Advancing sustainable implementation of an evidence-based mental health intervention in Sierra Leone's schools: protocol for a hybrid type 3 implementation-effectiveness trial.

BACKGROUND: Mental health disorders among youth contribute substantially to the global burden of disease, which is exacerbated in low- and middle-income countries (LMICs) due to large mental health treatment gaps. In Sierra Leone, a West African country with a long history of complex adversity, the mental health treatment gap is estimated at 98%. Implementing innovative mental health interventions that can be sustained at scale is a priority. The Youth Readiness Intervention (YRI) is an evidence-based mental health intervention for youth that can be delivered feasibly by lay health workers/nonspecialists. Using mobile-based technologies to assist implementation could improve the reach and sustainability of the YRI in Sierra Leone. This study aims to train teachers to deliver the YRI in Sierra Leone's secondary schools and test the feasibility, acceptability, cost, and fidelity to the YRI of a mobile-based supervision model compared with standard, in-person supervision. METHODS: We will conduct a hybrid type 3 implementation-effectiveness cluster randomized trial to assess the feasibility, acceptability, costs and fidelity to the YRI implemented by teachers receiving mobile-based supervision vs. standard supervision. Enrolled schools (N = 50) will be randomized to YRI + mobile supervision (N = 20), YRI + standard supervision (N = 20) or waitlist control (N = 10). We will recruit and enroll four teachers per intervention-condition school (N = 160) and 1200 youth. We will collect data on implementation outcomes among teachers, principals and youth via a mixed methods approach at baseline and post-intervention. We will also collect quantitative data on youth mental health and functioning as secondary outcomes at baseline and post-intervention, as well as cost-effectiveness data at 12-month follow-up. DISCUSSION: Study findings have the potential to expand the reach of mental health services among youth in low-resource settings via a teacher workforce. The use of mobile tools, if successful, could support further scale out and sustainment of the YRI to other regions of Sierra Leone and West Africa more broadly, which could help address the mental health treatment gap. TRIAL REGISTRATION: Clinical Trial Network: NCT05737667.

The feasibility and acceptability of Project POWER: a mindfulness-infused, cognitive-behavioral group intervention to address mental and sexual health needs of young pregnant women in Liberia.

BACKGROUND: Following 14 years of civil war in Liberia, war exposure, gender-based violence, and extreme poverty have been identified as key challenges affecting the mental and sexual health of young pregnant women and the health of their unborn children. Despite ongoing efforts to rebuild the country's healthcare infrastructure, empirical and culturally tailored interventions to address the consequences of war are severely limited. To address these concerns, we developed Project POWER (Progressing Our Well-being, Emotions, and Relationships), a mindfulness-infused, cognitive-behavioral intervention for young adult pregnant women. This study sought to 1) assess the feasibility and acceptability of POWER and 2) determine the preliminary efficacy of POWER for improving mental and sexual health outcomes among Liberian war-exposed young adult pregnant women. METHODS: Eighty-seven women aged 18-25 were recruited from three catchment areas in Monrovia, Liberia to participate in a two-condition, pre-post design quasi-experimental pilot trial. Participants were allocated to the intervention (POWER) or the control condition (a health education program) based on where they resided relative to the catchment areas. Each condition completed a ten-session program delivered over 5-weeks. Feasibility and acceptability of POWER were examined using program logs (e.g., the number of participants screened and enrolled, facilitator satisfaction, etc.) and data from an end-of-program exit interview. The preliminary efficacy of POWER on mental and sexual health outcomes was assessed using repeated measures ANOVA with time and condition as factors. RESULTS: Analyses provided preliminary support for the feasibility and acceptability of POWER. Participants attended an average of 8.99 sessions out of 10 and practiced material outside the sessions at least 2.77 times per week. Women in both conditions showed significant reductions in the level of prenatal distress (baseline, M = 16.84, 3-month assessment, M = 12.24), severity of post-traumatic stress disorder (PTSD) symptoms (baseline, M = 11.97, 3-month assessment, M = 9.79),), and the number of transactional sexual behaviors (baseline, M = 1.37, 3-month assessment, M = .94) over time. Participants who received POWER showed significant reductions in the frequency of depressive symptoms (baseline, M = 5.09, 3-month assessment, M = 2.63) over women in the control condition. CONCLUSIONS: Findings suggest that POWER may be a feasible and acceptable intervention to promote mental and sexual health for young adult pregnant women in Liberia. However, fully powered clinical trials are still needed to determine the efficacy and effectiveness of POWER before recommending its use on a larger scale in Liberia.

Classifying childhood war trauma exposure: latent profile analyses of Sierra Leone's former child soldiers.

BACKGROUND: Former child soldiers are at elevated risk for mental health problems (e.g., traumatic stress, emotion dysregulation, and internalizing and externalizing problems). To examine which groups of former child soldiers are more likely to have difficulties with emotion regulation, interpersonal relationships, and mental health postconflict, we explored patterns of war trauma exposure and their effects on subsequent mental health problems among former child soldiers in Sierra Leone. METHODS: Participants were 415 (23.86% female) Sierra Leonean former child soldiers participating in a 15-year, four-wave longitudinal study. At T1 (2002), 282 former child soldiers (aged 10-17) were recruited. T2 (2004) included 186 participants from T1 and an additional cohort of self-reintegrated former child soldiers (NT2 = 132). T3 (2008) and T4 (2016/2017) participants were youth enrolled in previous waves (NT3 = 315; NT4 = 364). Latent profile analysis (LPA) was used to classify participants based on the first-time reports of eight forms of war exposure (separation and loss of assets, parental loss, loss of loved ones, witnessing violence, victimization, perpetrating violence, noncombat activities, and deprivation). ANOVA examined whether patterns of war exposure were associated with sociodemographic characteristics and mental health outcomes between T1 and T4. RESULTS: LPA identified two profiles: higher exposure versus lower exposure, using cumulative scores of eight forms of war-related trauma exposure. The 'higher war exposure' group comprised 226 (54.5%) former child soldiers and the 'lower war exposure' group included 189 (45.5%). Significantly higher levels of violence-related and combat experiences characterized the group exposed to more traumatic events. The 'higher war exposure' group reported more PTSD symptoms at T2, more hyperarousal symptoms across all waves, and more difficulties in emotion regulation at T4. CONCLUSIONS: Former child soldiers exposed to higher levels of war-related traumatic events and loss should be prioritized for mental health services immediately postconflict and as they transition into adulthood.

Diffusion and spillover effects of an evidence-based mental health intervention among peers and caregivers of high risk youth in Sierra Leone: study protocol.

BACKGROUND: Evidence-based mental health interventions have helped address health services gaps, but their reach and societal benefit can be limited in low resource settings. The current study extends an ongoing scale-up study of a cognitive behavioral therapy (CBT)-based intervention, the Youth Readiness Intervention (YRI), among high risk youth in post-conflict Sierra Leone to investigate mechanisms of diffusion and spillover effects of the YRI among peers and caregivers of youth who receive the intervention. METHODS: We will recruit and enroll YRI index participants and control index participants (ages 18-30). Index participants will complete a standardized ego-network survey to nominate three peers in their social networks and identify their primary cohabitating caregiver. Identified peers and caregivers who consent to participate will complete a quantitative assessment battery on mental health outcomes, emotion regulation, and daily functioning at baseline and 8-month follow-up. Study outcomes also incorporate common indicators for implementation science, including measures of project context, evaluation, and scaleup. Social network analysis will investigate diffusion of YRI components across peer networks. Linear growth modeling will examine mental health spillover effects among caregivers. Incremental health costs and benefits among YRI participants' caregivers and peers will be assessed through cost-effectiveness and return on investment analysis. DISCUSSION: Assessing implementation research outcomes, including penetration of YRI effects across social networks and cost-effectiveness of the YRI as distinct outcomes, will provide key information about the success of YRI implementation. Lessons learned could inform decisions to increase scale up efforts in Sub-Saharan Africa and other low resource settings.

A systematic review of sexual and reproductive health interventions for young people in humanitarian and lower-and-middle-income country settings.

BACKGROUND: Accessibility of sexual and reproductive health (SRH) services in many lower-and-middle-income countries (LMICs) and humanitarian settings remains limited, particularly for young people. Young people facing humanitarian crises are also at higher risk for mental health problems, which can further exacerbate poor SRH outcomes. This review aimed to explore, describe and evaluate SRH interventions for young people in LMIC and humanitarian settings to better understand both SRH and psychosocial components of interventions that demonstrate effectiveness for improving SRH outcomes. METHODS: We conducted a systematic review of studies examining interventions to improve SRH in young people in LMIC and humanitarian settings following Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) standards for systematic reviews. Peer-reviewed journals and grey literature from January 1, 2000 to December 31, 2018 were included. Two authors performed title, abstract and full-text screening independently. Data was extracted and analyzed using a narrative synthesis approach and the practice-wise clinical coding system. RESULTS: The search yielded 813 results, of which 55 met inclusion criteria for full-text screening and thematic analysis. Primary SRH outcomes of effective interventions included: contraception and condom use skills, HIV/STI prevention/education, SRH knowledge/education, gender-based violence education and sexual self-efficacy. Common psychosocial intervention components included: assertiveness training, communication skills, and problem-solving. CONCLUSIONS: Findings suggest that several evidence-based SRH interventions may be effective for young people in humanitarian and LMIC settings. Studies that use double blind designs, include fidelity monitoring, and focus on implementation and sustainability are needed to further contribute to this evidence-base.

Social media photos of substance use and their relationship to attitudes and behaviors among ethnic and racial minority emerging adult men living in low-income areas.

OBJECTIVES: Emerging adult minority males have inequitable negative consequences from substance abuse. They are also frequent users of social media, logging into popular sites up to 25 times per week on average, so there may be opportunities to use these technologies for better understanding and preventing substance use behaviors. Through mobile phone monitoring, this study examined how social media sites are used to post substance use-related images and how posting such images is related to behaviors and attitudes. It also explored how self-presentation of masculinity norms, such as coolness and toughness, was related to posting of substance use-related photos. METHODS: Instagram and/or Twitter posts of 65 minority males aged 18-25 living in low-income areas were monitored for three months using phone tracking software. Over 2200 posted images were content analyzed to determine if they were related to alcohol or marijuana and if they displayed masculinity norms. Behavioral interviewing was also used to examine alcohol and marijuana attitudes, use, and problematic use. Analyses utilized t-tests and multiple and logistic regression. RESULTS: Many participants posted at least one substance use-related photo and a strong majority were exposed to such images through their network. Individuals who posted substance use-related images had more "followers." Posting substance-use related photos was related to marijuana use attitudes, behaviors, and problem behaviors, as well as depictions of toughness in photos. CONCLUSIONS: Social media monitoring has potential for use in identifying individuals at-risk for substance abuse and those who may be perpetuating unhealthy substance use norms.

Romantic partner influences on prenatal and postnatal substance use in young couples.

BACKGROUND: Alcohol, tobacco and other drug use (ATOD) among adolescent and young adult couples during prenatal and postnatal periods is a significant public health problem, and couples may mutually influence each others' ATOD behaviors. PURPOSE: The current study investigated romantic partner influences on ATOD among adolescent and young adult couples during pregnancy and postnatal periods. METHODS: Participants were 296 young couples in the second or third trimester of pregnancy recruited from OBGYN clinics between July 2007 and February 2011. Participants completed questionnaires at prenatal, 6 months postnatal, and 12 months postnatal periods. Dyadic data analysis was conducted to assess the stability and interdependence of male and female ATOD over time. RESULTS: Male partner cigarette and marijuana use in the prenatal period significantly predicted female cigarette and marijuana use at 6 months postnatal (b = 0.14, P < 0.01; b = 0.11, P < 0.05, respectively). Male partner marijuana use at 6 months postnatal also significantly predicted female marijuana use at 12 months postnatal (b = 0.11, P < 0.05). Additionally, significant positive correlations were found for partner alcohol and marijuana at pre-pregnancy and 6 months postnatal, and partner cigarette use at pre-pregnancy, 6 months and 12 months postnatal. CONCLUSIONS: Partner ATOD among young fathers, particularly during the prenatal period, may play an important role in subsequent ATOD among young mothers during postnatal periods.

Exploring Trajectories and Predictors of Depressive Symptoms Among Young Couples During Their Transition to Parenthood.

Objectives Young parents may be particularly vulnerable to poor mental health during the postpartum period. Little research exists, however, to adequately describe trajectories of depressive symptoms during their transition to parenthood, particularly among young fathers. Therefore, we aim to explore trajectories of depressive symptoms from pregnancy through 1 year postpartum among young expectant mothers and their partners. Methods Data are derived from a longitudinal cohort of pregnant adolescent females (ages 14-21; n = 220) and their male partners (n = 190). Multilevel regression models examined the impact of time on depressive symptoms, and generalized linear regression models examined predictors of experiencing elevated depressive symptoms. Results Depressive symptoms significantly decreased from pregnancy through 1 year postpartum among young females. Overall, depressive symptoms did not significantly change over time among young males. Predictors of elevated depressive symptoms common across genders included social support and relationship satisfaction. Marijuana use resulted in almost twice the odds of experiencing elevated depressive symptoms among young fathers (OR 1.82; 95 % CI 1.04, 3.20). Conclusion for Practice Providing strategies for strengthening social support networks among young parents may be an effective way to improve mental health among young parents, particularly during this period of potential social isolation. Additionally, providing tools to strengthen relationships between partners may also be effective for both young mothers and fathers. Substance use may be a marker for depressive symptoms among young fathers and thus screening for substance use could be important to improving their mental health. Future research is needed to better understand how IPV affects mental health, particularly among young fathers.

Emotion Expression and Substance Use in Newly Parenting Adolescents and Young Adults.

OBJECTIVE: Deficits in emotion expression skills have been associated with alcohol and substance use, but the mechanisms through which these associations occur are not well understood. The current study investigated (a) associations between emotion expression and substance use (i.e., alcohol, cigarettes, and marijuana) in newly parenting adolescents and young adults and (b) whether symptoms of depression and stress mediate these associations in young mothers and fathers. METHODS: Participants recruited from obstetrics and gynecology clinics completed the Center for Epidemiological Studies-Depression Scale, Perceived Stress Scale, Emotion Expression Scale for Children, and substance use items. RESULTS: Path analysis indicated that lower emotion expression at 6 months postpartum was significantly associated with more alcohol and marijuana use at 12 months postpartum for males but not females. Also among males, stress levels at 6 months postpartum partially mediated associations between emotion expression and alcohol and marijuana use at 12 months postpartum. CONCLUSIONS: Findings suggest that poor emotion expression skills are related to more substance use in young fathers, and levels of stress may partially account for this association.

"Love hurts": romantic attachment and depressive symptoms in pregnant adolescent and young adult couples.

OBJECTIVE: The current study investigates the relationship between romantic attachment style and depressive symptoms between both members of pregnant adolescent and young adult couples. METHOD: Participants were 296 pregnant young females (mean age = 18.7) and their male partners (mean age = 21.3; 592 total participants) who were recruited from obstetrics and gynecology clinics in Connecticut. The dimensions of avoidant and anxious romantic attachment were assessed using the Experiences in Close Relationships Inventory. Depressive symptoms were measured using the Center for Epidemiological Studies-Depression Scale. RESULTS: Results showed that avoidant attachment and anxious attachment were significantly positively related to depressive symptoms. Multilevel modeling for partner effects revealed that anxious attachment and depressive symptoms in partners were significantly positively associated with depressive symptoms CONCLUSION: Findings underscore the importance of considering couples-based approaches to supporting the transition to parenthood and developing the necessary self and relationship skills to manage attachment needs and relationship challenges.

The adaptation of a youth mental health intervention to a peer-delivery model utilizing CBPR methods and the ADAPT-ITT framework in Sierra Leone.

Low- and middle-income countries (LMICs) carry a significant proportion of the global burden of untreated mental health disorders. Peer-delivered programs offer LMICs with limited mental health professionals an opportunity to increase mental health service access. This study describes the process of adapting a lay-worker-delivered evidence-based youth mental health intervention to a peer-delivery model in Sierra Leone using participatory methods. We convened Youth Community Advisory Boards (YCABs) as partners to develop a peer-delivery model for an evidence-based intervention. In collaboration with YCABs, the Assessment, Decision, Administration, Production, Topical experts, Integration, Training, Testing (ADAPT-ITT) framework was applied to guide the adaptation. The ADAPT-ITT framework is an eight-step process to adapt evidence-based interventions. The ADAPT-ITT framework facilitated the adaptation of the Youth Readiness Intervention (YRI), an evidence-based mental health program intervention that has been delivered by adult lay-workers to the youth peer-delivery platform in Sierra Leone. The YCABs identified program modifications, including the incorporation of storytelling, refinement of metaphors, and alterations to make delivery more accessible to low-literacy youth with particular attention to gender. YCABs also provided recommendations on how to support youth facilitators in providing psychosocial support, emphasizing self-care and boundary setting to ensure high-quality intervention delivery and do-no-harm principles. Study findings suggest that the ADAPT-ITT framework can be feasibly applied to guide the intervention adaptation process in LMICs. The use of participatory methods generated modifications that reflected youth experiences, needs, and concerns as facilitators and participants. Next steps include refinement and pilot testing of the adapted intervention.

Integrating Youth Readiness Intervention and Entrepreneurship in Sierra Leone: A Hybrid Type II Cluster Randomized Trial.

OBJECTIVE: Conflict-affected youth are at risk for poor psychological and social outcomes, yet few receive mental health services. Strategies to expand access and sustain evidence-based interventions (EBIs) across novel delivery platforms must be tested. The present study was a hybrid type II implementation-effectiveness trial using a cluster randomized design. The primary goal was to evaluate feasibility and impact of using the collaborative team approach to deliver the Youth Readiness Intervention (YRI), an EBI, integrated into a youth entrepreneurship program (ENTR) with quality control in post-conflict Sierra Leone. METHOD: Youth were screened and randomly assigned to control, ENTR, or combined YRI and ENTR (YRI+ENTR). Implementation outcomes were dissemination and implementation indicators, competence, and fidelity. Effectiveness outcomes were emotion regulation, psychological distress, and interpersonal functioning. Secondary outcomes were third-party reporter assessments of youth functioning and behavior. RESULTS: Data were collected and analyzed from 1,151 youth participants and 528 third-party reporters. Scores on implementation constructs, competence, and fidelity demonstrated acceptable intervention response and quality. YRI+ENTR participants showed overall improvements in depression (ß = -.081, 95% CI -0.124 to -0.038, d = -0.154) and anxiety (ß = -.043, 95% CI -0.091 to -0.005, d = 0.082) symptoms compared with control participants. Community leaders indicated that YRI+ENTR participants demonstrated improvements in overall work or training performance compared with control participants (ß = -.114, 95% CI 0.004 to 0.232, d = 0.374). CONCLUSION: Integration of EBIs such as the YRI into youth employment programs has the potential to address limited reach of EBIs in conflict and post-conflict settings. A collaborative team implementation approach can facilitate integration and fidelity. PLAIN LANGUAGE SUMMARY: In a Hybrid Type-II Implementation-Effectiveness trial conducted in Sierra Leone, researchers tested a Collaborative Team Approach (CTA) for delivering an evidence-based mental health intervention, the Youth Readiness Intervention (YRI), within a youth entrepreneurship program. A total of 1,151 youth participated in the study, with outcomes measured on youth mental health indicators of emotional regulation, psychological distress, and interpersonal functioning, as well as implementation indicators, competence, and fidelity. Results demonstrated that the integrated YRI and entrepreneurship program led to significant improvements in depression and anxiety symptoms compared to the control group. Community leaders also noted enhanced overall performance in YRI participants, suggesting that integrating evidence-based interventions into youth employment programs can effectively address mental health challenges in low-resource regions. DIVERSITY & INCLUSION STATEMENT: We worked to ensure sex and gender balance in the recruitment of human participants. We worked to ensure that the study questionnaires were prepared in an inclusive way. We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented sexual and/or gender groups in science. We actively worked to promote sex and gender balance in our author group. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group. The author list of this paper includes contributors from the location and/or community where the research was conducted who participated in the data collection, design, analysis, and/or interpretation of the work. One or more of the authors of this paper received support from a program designed to increase minority representation in science. CLINICAL TRIAL REGISTRATION INFORMATION: Youth FORWARD Phase 2 YRI and EPP Study; https://clinicaltrials.gov/; NCT03542500. STUDY PREREGISTRATION INFORMATION: Youth Functioning and Organizational Success for West African Regional Development (Youth FORWARD): Study Protocol; https://doi.org/10.1176/appi.ps.202000009.

Mindfulness and emotion regulation in depression and anxiety: common and distinct mechanisms of action.

BACKGROUND: The current study seeks to investigate the mechanisms through which mindfulness is related to mental health in a clinical sample of adults by examining (1) whether specific cognitive emotion regulation strategies (rumination, reappraisal, worry, and nonacceptance) mediate associations between mindfulness and depression and anxiety, respectively, and (2) whether these emotion regulation strategies operate uniquely or transdiagnostically in relation to depression and anxiety. METHODS: Participants were 187 adults seeking treatment at a mood and anxiety disorders clinic in Connecticut. Participants completed a battery of self-report measures that included assessments of depression and anxiety (Mood and Anxiety Symptom Questionnaire), and emotion regulation (Ruminative Response Scale, Penn State Worry Questionnaire, Emotion Regulation Questionnaire, Difficulties in Emotion Regulation Scale). RESULTS: Simple mediation analyses indicated that rumination and worry significantly mediated associations between mindfulness and anxiety symptoms, whereas rumination and reappraisal significantly mediated associations between mindfulness and depressive symptoms. Multiple mediation analyses showed that worry significantly mediated associations between mindfulness and anxiety symptoms and rumination and reappraisal significantly mediated associations between mindfulness and depressive symptoms. CONCLUSIONS: Findings suggest that mindfulness operates through distinct and common mechanisms depending on clinical context.

Exploring potential mental health spillover effects among caregivers and partners of youth in Sierra Leone: A qualitative study.

Given the large mental health treatment gap in low- and middle-income countries (LMICs), particularly in post-conflict settings like Sierra Leone, and the limited healthcare infrastructure, understanding the wider benefits of evidence-based mental health interventions within households is critical. This study explored potential mental health spillover effects - the phenomenon of beneficial effects among nonparticipants - among cohabitating caregivers and partners of youth who participated in an evidence-based mental health intervention in Sierra Leone. We recruited a sub-sample of cohabitating caregivers and partners (N = 20) of youth intervention participants; caregivers had enrolled in a larger study investigating indirect benefits of the evidence-based intervention in Sierra Leone (MH117359). Qualitative interviews were conducted at two time points to explore the following: (a) potential mental health spillover effects and (b) through which mechanisms spillover may have occurred. Two trained coders reviewed transcripts and analyzed qualitative data, assisted by MaxQDA. Qualitative findings suggested that spillover effects likely occurred and supported three potential mechanisms: decreased caregiving burden, behavior changes among Youth Readiness Intervention participants and improved interpersonal relationships. Mental health spillover effects may occur following youth intervention participation in a post-conflict LMIC. Investing in evidence-based services may offer indirect benefits that extend beyond those directly receiving services.

Alternative Delivery Platforms for Expanding Evidence-based Mental Health Interventions for Youth in Sierra Leone: A Pilot Study.

Given the high rates of mental health problems and poor service access among youth in war-affected countries throughout Sub-Saharan Africa, incorporating evidence-based mental health interventions into alternative delivery platforms could improve service access in these settings. We conducted a randomized controlled pilot study with high-risk Sierra Leonean youth to investigate the feasibility of implementing the Youth Readiness Intervention (YRI), a cognitive behavioral and interpersonal therapy-based group intervention, within an employment promotion program (EPP) and preliminary effects of the YRI on mental health outcomes. Participants were 175 youth (females=62%) ages 18-30 recruited via flyers and radio announcements. Participants were assigned to geographic clusters stratified by gender; clusters were randomized into YRI+EPP (n=58) or EPP-only (n=57). Statistically matched controls were recruited from comparable chiefdoms (n=60). The 12-session YRI was delivered bi-weekly, following EPP completion. Qualitative findings indicated that the YRI was highly feasible and acceptable as integrated into the EPP. Mixed linear effects models showed promising trends. Compared with controls, both YRI+EPP and EPP-only males reported significantly reduced post-traumatic stress symptoms, and YRI+EPP reported marginally significantly reduced emotional regulation difficulties. EPP-only females reported significantly reduced functional impairment compared to controls. Findings suggest that the YRI can be feasibly implemented within an EPP. Integrating the YRI into existing delivery platforms may help increase access to mental health care in Sierra Leone and provide a leverage point for scaling up evidence-based mental health interventions in other low-resource settings globally. [Clinicaltrials.gov; NCT0360361; 5/18/18].

Exploring Naturalistic Diffusion of an Evidence-Based Mental Health Intervention across Peer Networks of Youth in Sierra Leone.

BACKGROUND: Understanding the mechanisms by which evidence-based interventions (EBIs) for mental health are naturally diffused among youth in low-and middle-income countries-particularly those with histories of violence and civil unrest-can illuminate which intervention elements are most transferrable and inform scale-up decisions that support youth adjustment. This study explored the diffusion of an evidence-based mental health intervention-the Youth Readiness Intervention (YRI)-among peer networks of Sierra Leonean youth (aged 18-30) who participated in a trial of the intervention as integrated into youth entrepreneurship programs. METHODS: Trained research assistants recruited index participants who had completed the YRI integrated within entrepreneurship training (N = 165) and control index participants (N = 165). Index participants nominated three of their closest peers. Nominated peers were recruited and enrolled in the current study (N = 289). A sub-sample of index participants and peers participated in dyadic interviews (N = 11) and focus group discussions (N = 16). Multivariate regression analysis compared YRI knowledge levels among YRI participants' peers relative to control participants' peers. RESULTS: Qualitative findings supported the diffusion of several YRI skills and components across peer networks (i.e., progressive muscle relaxation and diaphragmatic breathing). Quantitative findings indicated that YRI knowledge was significantly higher for YRI participants' peers (ß = 0.02, p < 0.00) compared to control participants' peers. CONCLUSION: Findings suggest that diffusion of evidence-based intervention components can occur naturally among peers in post-conflict LMIC settings. Developing tools to promote the diffusion of the most transferrable EBI components across peer networks could help maximize the benefits of mental health interventions for youth adjustment and resilience in post-conflict settings.

Applying Human-Centered Design in Global Mental Health to Improve Reach Among Underserved Populations in the United States and India.

INTRODUCTION: Human-centered design (HCD) refers to a diverse suite of interactive processes that engage end users in the development of a desired outcome. We showcase how 2 global mental health research teams applied HCD to develop mobile health tools, each directed at reducing treatment gaps in underserved populations. CASE STUDY 1: Refugees face higher risks for mental health problems, yet these communities face structural and cultural barriers that reduce access to and use of services. To address these challenges, the Research Program on Children and Adversity at the Boston College School of Social Work, in partnership with resettled refugee communities in the northeastern United States, used codesign methodology to digitally adapt delivery of the Family Strengthening Intervention for Refugees-a program designed to improve mental health and family functioning among resettled families. We describe how codesign methods support the development of more feasible, acceptable, and sustainable interventions. CASE STUDY 2: Sangath, an NGO in India focused on mental health services research, in partnership with Harvard Medical School, designed and evaluated a digital training program for community health workers to deliver an evidence-based, brief psychological treatment for depression as part of primary care in Madhya Pradesh, India. We describe how HCD was applied to program development and discuss our approach to scaling up training and capacity-building to deliver evidence-based treatment for depression in primary care. IMPLICATIONS: HCD involves a variety of techniques that can be flexibly adapted to engage end users in the conceptualization, implementation, scale-up, and sustainment of global mental health interventions. Community solutions generated using HCD offer important benefits for key stakeholders. We encourage widespread adoption of HCD within global mental health policy, research, and practice, especially for addressing mental health disparities with underserved populations.

Computer-assisted HIV prevention for youth with substance use disorders.

We developed an interactive, customizable, Web-based program focused on the prevention of HIV, sexually transmitted infections, and hepatitis among youth. Results from a randomized, controlled trial with youth in treatment for substance use demonstrated that this Web-based tool, when provided as an adjunct to an educator-delivered prevention intervention, increased accurate prevention knowledge, increased intentions to carefully choose partners, and was perceived as significantly more useful relative to the educator-delivered intervention when provided alone. Results suggest this Web-based program may be effective and engaging and may increase the adoption of effective HIV and disease prevention science for youth. Limitations are discussed.

Emergency medical care utilization, romantic attachment, and psychological distress in pregnant adolescent and young adult couples.

Purpose: The present study investigated the association of one's own and one'spartner's emergency medical care utilization during pregnancy with psychological distress in adolescent and young adult couples. Effect modification by sex and romantic attachment style was also explored. Method: Participants were pregnant adolescent and young adult couples recruited from 4 university-affiliated hospitals in Connecticut. Participants self-reported demographics, emergency medical care utilization (emergency room or overnight hospitalization), romantic attachment style, and psychological distress at baseline during the second or third trimester. Multilevel models were estimated to account for interdependence within couples. Results: One's own and one's partner's emergency medical care was associated with higher levels of psychological distress only at low levels of avoidant attachment (-1 SD), B = 2.20, p < .001, and, B = 1.15, p = .097, respectively (associations were not significant at high levels of attachment avoidance, ps > .12). No significant interactions emerged for medical care utilization with sex or attachment anxiety. Conclusions: Emergency medical care utilization during pregnancy was associated with higher psychological distress only for individuals reporting lower avoidant attachment. These individuals may have more resources to deal with distress (e.g., coping, social support), and may therefore also be more capable of experiencing it. Tailoring interventions to bolster healthy romantic attachment and relational wellbeing could improve mental health outcomes in at-risk pregnant adolescent and young adult couples. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Correction: mHealth-Supported Delivery of an Evidence-Based Family Home-Visiting Intervention in Sierra Leone: Protocol for a Pilot Randomized Controlled Trial.

[This corrects the article DOI: 10.2196/25443.].