness to change' on clinical outcomes. METHODS AND FINDINGS: Male primary care attendees aged 18-65 years screening with harmful drinking on the Alcohol Use Disorders Identification Test (AUDIT) were randomised to either CAP plus enhanced usual care (EUC) (n = 188) or EUC alone (n = 189), of whom 89% completed assessments at 3 months, and 84% at 12 months. Primary outcomes were remission and mean standard ethanol consumed in the past 14 days, and the proposed mediating variable was readiness to change at 3 months. CAP participants maintained the gains they showed at the end of treatment through the 12-month follow-up, with the proportion with remission (AUDIT score < 8: 54.3% versus 31.9%; adjusted prevalence ratio [aPR] 1.71 [95% CI 1.32, 2.22]; p < 0.001) and abstinence in the past 14 days (45.1% versus 26.4%; adjusted odds ratio 1.92 [95% CI 1.19, 3.10]; p = 0.008) being significantly higher in the CAP plus EUC arm than in the EUC alone arm. CAP participants also fared better on secondary outcomes including recovery (AUDIT score < 8 at 3 and 12 months: 27.4% versus 15.1%; aPR 1.90 [95% CI 1.21, 3.00]; p = 0.006) and percent of days abstinent (mean percent [SD] 71.0% [38.2] versus 55.0% [39.8]; adjusted mean difference 16.1 [95% CI 7.1, 25.0]; p = 0.001). The intervention effect for remission was higher at 12 months than at 3 months (aPR 1.50 [95% CI 1.09, 2.07]). There was no evidence of an intervention effect on Patient Health Questionnaire 9 score, suicidal behaviour, percentage of days of heavy drinking, Short Inventory of Problems score, WHO Disability Assessment Schedule 2.0 score, days unable to work, or perpetration of intimate partner violence. Economic analyses indicated that CAP plus EUC was dominant over EUC alone, with lower costs and better outcomes; uncertainty analysis showed a 99% chance of CAP being cost-effective per remission achieved from a health system perspective, using a willingness to pay threshold equivalent to 1 month's wages for an unskilled manual worker in Goa. Readiness to change level at 3 months mediated the effect of CAP on mean standard ethanol consumption at 12 months (indirect effect -6.014 [95% CI -13.99, -0.046]). Serious adverse events were infrequent, and prevalence was similar by arm. The methodological limitations of this trial are the susceptibility of self-reported drinking to social desirability bias, the modest participation rates of eligible patients, and the examination of mediation effects of only 1 mediator and in only half of our sample. CONCLUSIONS: CAP's superiority over EUC at the end of treatment was largely stable over time and was mediated by readiness to change. CAP provides better outcomes at lower costs from a societal perspective. TRIAL REGISTRATION: ISRCTN registry ISRCTN76465238.

Sustained effectiveness and cost-effectiveness of the Healthy Activity Programme, a brief psychological treatment for depression delivered by lay counsellors in primary care: 12-month follow-up of a randomised controlled trial.

BACKGROUND: The Healthy Activity Programme (HAP), a brief behavioural intervention delivered by lay counsellors, enhanced remission over 3 months among primary care attendees with depression in peri-urban and rural settings in India. We evaluated the sustainability of the effects after treatment termination, the cost-effectiveness of HAP over 12 months, and the effects of the hypothesized mediator of activation on clinical outcomes. METHODS AND FINDINGS: Primary care attendees aged 18-65 years screened with moderately severe to severe depression on the Patient Health Questionnaire 9 (PHQ-9) were randomised to either HAP plus enhanced usual care (EUC) (n = 247) or EUC alone (n = 248), of whom 95% completed assessments at 3 months, and 91% at 12 months. Primary outcomes were severity on the Beck Depression Inventory-II (BDI-II) and remission on the PHQ-9. HAP participants maintained the gains they showed at the end of treatment through the 12-month follow-up (difference in mean BDI-II score between 3 and 12 months = -0.34; 95% CI -2.37, 1.69; p = 0.74), with lower symptom severity scores than participants who received EUC alone (adjusted mean difference in BDI-II score = -4.45; 95% CI -7.26, -1.63; p = 0.002) and higher rates of remission (adjusted prevalence ratio [aPR] = 1.36; 95% CI 1.15, 1.61; p < 0.009). They also fared better on most secondary outcomes, including recovery (aPR = 1.98; 95% CI 1.29, 3.03; p = 0.002), any response over time (aPR = 1.45; 95% CI 1.27, 1.66; p < 0.001), higher likelihood of reporting a minimal clinically important difference (aPR = 1.42; 95% CI 1.17, 1.71; p < 0.001), and lower likelihood of reporting suicidal behaviour (aPR = 0.71; 95% CI 0.51, 1.01; p = 0.06). HAP plus EUC also had a marginal effect on WHO Disability Assessment Schedule score at 12 months (aPR = -1.58; 95% CI -3.33, 0.17; p = 0.08); other outcomes (days unable to work, intimate partner violence toward females) did not statistically significantly differ between the two arms. Economic analyses indicated that HAP plus EUC was dominant over EUC alone, with lower costs and better outcomes; uncertainty analysis showed that from this health system perspective there was a 95% chance of HAP being cost-effective, given a willingness to pay threshold of Intl$16,060-equivalent to GDP per capita in Goa-per quality-adjusted life year gained. Patient-reported behavioural activation level at 3 months mediated the effect of the HAP intervention on the 12-month depression score (ß = -2.62; 95% CI -3.28, -1.97; p < 0.001). Serious adverse events were infrequent, and prevalence was similar by arm. We were unable to assess possible episodes of remission and relapse that may have occurred between our outcome assessment time points of 3 and 12 months after randomisation. We did not account for or evaluate the effect of mediators other than behavioural activation. CONCLUSIONS: HAP's superiority over EUC at the end of treatment was largely stable over time and was mediated by patient activation. HAP provides better outcomes at lower costs from a perspective covering publicly funded healthcare services and productivity impacts on patients and their families. TRIAL REGISTRATION: ISRCTN registry ISRCTN95149997.

Trajectories of Alcohol Use Disorders and Their Differential Impact: A Population-Based Cohort Study in Goa, India.

AIMS: The aim of this study was to examine trajectories of Alcohol Use Disorders (AUD) over a 6 year period and compare the bio-psycho-social correlates between these trajectories. METHODS: Community-based cohort of 1899 adult men were interviewed in 2006-2008 and 2012-2014. AUD were assessed using the Alcohol Use Disorder Identification Test, and potential correlates including psycho-social problems, morbidity and physiological parameters were measured at follow-up. Logistic regression was conducted to estimate odds ratios (ORs) for the association of persistent and incident AUD, respectively, with the potential correlates. Analyses were weighted to account for sampling design, number of adults aged 18-49 years in the household and non-response. RESULTS: Compared with men who had recovered from AUD, there was strong evidence (P < 0.001) that men with persistent AUD were more likely to have marital problems, tobacco use, and raised Gamma Glutamyl Transferase (GGT) and strong evidence (0.001 < P < 0.01) that they were more likely to have workplace problems, social problems, increased healthcare contact and raised Mean Corpuscular Volume (MCV). Compared with men who did not have AUD at baseline and follow-up, there was strong evidence (P < 0.001) that men with incident AUD were more likely to have workplace problems, social problems, marital problems, tobacco use, and raised GGT and strong evidence (0.001 < P < 0.01) that they were more likely to have hypertension, accident and injuries and Common Mental Disorders (CMD). CONCLUSION: This community-based longitudinal study of AUD, the first from a low and middle income country, clearly demonstrates significant health and social consequences of AUD in men and highlights the need for interventions for their treatment and prevention. SHORT SUMMARY: Compared to persistent AUD, recovery from AUD has several benefits in health and social domains. Compared to developing new AUD, not having AUD has several benefits in health and social domains. Sustaining the state of not having AUD or recovery can lead to accumulation of health and social capital over time.

The systematic development and pilot randomized evaluation of counselling for alcohol problems, a lay counselor-delivered psychological treatment for harmful drinking in primary care in India: the PREMIUM study.

BACKGROUND: Despite harmful drinking causing a significant burden on global health, there is a large treatment gap, especially in low- and middle-income countries. A major barrier to care is the lack of adequately skilled human resources to deliver contextually appropriate treatments. This paper describes the systematic process used to develop Counselling for Alcohol Problems (CAP), a brief psychological treatment (PT) for delivery by lay counselors in routine primary care settings to men with harmful drinking in India. METHODS: CAP was developed using a methodology involving 3 sequential steps: (i) identifying potential treatment strategies; (ii) developing a theoretical framework for the treatment; and (iii) evaluating the acceptability and feasibility of the treatment. RESULTS: CAP is a 3-phase treatment delivered over 1 to 4 sessions based on a motivational interviewing (MI) stance and involves the following strategies: assessment and personalized feedback, family engagement, drink refusal skills, skills to address drinking urges, problem-solving skills and handling difficult emotions, and relapse prevention and management. Data from a case series were used to inform several adaptations to enhance the acceptability of CAP to the recipients and feasibility of delivery by lay counselors of the treatment, for example expansion of the target group to include alcohol-dependent patients and the extension of the delivery settings to include home-based delivery. There was preliminary evidence of the effectiveness of CAP. CONCLUSIONS: CAP is an acceptable brief PT for harmful drinking delivered by lay counselors in primary care whose effectiveness is currently being tested in a randomized controlled trial based in primary care in Goa, India.

Barriers and facilitators to the implementation of mental health and psychosocial support programmes following natural disasters in developing countries: A systematic review.

Climate change is leading to more frequent and intense natural disasters, with developing countries particularly at risk. However, most research concerning mental health and natural disasters is based in high-income country settings. It is critically important to provide a mental health response to such events, given the negative psychosocial impacts they elicit. The aim of this systematic review is to explore the barriers and facilitators to implementing mental health and psychosocial support (MHPSS) following natural disasters in developing countries. Eight databases were searched for relevant quantitative and qualitative studies from developing countries. Only studies reporting barriers and/or facilitators to delivering MHPSS in response to natural disasters in a low- or middle-income country were included and full texts were critically appraised using the McGill University Mixed Methods Appraisal Tool. Reported barriers and facilitators were extracted and analysed thematically. Thirty-seven studies were included in the review, reflecting a range of natural disaster settings and developing countries. Barriers to implementing MHPSS included cultural relevance, resources for mental health, accessibility, disaster specific factors and mental health stigma. Facilitators identified included social support, cultural relevance and task-sharing approaches. A number of practical approaches can be used to facilitate the implementation of MHPSS in developing country settings. However, more research is needed on MHPSS in the developing country natural disaster context, especially in Africa, and international policies and guidelines need to be re-evaluated using a decolonial lens.

Unpacking the 'black box' of suicide: A latent class analysis predicting profiles of suicidal ideation in a longitudinal cohort of adolescent girls from India.

INTRODUCTION: Indian women account for 37% of global suicide-related deaths. As suicide is a growing concern among adolescent girls, identifying the social determinants of suicide with this group targeted prevention. We selected social determinants that include intersectional identities and broader syndemics; we then used longitudinal data from a prospective cohort of adolescent girls from Northern India to classify them into unique profiles across multiple socioecological levels. METHODS: Girls aged 10-19 (N = 11,864) completed self-report questionnaires measuring socio-demographic and trauma exposure variables. At three-year follow-up, they were asked to indicate current suicidal ideation (SI). We conducted latent class analysis (LCA) to classify profiles and then predicted risk of current SI at three-year follow-up. RESULTS: LCA supported a four-class solution: a 'privileged' class (Class 1; n = 1,470), a 'modal' class (Class 2; n = 7,449), an 'intergenerational violence' class (Class 3; n = 2,113), and a 'psychological distress' class (Class 4; n = 732). Classes significantly predicted odds ratios (OR) for SI at follow up; women in Class 4 were associated with the greatest likelihood of SI (OR 1.84, 95% CI 1.38, 2.47), suggesting that psychological distress factors confer greatest risk. CONCLUSION: Results of the distinct classes of risk and protective factors indicate targets for policy-level interventions. Disrupting cycles of psychological distress and substance use, increasing access to behavioral interventions, and intervening to mitigate intergenerational violence may be particularly impactful with this population.

A systematic review of task-sharing interventions for substance use and substance use disorder in low- and middle-income countries.

INTRODUCTION: Substance use (SU) and substance use disorders (SUDs) are associated with adverse health and socio-economic consequences. Due to the shortage of specialist healthcare providers, people with SUDs in low- and middle-income countries (LMICs) have limited access to adequate treatment. Task-sharing with non-specialist health workers (NSHWs) has the potential to improve treatment accessibility for these individuals. This review synthesizes the evidence on the effectiveness of task-sharing interventions for SU and SUDs outcomes in LMICs. METHODS: PsycINFO, MEDLINE, EMBASE, Global Health and CENTRAL databases were searched to identify eligible studies. Quality assessment was conducted using the Cochrane risk of bias (RoB2) and Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool. A narrative synthesis was undertaken to analyze the data. RESULTS: Nineteen RCTs and two quasi-experimental studies met the eligibility criteria, and the majority had a low risk of bias rating. NSHW-delivered interventions significantly impact SU and SUDs outcomes, particularly in reducing alcohol and other substance use, cessation of smoking, and use of opioids. Multiple sessions delivered via face-to-face interactions was the most utilized method for intervention delivery. There were variations in terms of components of the intervention across studies; however, the most common intervention strategies used were a) personalized feedback, b) psychoeducation, c) motivational enhancement, d) problem-solving, and e) coping skills. CONCLUSION: Our review highlights the growing interests in leveraging NSHWs to provide interventions to people with SU and SUDs in LMICs where access to treatment is limited. However, additional research is necessary to explore the effectiveness of these interventions and identify the specific active components linked to enhancing treatment outcomes on a broader scale.

Erratum: Scaling up the task-sharing of psychological therapies: A formative study of the PEERS smartphone application for supervision and quality assurance in rural India - CORRIGENDUM.

[This corrects the article DOI: 10.1017/gmh.2024.11.].

Scaling up the task-sharing of psychological therapies: A formative study of the PEERS smartphone application for supervision and quality assurance in rural India.

Measurement-based peer supervision is one strategy to assure the quality of psychological treatments delivered by non-mental health specialist providers. In this formative study, we aimed to 1) describe the development and 2) examine the acceptability and feasibility of PEERS (Promoting Effective mental healthcare through peER Supervision)-a novel smartphone app that aims to facilitate registering and scheduling patients, collecting patient outcomes, rating therapy quality and assessing supervision quality-among frontline treatment providers delivering behavioral activation treatment for depression. The PEERS prototype was developed and tested in 2021, and version 1 was launched in 2022. To date, 215 treatment providers (98% female; ages 30-35) in Madhya Pradesh and Goa, India, have been trained to use PEERS and 65.58% have completed the supplemental, virtual PEERS course. Focus group discussions with 98 providers were examined according to four themes-training and education, app effectiveness, user experience and adherence and data privacy and safety. This yielded commonly endorsed facilitators (e.g., collaborative learning through group supervision, the convenience of consolidated patient data), barriers (e.g., difficulties with new technologies) and suggested changes (e.g., esthetic improvements, suicide risk assessment prompt). The PEERS app has the potential to scale measurement-based peer supervision to facilitate quality assurance of psychological treatments across contexts.

Using theory of change to plan for the implementation of a psychological intervention addressing alcohol use disorder and psychological distress in Uganda.

In conflict-affected settings, prevalence of alcohol use disorders (AUDs) can be high. However, limited practical information exists on AUD management in low-income settings. Using a theory of change (ToC) approach, we aimed to identify pathways influencing the implementation and maintenance of a new transdiagnostic psychological intervention ("CHANGE"), targeting both psychological distress and AUDs in humanitarian settings. Three half-day workshops in Uganda engaged 41 stakeholders to develop a ToC map. ToC is a participatory program theory approach aiming to create a visual representation of how and why an intervention leads to specific outcomes. Additionally, five semi-structured interviews were conducted to explore experiences of stakeholders that participated in the ToC workshops. Two necessary pathways influencing the implementation and maintenance of CHANGE were identified: policy impact, and mental health service delivery. Barriers identified included policy gaps, limited recognition of social determinants and the need for integrated follow-up care. Interviewed participants valued ToC's participatory approach and expressed concerns about its adaptability in continuously changing contexts (e.g., humanitarian settings). Our study underscores ToC's value in delineating context-specific outcomes and identifies areas requiring further attention. It emphasizes the importance of early planning and stakeholder engagement for sustainable implementation of psychological interventions in humanitarian settings.