Assessing the effectiveness and cost-effectiveness of a solution-focused resource-orientated approach (DIALOG+) to improving the quality of life for people with psychosis in India and Pakistan-a cluster RCT.

BACKGROUND: Severe mental illness (SMI) presents a major challenge worldwide, affecting approximately 5-8% of the world's population. It causes significant distress to affected people, families and wider communities, generating high costs through loss of productivity and ongoing healthcare use. Over 75% of patients with psychosis receive inadequate care and experience a negative financial impact and reduced quality of life (QoL). It is therefore a priority to reduce the treatment gap by providing low-cost, effective interventions for people with psychosis. Our research project, PIECEs, is designed to explore, adapt and test a low-cost, approach (DIALOG+) that makes use of existing resources to improve community-based care for patients with psychosis. The research will be conducted in two urban sites: Karachi, Pakistan and Chennai, India. DIALOG+ is a novel, technology-assisted and resource-oriented intervention, based on QoL research, concepts of patient-centred communication, IT developments and solution-focused therapy. However, the approach has not been rigorously tested within India and Pakistan. Our randomised controlled trial (RCT) aims to test the effectiveness and cost-effectiveness of DIALOG+ in improving the QoL and clinical outcomes for individuals with long-term psychosis being treated in the community in India and Pakistan. METHODS: To assess the acceptability, feasibility, and cost effectiveness of DIALOG+, we will conduct a cluster RCT with 210 patients and 14 clinicians in each country. The intervention will be used during a routine interaction between a clinician and a patient. It consists of a patient-centred assessment (the DIALOG scale) whereby the clinician invites the patient to rate their satisfaction with different life domains and treatment aspects, which forms the active control group. The intervention group will follow this up with a four-step solution-focused approach to identify the patient's resources and develop solutions to deal with the patient's concerns (DIALOG+). DISCUSSION: If shown to be effective DIALOG+ has the potential to improve community-based care and the QoL for millions of people within India and Pakistan who experience psychosis. TRIAL REGISTRATION: The trial was registered prospectively on the ISRCTN Registry: ISRCTN13022816 on 9 February 2022.

A mixed methods exploration of the role of multi-family groups in community treatment of patients with depression and anxiety in Pakistan.

BACKGROUND: An open, non-controlled trial was conducted to explore the feasibility, experiences and outcomes of multi-family groups in community mental health care of patients with depression and anxiety. METHODS: The study was conducted in community settings within the catchment area of a free of cost primary care center in Karachi, Pakistan. 30 patients with symptoms of depression and anxiety, their caregivers and 3 lay counsellors were recruited enrolled in the study between May-September 2019. Patients were enrolled for monthly multi-family group meetings conducted over 6 months in groups of 5-6 patients and 1-2 nominated caregivers each. Meetings were facilitated by the non-specialist trained counsellors. The primary outcome was quality of life (assessed using Manchester Short Assessment of Quality of Life) and secondary outcomes were symptoms of depression and anxiety (assessed on Aga Khan University Depression and Anxiety Scale), social outcomes (Social Outcome Index), and caregiver burden (Burden Assessment Scale). Change in all measures was assessed pre and 6-month post intervention using t-test. In-depth interviews were conducted with 7 patients, 7 caregivers and the 3 lay counsellors. RESULTS: A total of 36 family intervention meetings were conducted with six groups with a total of 30 patients, 34 caregivers and 3 counsellors. Between baseline and the end of the intervention, subjective quality of life increased significantly from 3.34 to 4.58 (p < 0.001, 95% CI 0.93-1.54). Self-reported depression and anxiety scores reduced from 34.7 to 19.5 (p < 0.001, 95% CI 10.8-19.8) and the Social Outcome Index improved from 3.63 to 4.52 (p < 0.001, 95% CI 0.39-1.39). There was no change in family burden. Participants reported that the group meetings were seen as a safe space for shared learning, and that the experience helped improve self-regulation of emotions and behaviors and instilled a sense of belonging. CONCLUSION: Multi-family groups in community treatment of common mental health disorders facilitated by non-specialist mental health service providers is feasible, experienced positively and has the potential for large and positive effects on subjective quality of life, self-reported depression and anxiety, and objective social outcomes. TRIAL REGISTRATION: ISRCTN, ISRCTN12299326. Registered 05 June 2019. Retrospectively registered, https://doi.org/10.1186/ISRCTN12299326 .

Understanding global mental health: a conceptual review.

BACKGROUND: Mental health disorders are viewed as a global concern requiring globally led approaches to address them. Since the publication of the 2007 Lancet series on global mental health (GMH), the term has become widespread. Over the last two decades, GMH has become increasingly affiliated with policy reform, academic courses, funding bodies and research. However, it is not always obvious how those working in the field of GMH are using the term, resulting in a lack of clarity. Therefore, work is needed to synthesise the current understanding(s) of GMH to help characterise its meaning. AIM: To synthesise the literature and identify the different ways GMH is understood. METHOD: A conceptual review, using a systematic search and a content analysis, was conducted to develop a conceptual framework of the different conceptual understandings of GMH. RESULTS: We developed a conceptual framework of four understandings of GMH. These understandings of GMH are as follows: an area of research generating findings to establish a GMH evidence-base; implementation of research into practice; improving the mental health environment; learning from and supporting low-and-middle-income countries (LMICs). CONCLUSION: Our review proposes a simple framework, clarifying the key characteristics of the GMH landscape. The findings highlight the diversity of usage of the term in the literature, as well as present the wide scope that comprises the field of GMH. Referring to this framework may help those engaged with GMH to be more specific with which aspect of the field they are concerned with.

Self-Diagnosis of Surgical Site Infections: Lessons from a tertiary care centre in Karachi, Pakistan.

BACKGROUND AND OBJECTIVE: Surgical site infections (SSIs) usually manifest post-discharge, rendering accurate diagnosis and treatment challenging, thereby catalyzing the development of alternate strategies like self-monitored SSI surveillance. This study aimed to evaluate the diagnostic accuracy of patients and Infection Control Monitors (ICMs) to develop a replicable method of SSI-detection. METHODS: A two-year prospective diagnostic accuracy study was conducted in Karachi, Pakistan between 2015 and 2017. Patients were educated about SSIs and provided with questionnaires to elicit symptoms of SSI during post-discharge self-screening. Results of patient's self-screening and ICM evaluation at follow-ups were compared to surgeon evaluation. RESULTS: A total of 348 patients completed the study, among whom 18 (5.5%) developed a SSI. Patient self-screening had a sensitivity of 39%, specificity of 95%, positive predictive value (PPV) of 28%, and negative predictive value (NPV) of 97%. ICM evaluation had a sensitivity of 82%, specificity of 99%, PPV of 82%, and NPV of 99%. CONCLUSION: Patients cannot self-diagnose a SSI reliably. However, diagnostic accuracy of ICMs is significantly higher and they may serve as a proxy for surgeons, thereby reducing the burden on specialized surgical workforce in LMICs. Regardless, supplementing post-discharge follow-up with patient self-screening could increase SSI-detection and reduce burden on health systems.

Job morale of physicians in low-income and middle-income countries: a systematic literature review of qualitative studies.

OBJECTIVES: To systematically review the available literature on physicians' and dentists' experiences influencing job motivation, job satisfaction, burnout, well-being and symptoms of depression as indicators of job morale in low-income and middle-income countries. DESIGN: The review was reported following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for studies evaluating outcomes of interest using qualitative methods. The framework method was used to analyse and integrate review findings. DATA SOURCES: A primary search of electronic databases was performed by using a combination of search terms related to the following areas of interest: 'morale', 'physicians and dentists' and 'low-income and middle-income countries'. A secondary search of the grey literature was conducted in addition to checking the reference list of included studies and review papers. RESULTS: Ten papers representing 10 different studies and involving 581 participants across seven low-income and middle-income countries met the inclusion criteria for the review. However, none of the studies focused on dentists' experiences was included. An analytical framework including four main categories was developed: work environment (physical and social), rewards (financial, non-financial and social respect), work content (workload, nature of work, job security/stability and safety), managerial context (staffing levels, protocols and guidelines consistency and political interference). The job morale of physicians working in low-income and middle-income countries was mainly influenced by negative experiences. Increasing salaries, offering opportunities for career and professional development, improving the physical and social working environment, implementing clear professional guidelines and protocols and tackling healthcare staff shortage may influence physicians' job morale positively. CONCLUSIONS: There were a limited number of studies and a great degree of heterogeneity of evidence. Further research is recommended to assist in scrutinising context-specific issues and ways of addressing them to maximise their utility. PROSPERO REGISTRATION NUMBER: CRD42017082579.

Resource-oriented interventions for patients with severe mental illnesses in low- and middle-income countries: trials in Bosnia-Herzegovina, Colombia and Uganda.

BACKGROUND: Severe mental illness (SMI) presents a major burden to societies worldwide. Low- and middle-income countries (LMICs) often do not have sufficient financial resources and qualified staff to provide extensive specialised services for outpatients with SMI. Our research therefore aims to explore and test low-cost interventions that use existing resources in routine patient-clinician meetings, families and communities. METHODS: In Bosnia-Herzegovina, Colombia and Uganda, three psychosocial interventions will be tested, i.e. making patient-clinician meetings therapeutically effective through DIALOG+, family involvement in multi-family group meetings, and support for patients in befriending schemes with volunteers. All interventions will be provided to patients with SMI, delivered over a six-month period and evaluated with assessments at baseline and after six and 12 months. We will conduct nine trials including non-controlled trials, non-randomised controlled trials and randomised controlled trials (RCTs). Core outcome criteria will be used across all studies. However, details of study delivery and additional outcome criteria vary to accommodate local contexts, interests and priorities. The studies will be analysed separately, but with the option to compare and combine findings. DISCUSSION: The approach provides the opportunity to learn from commonalities and differences in the results and experiences across the three resource-oriented approaches and the three countries. If successfully implemented the studies can lead to more extensive research and are expected to inform health policies and clinical practice of community care for patients with SMI in the three participating countries and other LMICs. TRIAL REGISTRATION: All RCTs were registered prospectively and non-randomised trials retrospectively within the ISRCTN Registry. DIALOG+ in Uganda: ISRCTN25146122 (Date of Registration: 20/11/2018, prospective); DIALOG+ in Colombia: ISRCTN83333181 (Date of Registration: 20/11/2018, prospective); DIALOG+ in Bosnia-Herzegovina: ISRCTN13347129 (Date of Registration: 20/11/2018, prospective); Volunteer Support in Uganda: ISRCTN86689958 (Date of Registration: 04/03/2019, retrospective); Volunteer Support in Colombia: ISRCTN72241383 (Date of Registration: 04/03/2019, retrospective);Volunteer Support in Bosnia-Herzegovina: ISRCTN51290984 (Date of Registration: 20/11/2018, prospective); Family Involvement in Uganda: ISRCTN78948497 (Date of Registration: 04/03/2019, retrospective); Family Involvement in Colombia: ISRCTN11440755 (Date of Registration: 04/03/2019, retrospective); Family Involvement in Bosnia-Herzegovina: ISRCTN13347355 (Date of Registration: 20/11/2018, prospective).

Community-based assessment of surgical symptoms in a low-income urban population.

BACKGROUND: The global burden of surgical disease has not been well quantified, but is potentially immense. Given the enormity of the problem and the relative paucity of data, definition and monitoring of surgical burden of disease is an essential step in confronting the problem. This study aimed to estimate the prevalence of non-acute surgical disease symptoms in a low-income population. METHODS: The survey was conducted as part of the Indus Hospital Community Cohort in Karachi, Pakistan. A systematic random sampling design was used to enroll 667 households from March to August 2011. An unvalidated questionnaire intending to measure prevalence of surgical symptoms was administered to 780 participants. RESULTS: 761 participants completed the screening questionnaire, with 346 (45%) reporting one or more symptoms requiring surgical assessment (excluding those screened positive for symptoms of osteoarthritis), of which only 8.4% followed up on scheduled appointments at the referral hospital. A total of 126 past surgical procedures were recorded in 120 participants. CONCLUSION: There is a high prevalence of symptoms suggestive of surgical diseases in our urban catchment population with relatively convenient access to health facilities including a tertiary care hospital providing free of cost care. The perceived severity of symptoms, and a complex interaction of other factors, may play an important role in understanding health seeking behavior in our population. Developing a context-specific validated tool to correctly identify surgical symptoms disease in the community with appropriate referral for early management is essential to identify and therefore reduce the burden of surgical diseases within the community. This must happen hand in hand with further studies to understand the barriers to seeking timely health care.

Harnessing Photovoice for tuberculosis advocacy in Karachi, Pakistan.

In Pakistan, despite publically available free testing and treatment throughout the country, there were an estimated 58,000 deaths due to tuberculosis in 2010. Understanding the experiences of people affected by TB is essential in addressing barriers to effective treatment. The Indus Hospital used Photovoice to understand the experiences of people affected by TB in Karachi. Two hundred and thirty photographs and stories were collected from 55 people affected by TB. Five major themes and 12 sub-themes emerged from the data: the physical aspects of TB (weakness and the side effects of the medication), the social aspects of TB (loneliness, stigma, and the fear/guilt of infecting family members), the socio-economic aspects of TB (financial difficulties/poverty and poor living conditions), supportive factors during treatment (support from family and friends, support from welfare organizations, prayer, visiting peaceful places), and recovery (happiness about getting better). The photographs, stories, and a Call for Action were shared at a Gallery event with patients, practitioners, and policy-makers. This study provides a look at the complexities surrounding TB and emphasizes the need for holistic interventions for TB that address all aspects of the disease, including its social determinants. It also highlights the potential of Photovoice as an effective means to bring much-needed attention to this disease.

Barriers to accessing surgical care: a cross-sectional survey conducted at a tertiary care hospital in Karachi, Pakistan.

BACKGROUND: The need for surgical care far exceeds available facilities, especially in low income and poor countries. Limited data are available to help us understand the extent and nature of barriers that limit access to surgical care, particularly in the Asian subcontinent. The aim of this study was to understand factors that influence access to surgical care in a low-income urban population. METHODS: An observational cross-sectional study was conducted on 199 consecutive patients admitted for elective surgery from February to April 2010 to identify the presence and causes of delay in accessing surgical care. RESULTS: The median duration of symptoms were 7 and 4 months in women and men, respectively. The odds of delay between the onset of symptoms and seeking initial health care (first interval) is twice as likely for women than for men [52.7 vs. 37.5 %, odds ratio (OR) 1.9]. Lack of knowledge regarding treatment options [OR 3.8; 95 % confidence interval (CI) 1.4-10.3] and about disease implications (OR 2.4; 95 % CI 1.2-4.8) were cited most often. A second interval of delay (time from when surgery was first advised to the surgery) was reported by 123 (61.8 %) patients. Financial constraints (29.6 %) and environment-related delays (10.6 %) were cited most often. More women than men thought there was a second delay interval (73 vs. 58 %). The odds of women having more co-morbid conditions were nearly 4.7 times that of men (95 % CI 1.5-15.1). CONCLUSIONS: A complex interaction of factors limits access to surgical care in developing countries. Women appear to face greater hurdles to accessing health care. Understanding local factors is essential to make care accessible.

The burden of non-communicable disease in transition communities in an Asian megacity: baseline findings from a cohort study in Karachi, Pakistan.

BACKGROUND: The demographic transition in South Asia coupled with unplanned urbanization and lifestyle changes are increasing the burden of non-communicable disease (NCD) where infectious diseases are still highly prevalent. The true magnitude and impact of this double burden of disease, although predicted to be immense, is largely unknown due to the absence of recent, population-based longitudinal data. The present study was designed as a unique 'Framingham-like' Pakistan cohort with the objective of measuring the prevalence and risk factors for hypertension, obesity, diabetes, coronary artery disease and hepatitis B and C infection in a multi-ethnic, middle to low income population of Karachi, Pakistan. METHODS: We selected two administrative areas from a private charitable hospital's catchment population for enrolment of a random selection of cohort households in Karachi, Pakistan. A baseline survey measured the prevalence and risk factors for hypertension, obesity, diabetes, coronary artery disease and hepatitis B and C infection. RESULTS: Six hundred and sixty-seven households were enrolled between March 2010 and August 2011. A majority of households lived in permanent structures (85%) with access to basic utilities (77%) and sanitation facilities (98%) but limited access to clean drinking water (68%). Households had high ownership of communication technologies in the form of cable television (69%) and mobile phones (83%). Risk factors for NCD, such as tobacco use (45%), overweight (20%), abdominal obesity (53%), hypertension (18%), diabetes (8%) and pre-diabetes (40%) were high. At the same time, infectious diseases such as hepatitis B (24%) and hepatitis C (8%) were prevalent in this population. CONCLUSION: Our findings highlight the need to monitor risk factors and disease trends through longitudinal research in high-burden transition communities in the context of rapid urbanization and changing lifestyles. They also demonstrate the urgency of public health intervention programs tailored for these transition communities.

Breast cancer in Pakistan: identifying local beliefs and knowledge.

PURPOSE: The aim of this study was to assess the attitudes of women and general practitioners (GPs) living in Karachi, Pakistan, regarding breast cancer, mammographic screening, and local barriers to breast health care. METHODS: This study was performed using questionnaires designed specifically for women and for GPs in Karachi. Geographically dispersed collaborators identified GPs from neighborhoods across Karachi; snowball sampling located additional GPs and women in neighboring areas. Trained local community health workers conducted one-on-one surveys and used specially equipped (openXdata) mobile phones to enter and upload participant responses in real time. RESULTS: The survey included 200 women (median age, 35 years; range, 24-63 years), and 100 GPs (49% men, 51% women). Women's knowledge of breast cancer incidence, diagnosis, and treatment was proportionate to educational level, while willingness to address breast health issues and interest in early detection were high regardless of education level. Very few women had ever undergone clinical breast examinations (16%) or mammography (9%). Among GPs (median time practicing, 12 years; range, 1-40 years), most understood major risk factors and importance of early detection. However, 20% did not believe breast cancer occurs in Pakistan, and 30% believed that it is a fatal disease. Female GPs were more likely to perform clinical breast examinations (98%) than male GPs (24%). CONCLUSIONS: This study has identified specific areas to target for educational and early detection programs. Women need more awareness and access to routine examinations and mammography; GPs need more education regarding the incidence and management of breast cancer. Male GPs would benefit from having trained female assistants to perform clinical breast examinations.