Core components of mental health stigma reduction interventions in low- and middle-income countries: a systematic review.

AIMS: To identify and categorise core components of effective stigma reduction interventions in the field of mental health in low- and middle-income countries (LMICs) and compare these components across cultural contexts and between intervention characteristics. METHODS: Seven databases were searched with a strategy including four categories of terms ('stigma', 'mental health', 'intervention' and 'low- and middle-income countries'). Additional methods included citation chaining of all papers identified for inclusion, consultation with experts and hand searching reference lists from other related reviews. Studies on interventions in LMICs aiming to reduce stigma related to mental health with a stigma-related outcome measure were included. All relevant intervention characteristics and components were extracted and a quality assessment was undertaken. A 'best fit' framework synthesis was used to organise data, followed by a narrative synthesis. RESULTS: Fifty-six studies were included in this review, of which four were ineffective and analysed separately. A framework was developed which presents a new categorisation of stigma intervention components based on the included studies. Most interventions utilised multiple methods and of the 52 effective studies educational methods were used most frequently (n = 83), and both social contact (n = 8) and therapeutic methods (n = 3) were used infrequently. Most interventions (n = 42) based their intervention on medical knowledge, but a variety of other themes were addressed. All regions with LMICs were represented, but every region was dominated by studies from one country. Components varied between regions for most categories indicating variation between cultures, but only a minority of studies were developed in the local setting or culturally adapted. CONCLUSIONS: Our study suggests effective mental health stigma reduction interventions in LMICs have increased in quantity and quality over the past five years, and a wide variety of components have been utilised successfully - from creative methods to emphasis on recovery and strength of people with mental illness. Yet there is minimal mention of social contact, despite existing strong evidence for it. There is also a lack of robust research designs, a high number of short-term interventions and follow-up, nominal use of local expertise and the research is limited to a small number of LMICs. More research is needed to address these issues. Some congruity exists in components between cultures, but generally they vary widely. The review gives an in-depth overview of mental health stigma reduction core components, providing researchers in varied resource-poor settings additional knowledge to help with planning mental health stigma reduction interventions.

HESPER web - development and reliability evaluation of a web-based version of the humanitarian emergency settings perceived needs scale.

BACKGROUND: The Humanitarian Emergency Settings Perceived Needs Scale (HESPER) assesses a wide range of physical, psychological and social perceived needs across 26 questions, and can be used in humanitarian emergencies and disasters for needs assessment or research studies. The original HESPER collects data through individual interviews. Today, a large number of people have access to the internet, including in humanitarian emergencies and disasters. Therefore, this paper aimed to report the development, reliability evaluation and feasibility evaluation of the HESPER Web. METHODS: First, the original HESPER was developed into a web based survey. Thereafter, alternate forms reliability between the HESPER and HESPER Web, and test-retest reliability for the HESPER Web, was evaluated using a study sample of 85 asylum seekers in Sweden in total. RESULTS: The alternate forms reliability evaluation showed that the HESPER Web was a reliable instrument to assess perceived needs. Intraclass correlation coefficient (ICC) for total number of serious needs was 0.96 (CI 0.93-09.98, p < 0.001). Cohen's κ was used to analyse the alternate forms reliability between the HESPER and HESPER Web item per item; the correspondence between HESPER and HESPER Web varied between 0.54 and 1.0 for the 26 questions. There was a strong nominal association in first priority need between the HESPER and HESPER Web (Cramer's V 0.845, p < 0.001). In the test-retest reliability evaluation of HESPER Web, ICC was 0.98 (CI 0.97-0.99, p < 0.001), and Cohen's κ varied between 0.53 and 1.0. There was a strong nominal association in first priority need between test and re-test (Cramer's V 0.93, p < 0.001). The HESPER Web was experienced as easy and safe to use and was found less time consuming than the original HESPER interview, according to the study participants. CONCLUSION: The HESPER Web is a reliable and usable instrument to assess perceived needs. It can reduce a number of practical challenges both for needs assessment in disasters or humanitarian emergencies as well as in research.

Developing capacity-building activities for mental health system strengthening in low- and middle-income countries for service users and caregivers, service planners, and researchers.

There is increasing international recognition of the need to build capacity to strengthen mental health systems. This is a fundamental goal of the 'Emerging mental health systems in low- and middle-income countries' (Emerald) programme, which is being implemented in six low- and middle-income countries (LMICs) (Ethiopia, India, Nepal, Nigeria, South Africa, Uganda). This paper discusses Emerald's capacity-building approaches and outputs for three target groups in mental health system strengthening: (1) mental health service users and caregivers, (2) service planners and policy-makers, and (3) mental health researchers. When planning the capacity-building activities, the approach taken included a capabilities/skills matrix, needs assessments, a situational analysis, systematic reviews, qualitative interviews and stakeholder meetings, as well as the application of previous theory, evidence and experience. Each of the Emerald LMIC partners was found to have strengths in aspects of mental health system strengthening, which were complementary across the consortium. Furthermore, despite similarities across the countries, capacity-building interventions needed to be tailored to suit the specific needs of individual countries. The capacity-building outputs include three publicly and freely available short courses/workshops in mental health system strengthening for each of the target groups, 27 Masters-level modules (also open access), nine Emerald-linked PhD students, two MSc studentships, mentoring of post-doctoral/mid-level researchers, and ongoing collaboration and dialogue with the three groups. The approach taken by Emerald can provide a potential model for the development of capacity-building activities across the three target groups in LMICs.

Evaluating capacity-building for mental health system strengthening in low- and middle-income countries for service users and caregivers, service planners and researchers.

Efforts to support the scale-up of integrated mental health care in low- and middle-income countries (LMICs) need to focus on building human resource capacity in health system strengthening, as well as in the direct provision of mental health care. In a companion editorial, we describe a range of capacity-building activities that are being implemented by a multi-country research consortium (Emerald: Emerging mental health systems in low- and middle-income countries) for (1) service users and caregivers, (2) service planners and policy-makers and (3) researchers in six LMICs (Ethiopia, India, Nepal, Nigeria, South Africa and Uganda). In this paper, we focus on the methodology being used to evaluate the impact of capacity-building in these three target groups. We first review the evidence base for approaches to evaluation of capacity-building, highlighting the gaps in this area. We then describe the adaptation of best practice for the Emerald capacity-building evaluation. The resulting mixed method evaluation framework was tailored to each target group and to each country context. We identified a need to expand the evidence base on indicators of successful capacity-building across the different target groups. To address this, we developed an evaluation plan to measure the adequacy and usefulness of quantitative capacity-building indicators when compared with qualitative evaluation. We argue that evaluation needs to be an integral part of capacity-building activities and that expertise needs to be built in methods of evaluation. The Emerald evaluation provides a potential model for capacity-building evaluation across key stakeholder groups and promises to extend understanding of useful indicators of success.

Service user and caregiver involvement in mental health system strengthening in low- and middle-income countries: a cross-country qualitative study.

AIMS: The aims of this paper are to: (i) explore the experiences of involvement of mental health service users, their caregivers, mental health centre heads and policy makers in mental health system strengthening in three low- and middle-income countries (LMICs) (Ethiopia, Nepal and Nigeria); (ii) analyse the potential benefits and barriers of such involvement; and (iii) identify strategies required to achieve greater service user and caregiver participation. METHODS: A cross-country qualitative study was conducted, interviewing 83 stakeholders of mental health services. RESULTS: Our analysis showed that service user and caregiver involvement in the health system strengthening process was an alien concept for most participants. They reported very limited access to direct participation. Stigma and poverty were described as the main barriers for involvement. Several strategies were identified by participants to overcome existing hurdles to facilitate service user and caregiver involvement in the mental health system strengthening process, such as support to access treatment, mental health promotion and empowerment of service users. This study suggests that capacity building for service users, and strengthening of user groups would equip them to contribute meaningfully to policy development from informed perspectives. CONCLUSION: Involvement of service users and their caregivers in mental health decision-making is still in its infancy in LMICs. Effective strategies are required to overcome existing barriers, for example making funding more widely available for Ph.D. studies in participatory research with service users and caregivers to develop, implement and evaluate approaches to involvement that are locally and culturally acceptable in LMICs.

Stigma and discrimination related to mental illness in low- and middle-income countries.

AIMS: This paper aims to provide an overview of evidence from low- and middle-income countries (LAMICs) worldwide to address: the nature of stigma and discrimination, relevant context-specific factors, global patterns of these phenomena and their measurement and quantitative and qualitative evidence of interventions intended to reduce their occurrence and impact. The background to this study is that the large majority of studies concerned with identifying effective interventions to reduce stigma and discrimination originate in high-income countries (HICs). This paper therefore presents such evidence from, and relevant to, LAMICs. METHODS: Conceptual overview of the relevant peer-reviewed and grey literature on stigma and discrimination related to mental illness in LAMICs are available in English, Spanish, French and Russian. RESULTS: Few intervention studies were identified related to stigma re-education in LAMICs. None of these addressed behaviour change/discrimination, and there were no long-term follow-up studies. There is therefore insufficient evidence at present to know which overall types of intervention may be effective and feasible and in LAMICs, how best to target key groups such as healthcare staff, and how far they may need to be locally customised to be acceptable for large-scale use in these settings. In particular, forms of social contacts, which have been shown to be the most effective intervention to reduce stigma among adults in HICs, have not yet been assessed sufficiently to know whether these methods are also effective in LAMICs. CONCLUSION: Generating information about effective interventions to reduce stigma and discrimination in LAMICs is now an important mental health priority worldwide.

Absence of muscle capillary basement membrane thickening and retinopathy in patients with myocardial infarction and impaired i.v. glucose tolerance.

We have investigated the possible contribution of an early capillaropathy to the increased incidence of myocardial infarction (MI) in patients who had impaired glucose tolerance (IGT) during an i.v. glucose tolerance test (IVGTT). In lieu of the myocardium, biopsies from the quadriceps femoris muscle were studied for muscle capillary basement membrane (MCBM) thickening. Fluorescence angiography was performed to detect capillary retinopathy. Plasma growth hormone (GH) concentrations were determined during IGT. Data were obtained from 14 male patients with MI and IGT on IVGTT. Nine healthy subjects served as controls. MCBM thickness was similar in patients and controls (1,107 +/- 55 vs 1,067 +/- 88 A). None of the patients had signs of capillary retinopathy, and plasma GH concentrations were not higher in the patients as compared to control subjects. It is concluded that, in patients with IGT on IVGTT, MCBM thickening is probably not a factor for the development of MI.