Challenges to peer support in low- and middle-income countries during COVID-19.

BACKGROUND: A recent editorial urged those working in global mental health to "change the conversation" on coronavirus disease (Covid-19) by putting more focus on the needs of people with severe mental health conditions. UPSIDES (Using Peer Support In Developing Empowering mental health Services) is a six-country consortium carrying out implementation research on peer support for people with severe mental health conditions in high- (Germany, Israel), lower middle- (India) and low-income (Tanzania, Uganda) settings. This commentary briefly outlines some of the key challenges faced by UPSIDES sites in low- and middle-income countries as a result of Covid-19, sharing early lessons that may also apply to other services seeking to address the needs of people with severe mental health conditions in similar contexts. CHALLENGES AND LESSONS LEARNED: The key take-away from experiences in India, Tanzania and Uganda is that inequalities in terms of access to mobile technologies, as well as to secure employment and benefits, put peer support workers in particularly vulnerable situations precisely when they and their peers are also at their most isolated. Establishing more resilient peer support services requires attention to the already precarious situation of people with severe mental health conditions in low-resource settings, even before a crisis like Covid-19 occurs. While it is essential to maintain contact with peer support workers and peers to whatever extent is possible remotely, alternatives to face-to-face delivery of psychosocial interventions are not always straightforward to implement and can make it more difficult to observe individuals' reactions, talk about emotional issues and offer appropriate support. CONCLUSIONS: In environments where mental health care was already heavily medicalized and mostly limited to medications issued by psychiatric institutions, Covid-19 threatens burgeoning efforts to pursue a more holistic and person-centered model of care for people with severe mental health conditions. As countries emerge from lockdown, those working in global mental health will need to redouble their efforts not only to make up for lost time and help individuals cope with the added stressors of Covid-19 in their communities, but also to regain lost ground in mental health care reform and in broader conversations about mental health in low-resource settings.

Societal and organisational influences on implementation of mental health peer support work in low-income and high-income settings: a qualitative focus group study.

OBJECTIVES: Despite the established evidence base for mental health peer support work, widespread implementation remains a challenge. This study aimed to explore societal and organisational influences on the implementation of peer support work in low-income and high-income settings. DESIGN: Study sites conducted two focus groups in local languages at each site, using a topic guide based on a conceptual framework describing eight peer support worker (PSW) principles and five implementation issues. Transcripts were translated into English and an inductive thematic analysis was conducted to characterise implementation influences. SETTING: The study took place in two tertiary and three secondary mental healthcare sites as part of the Using Peer Support in Developing Empowering Mental Health Services (UPSIDES) study, comprising three high-income sites (Hamburg and Ulm, Germany; Be'er Sheva, Israel) and two low-income sites (Dar es Salaam, Tanzania; Kampala, Uganda) chosen for diversity both in region and in experience of peer support work. PARTICIPANTS: 12 focus groups were conducted (including a total of 86 participants), across sites in Ulm (n=2), Hamburg (n=2), Dar es Salaam (n=2), Be'er Sheva (n=2) and Kampala (n=4). Three individual interviews were also done in Kampala. All participants met the inclusion criteria: aged over 18 years; actual or potential PSW or mental health clinician or hospital/community manager or regional/national policy-maker; and able to give informed consent. RESULTS: Six themes relating to implementation influences were identified: community and staff attitudes, resource availability, organisational culture, role definition, training and support and peer support network. CONCLUSIONS: This is the first multicountry study to explore societal attitudes and organisational culture influences on the implementation of peer support. Addressing community-level discrimination and developing a recovery orientation in mental health systems can contribute to effective implementation of peer support work. The relationship between societal stigma about mental health and resource allocation decisions warrants future investigation. TRIAL REGISTRATION NUMBER: ISRCTN26008944.

Analysis of news media reports of suicides and attempted suicides during the COVID-19 lockdown in India.

BACKGROUND: Based on previous experience there is justifiable concern about suicidal behaviour and news media reporting of it during COVID-19 pandemic. METHODS: This study used a systematic search of online news media reports (versions of newspapers, magazine and other digital publications) of suicidal behaviour during India's COVID-19 lockdown and compared it to corresponding dates in 2019. Data was gathered using a uniform search strategy from 56 online news media publications 24 March to 3 May for the years 2019 and 2020 using keywords, suicide, attempted suicide, hangs self and kills self. Demographic variables and methods used for suicide were compared for suicide and attempts between the 2 years using chi-squared tests (χ2). RESULTS: There were online news media reports of 369 cases of suicides and attempted suicides during COVID lockdown vs 220 reports in 2019, a 67.7% increase in online news media reports of suicidal behaviour. Compared to 2019, suicides reported during lockdown were significantly older (30 vs 50 years, p < 0.05), men (71.2% vs 58.7%; p < 0.01), married (77.7% vs 49%; p < 0.01) and employed (82.9% vs 59.5%; p < 0.01). During the lockdown, significantly more suicides were by hanging (64.4% vs 42%), while poisoning (8.5% vs 21.5%) and jumping in front of a train (2% vs 9.4%) (p < 0.05) were significantly reduced. Comparison of COVID and non-COVID groups showed that online news media reports of COVID cases of suicide and attempted suicide were significantly more likely to be men (84.7% vs 60.4%; p < 0.01), older (31-50 years 52.9% vs 25.8%; p < 0.01) employed (91.5% vs 64.3%; p < 0.01), had poor mental (40.1% vs 20.8%; p < 0.01) and poor physical health (24.8% vs 7.9%;11.8, p < 0.01). CONCLUSION: Increase in online news media reports of suicides and attempts during COVID-19 lockdown may indicate an increase in journalists' awareness about suicide or more sensational media reporting or may be a proxy indicator of a real community increase in suicidal behaviour. It is difficult to attribute changes in demographic profile and methods used only to changes in journalists' reporting behaviour and should be further explored. We therefore call upon the Government of India to urgently release national suicide data to help devise a comprehensive suicide prevention strategy to address COVID-19 suicidal behaviour.

Estimation of Eye Lens Dose During Brain Scans Using Gafchromic Xr-QA2 Film in Various Multidetector CT Scanners.

The purpose of this study was to estimate eye lens dose during brain scans in 16-, 64-, 128- and 256-slice multidetector computed tomography (CT) scanners in helical acquisition mode and to test the feasibility of using radiochromic film as eye lens dosemeter during CT scanning. Eye lens dose measurements were performed using Gafchromic XR-QA2 film on a polystyrene head phantom designed with outer dimensions equivalent to the head size of a reference Indian man. The response accuracy of XR-QA2 film was validated by using thermoluminescence dosemeters. The eye lens dose measured using XR-QA2 film on head phantom for plain brain scanning in helical mode ranged from 43.8 to 45.8 mGy. The XR-QA2 film measured dose values were in agreement with TLD measured dose values within a maximum variation of 8.9%. The good correlation between the two data sets confirms the viability of using XR-QA2 film for eye lens dosimetry.

Radiological safety status and quality assurance audit of medical X-ray diagnostic installations in India.

We conducted a radiological safety and quality assurance (QA) audit of 118 medical X-ray diagnostic machines installed in 45 major hospitals in India. The main objective of the audit was to verify compliance with the regulatory requirements stipulated by the national regulatory body. The audit mainly covered accuracy check of accelerating potential (kVp), linearity of tube current (mA station) and timer, congruence of radiation and optical field, and total filtration; in addition, we also reviewed medical X-ray diagnostic installations with reference to room layout of X-ray machines and conduct of radiological protection survey. A QA kit consisting of a kVp Test-O-Meter (ToM) (Model RAD/FLU-9001), dose Test-O-Meter (ToM) (Model 6001), ionization chamber-based radiation survey meter model Gun Monitor and other standard accessories were used for the required measurements. The important areas where there was noncompliance with the national safety code were: inaccuracy of kVp calibration (23%), lack of congruence of radiation and optical field (23%), nonlinearity of mA station (16%) and timer (9%), improper collimator/diaphragm (19.6%), faulty adjustor knob for alignment of field size (4%), nonavailability of warning light (red light) at the entrance of the X-ray room (29%), and use of mobile protective barriers without lead glass viewing window (14%). The present study on the radiological safety status of diagnostic X-ray installations may be a reasonably good representation of the situation in the country as a whole. The study contributes significantly to the improvement of radiological safety by the way of the steps already taken and by providing a vital feed back to the national regulatory body.