Non-specialist Health Workers Research Articles

Who is helping students? A qualitative analysis of task-shifting and on-campus mental health services in China's university settings

The mental health of university students is a major concern worldwide. Current literature has highlighted workforce shortage as one of the main barriers for delivering mental health care in China and elsewhere. A common strategy to tackle this shortage involves engaging non-specialist health workers and professionals from non-medical backgrounds in mental health promotion within university settings. Yet, there remains limited understanding of how this approach operates in practice and its effectiveness in delivering essential on-campus services to students. This study contributes to narrowing this knowledge gap through the engagement with interdisciplinary mental health service providers (n = 141) at six universities in Shandong, China. We used focus group interviews to explore how task-shift practices operate in the Chinese university context and analyze the main barriers in the practitioners’ delivery of mental health care practices. According to our analysis, (1) competing roles of non-health actors create a trust-privacy dilemma in the delivery of mental health service; (2) knowledge gap and workload issues become new barriers for effective mental health promotion; and (3) the lack of structured intersectoral collaboration creates barriers to establish effective mental health care networks to meet the needs of university students. These results highlight the importance of using a settings approach in designing and assessing mental health interventions based on task-shifting within the contexts of Chinese universities. The study also helps to map out the unique features of the workforce situation in the mental health support system of Chinese universities, offering researchers and practitioners insights on how to better localize their assessment and programming.

Updated guidelines on HIV post-exposure prophylaxis: continued efforts towards increased accessibility.

HIV transmission is ongoing in both high- and low-resource settings. Post-exposure prophylaxis (PEP) remains an important tool in preventing HIV; however, PEP is significantly underutilized. The multitude of barriers to PEP implementation include low patient and provider awareness and acceptability, limited access to treatment and prevention services, and high rates of stigma. The World Health Organization (WHO) recently released updated guidance on the delivery of HIV PEP. This commentary aims to highlight the salient changes, evaluate how such recommendations can overcome the existing barriers to PEP implementation and discuss strategies needed to put the updated guidance into practice. The 2024 WHO PEP guidelines continue a trend towards increasing access to PEP. Most notably, the WHO now provides strong recommendations that: (1) PEP be delivered in community settings (e.g. pharmacies, police stations and online platforms), and (2) PEP delivery and monitoring be done via task sharing involving non-specialist health workers (e.g. pharmacists or community health workers). The guidelines also emphasize that the PEP encounter is an important educable moment whereby a transition to pre-exposure prophylaxis among individuals at continued risk for HIV infection should be discussed. The decentralization of PEP delivery has the potential to overcome numerous barriers to PEP implementation, reduce time to initiation and support adherence with the 28-day course. To translate the recommendations into delivery programmes, however, much more work is needed. Detailed templates can help overcome the heterogeneity of both the community settings in which PEP can now be provided and the populations (e.g. survivors of sexual assault, healthcare workers, sex workers, etc.) among whom PEP may be indicated. Training of the workforce will be essential, which should include, as emphasized by the WHO, training in trauma-based care. Novel formulations of and delivery mechanisms for PEP are also emerging, and how such iterations can synergize with decentralized PEP delivery programmes remains to be seen. The updated WHO PEP guidelines make major strides towards increasing access to PEP. Realization of such aims will require ongoing evaluation and support given the heterogeneity in who benefits most from PEP.

Development and Implementation of Mental Healthcare Plans in Three Districts in Ghana: A Mixed-Method Process Evaluation Using Theory of Change.

In Ghana, a severe mental healthcare gap of 95-98% exists due to limited services. Ghana Somubi Dwumadie set out to address this by developing district mental healthcare plans (DMHPs) in three demonstration districts. Following the Programme for Improving Mental Healthcare model, district mental health operations teams were formed and used Theory of Change (ToC) to develop DMHPs. Key elements included training non-specialist health workers and enrolling individuals in relevant healthcare programmes. Evaluation methods included routine data, health facility surveys, and qualitative analysis within the ToC framework. Results showed improved integration of mental health services, enhanced case management through training, and increased service utilisation, shown through 691 service user enrollments. However, there was limited commitment of new resources and no significant improvement in primary care workers' capacity to detect priority mental health conditions. The study concludes that DMHPs, implemented with an integrated approach, can improve mental health service utilisation, contingent on committed leadership, resource availability, and stakeholder engagement.

Cancer Care Disparities: Overcoming Barriers to Cancer Control in Low- and Middle-Income Countries.

The rising global burden of cancer disproportionately affects low- and middle-income countries (LMICs), which account for over half of new patients and cancer deaths worldwide. However, LMIC health systems face profound challenges in implementing comprehensive cancer control programs because of limited health care resources and infrastructure. This analytical review explores contemporary evidence on barriers undermining cancer control efforts in resource-constrained LMIC settings. We conducted a comprehensive literature review of peer-reviewed evidence on cancer control challenges and solutions tailored to resource-limited settings. We provide a conceptual framework categorizing these barriers across the cancer care continuum, from raising public awareness to palliative care. We also appraise evidence-based strategies proposed to overcome identified obstacles to cancer control in the published literature, including task-shifting to nonspecialist health workers, strategic prioritization of high-impact interventions, regional collaborations, patient navigation systems, and novel financing mechanisms. Developing strong primary care delivery platforms integrated with specialized oncology care, alongside flexible and resilient health system models tailored to local contexts, will be critical to curb the rising tide of cancer in resource-limited settings. Urgent global commitments and investments are needed to dismantle barriers and expand access to prevention, early detection, diagnosis, treatment, and palliation services for all patients with cancer residing in LMICs as an ethical imperative. The review elucidates priority areas for policy actions, health systems strengthening, and future research to guide international efforts toward more equitable cancer control globally.

"Early in the morning, there's tolerance and later in the day it disappears" - The intersection of resource scarcity, stress and stigma in mental health and substance use care in South Africa.

Stress is a challenge among non-specialist health workers worldwide, particularly in low-resource settings. Understanding and targeting stress is critical for supporting non-specialists and their patients, as stress negatively affects patient care. Further, stigma toward mental health and substance use conditions also impacts patient care. However, there is little information on the intersection of these factors. This sub-analysis aims to explore how substance use and mental health stigma intersect with provider stress and resource constraints to influence the care of people with HIV/TB. We conducted semi-structured interviews (N=30) with patients (n=15) and providers (n=15, non-specialist health workers) within a low-resource community in Cape Town, South Africa. Data were analyzed using thematic analysis. Three key themes were identified: (1) resource constraints negatively affect patient care and contribute to non-specialist stress; (2) in the context of stress, non-specialists are hesitant to work with patients with mental health or substance use concerns, who they view as more demanding and (3) stress contributes to provider stigma, which negatively impacts patient care. Findings highlight the need for multilevel interventions targeting both provider stress and stigma toward people with mental health and substance use concerns, especially within the context of non-specialist-delivered mental health services in low-resource settings.

A Supervision Framework for Task-Shared Mental Health Workers: Implications for Clinical Trials and Beyond.

The rise in task-shared interventions that address the mental health treatment gap in low- and middle-income countries (LMICs) has highlighted the need for additional support and supervision of nonspecialist mental health workers (NHWs). The supervision of NHWs in most resource-limited settings is still primarily disorganized, without clear guidelines that provide the necessary structure for supervision. The need for supervision is even greater for NHWs working in the context of trauma, not only to provide training and ensure adequate delivery of care but also to provide support to minimize the psychological impact of their work. In South Africa, women face intersecting epidemics of HIV, intimate partner violence, and sexual trauma. This syndemic highlights the importance of integrating mental health treatment in HIV care, especially in settings like South Africa, where mental health services are limited. In this context, our group developed and is evaluating the effectiveness of ImpACT+, a task-shared coping intervention to improve clinical and mental health outcomes among HIV-infected women with sexual trauma in South Africa. We describe the ImpACT+ supervision model that is currently being implemented in the context of a hybrid effectiveness-implementation clinical trial. Combining experiences from clinical psychology, task-shared interventions, and trauma-informed care, the supervision model integrates formal elements of clinical supervision into categories that are suitable for use in task-shared trauma interventions in low-resource settings. To the best of our knowledge, such a trauma-informed supervision approach has not been widely documented in the literature, particularly in task-shared interventions in LMICs. In this article, we describe the ImpACT+ intervention, provide an overview of the supervision model, and provide illustrative examples of how the supervision model has been implemented.

A randomised controlled trial of clinical and cost-effectiveness of the PASS Plus intervention for young children with autism spectrum disorder in New Delhi, India: study protocol for the COMPASS trial

BackgroundAutism Spectrum Disorder (ASD) is a neurodevelopmental disability affecting at least 5 million children in South Asia. Majority of these children are without access to evidence-based care. The UK Pre-school Autism Communication Therapy (PACT) is the only intervention to have shown sustained impact on autism symptoms. It was systematically adapted for non-specialist community delivery in South Asia, as the ‘Parent-mediated Autism Social Communication Intervention for non-Specialists (PASS)’ and extended ‘PASS Plus’ interventions. RCTs of both showed feasibility, acceptability and positive effect on parent and child dyadic outcomes.MethodsThe Communication-centred Parent-mediated treatment for Autism Spectrum Disorder in South Asia (COMPASS) trial is now a scale-up two-centre, two-arm single (rater) blinded random allocation parallel group study of the PASS Plus intervention in addition to treatment as usual (TAU) compared to TAU alone, plus health economic evaluation embedded in the India health system. Two hundred forty children (approximately 120 intervention/120 TAU) with ASD aged 2–9 years will be recruited from two tertiary care government hospitals in New Delhi, India. Accredited Social Health Activists will be one of the intervention delivery agents. Families will undertake up to 12 communication sessions over 8 months and will be offered the Plus modules which address coexisting problems. The trial’s primary endpoint is at 9 months from randomisation, with follow-up at 15 months. The primary outcome is autism symptom severity; secondary outcomes include parent–child communication, child adaptation, quality of life and parental wellbeing. Primary analysis will follow intention-to-treat principles using linear mixed model regressions with group allocation and repeated measures as random effects. The cost-effectiveness analysis will use a societal perspective over the 15-month period of intervention and follow-up.DiscussionIf clinically and cost-effective, this programme will fill an important gap of scalable interventions delivered by non-specialist health workers within the current care pathways for autistic children and their families in low-resource contexts. The programme has been implemented through the COVID-19 pandemic when restrictions were in place; intervention delivery and evaluation processes have been adapted to address these conditions.Trial registrationISRCTN; ISRCTN21454676; Registered 22 June 2018.

Social support and user engagement with task-shared psychological treatments in the real world: Findings from the PRIME India study

PurposeTask sharing in psychological treatments has been recognized as an effective strategy for bridging the global mental health treatment gap. However, more research is needed to better support its implementation in routine care. Mental health services users' engagement with treatment is a crucial implementation factor, yet empirical evidence on its determinants remains sparse. The current study aims to investigate social support as a predictor of users’ session attendance, a key indicator of treatment engagement, within a task-shared psychological treatment. MethodsThis is a secondary analysis of cohort study data from the Program for Improving Mental Health Care (PRIME) implemented in Sehore district, India, where trained non-specialist health workers delivered manualized treatment for depression and alcohol use disorder (AUD; n = 240 in depression cohort, n = 190 in AUD cohort). Quasi-Poisson regression models were used to assess the association between users’ perceived social support at baseline and treatment session attendance at 3-month follow-up, controlling for socio-demographic and clinical characteristics. ResultWithin the depression cohort, a 4-point increase in social support score at baseline predicted a higher number of treatment sessions attended by 3-month follow up (IRR = 1.44, 95% CI: 1.06, 1.93). Within the AUD cohort, we noted insufficient statistical evidence for a weak association between users’ social support and the number of treatment sessions attended in adjusted analysis (IRR = 1.02; 95% CI: 0.69, 1.49). ConclusionOur findings suggest that the implementation of task-shared psychological treatments for depression into routine care may be enhanced by strategies that activate or build upon the functional roles of users’ social support.

Using mobile health technology to assess childhood autism in low-resource community settings in India: An innovation to address the detection gap.

Autism is diagnosed by highly trained professionals- but most autistic people live in parts of the world that harbour few or no such autism specialists and little autism awareness. So many autistic people go undiagnosed, misdiagnosed, and misunderstood. We designed an app (START) to identify autism and related conditions in such places, in an attempt to address this global gap in access to specialists. START uses computerised games and activities for children and a questionnaire for parents to measure social, sensory, and motor skills. To check whether START can flag undiagnosed children likely to have neurodevelopmental conditions, we tested START with children whose diagnoses already were known: Non-specialist health workers with just a high-school education took START to family homes in poor neighbourhoods of Delhi, India to work with 131 two-to-seven-year-olds. Differences between typically and atypically developing children were highlighted in all three types of skills that START assesses: children with neurodevelopmental conditions preferred looking at geometric patterns rather than social scenes, were fascinated by predictable, repetitive sensory stimuli, and had more trouble with precise hand movements. Parents' responses to surveys further distinguished autistic from non-autistic children. An artificial-intelligence technique combining all these measures demonstrated that START can fairly accurately flag atypically developing children. Health workers and families endorsed START as attractive to most children, understandable to health workers, and adaptable within sometimes chaotic home and family environments. This study provides a proof of principle for START in digital screening of autism and related conditions in community settings.

Designing interventions to ameliorate mental health conditions in resource-constrained contexts: some considerations

Health interventions, including those directed at ameliorating symptoms of mental disorders, can contribute significantly to realising the goal of sustainable development. The Strategic Development Goal of ensuring healthy lives and well-being for all, at all ages, pertains all health conditions, including those affecting mental health. Considering the low ratio of researchers to the population of many low- and middle-income countries, there is a specific need to build capacity for research so as to ensure good quality data so that social policies can be data-informed. This article outlines four considerations for trial investigators assessing the effectiveness of mental health interventions in low- and middle-income countries, namely, task sharing, scaling up, structural barriers, and the transformation imperative. Task sharing is an arrangement in which non-specialist health workers receive training and supervision to screen for and diagnose mental disorders and intervene with persons affected by them. Scaling up a proof of concept is appropriate when trials yield positive results showing effectiveness of the intervention. Structural barriers such as transport difficulties, long waiting times in clinics, food insecurity, competing demands on people’s time, childcare concerns, and poor health literacy play an important role in driving health behaviours and should be considered in intervention design. Transformation of the cadre of researchers to include those from oppressed and marginalised groups will yield investigators who are able to frame research questions and develop methodologies that reflect the lived realities of these communities.

Contact screening and management in a high-transmission MDR-TB setting in Papua New Guinea: Progress, challenges and future directions

Daru, South Fly District, Papua New Guinea is a high transmission setting for multidrug-resistant tuberculosis (MDR-TB). An emergency response by the Government in 2014 established a high-quality model for treatment and care. Household contact screening and management commenced in 2016 with TB preventive treatment (TPT) for well young child (<5 years) contacts of people with drug-susceptible TB and later expanded to young child contacts of MDR-TB. The model of care is community-based and led by non-specialist health workers, under supervision. An electronic medical record system supports care, reporting and operational research. Community engagement and education has been central, with a concerted focus on peer-led counselling and patient-centred services to improve TPT uptake and completion. Challenges include the application of households as the unit of intervention for detection of active TB and TPT provision. Our implementation experience in Daru has highlighted significant population mixing dynamics with most transmission likely occurring outside the household. We propose a community-wide screening approach with the provision of TPT based on testing to include older children, adolescents, and young adults. As there is the possibility of MDR-TB infection irrespective of the drug susceptibility of the household index case, a novel option is a combination TPT regimen of 6 months of daily isoniazid and levofloxacin (6HLfx). A sensitive aged-related algorithm to detect and exclude active TB is being developed. Ongoing community engagement, quality data systems with operational research to evaluate approaches are critical in high transmission MDR-TB settings.

Implementing hearing screening among children aged 0-59 months at established immunization clinics in Uganda: A multi-center study.

The prevalence of childhood hearing loss (HL) is high in low and middle income countries (LMICs), with many of the affected children facing communication delays and poor opportunities for education. Despite the increased advocacy for childhood hearing screening globally, Uganda has no established childhood hearing screening programs. This study set out to introduce hearing screening services by non-specialist health workers at routine immunization clinics among children aged 0-59 months and describe the prevalence and factors associated with failed hearing screening (HS) in these children. A cross-sectional multi-center study was conducted at immunization clinics at three regional referral hospitals (RRHs). A semi structured questionnaire was used to capture data on socio-demographic, clinical factors and the two stage Transient Evoked Oto-acoustic emissions (TEOAEs) screening performed on children aged 0-59 months. A child that failed two stage screening was considered to have failed HS. Logistic regression was used to calculate odds ratios (OR) for factors associated with failed HS. 1217 children were recruited at three RRHs, with a median age of 2 months (range: 0 to 59), half were male 52% (n=633). Overall 45 children failed two staged TEOAE screening giving a prevalence of failed HS of 3.7%, of these 27 (2.2%) and 18 (1.5%) failed unilaterally and bilaterally respectively. Children of rural residence (aOR=2.18, p=0.027), of low birth weight (aOR=0.42, p=0.045), with relatives having hearing loss (aOR=4.64, p= <0.001), who were admitted in hospital after birth (aOR=3.72, p=0.012) and a history of a childhood suppurative otitis media (aOR=9.53, p=0.015) all had increased odds of failed HS. The prevalence of failed screening is high. Implementation of childhood hearing screening by non-specialist health workers at immunization clinics using TEOAEs is possible and may be a necessary initial step in starting countrywide hearing screening in Uganda.

Diseasomics: Actionable machine interpretable disease knowledge at the point-of-care.

Physicians establish diagnosis by assessing a patient's signs, symptoms, age, sex, laboratory test findings and the disease history. All this must be done in limited time and against the backdrop of an increasing overall workload. In the era of evidence-based medicine it is utmost important for a clinician to be abreast of the latest guidelines and treatment protocols which are changing rapidly. In resource limited settings, the updated knowledge often does not reach the point-of-care. This paper presents an artificial intelligence (AI)-based approach for integrating comprehensive disease knowledge, to support physicians and healthcare workers in arriving at accurate diagnoses at the point-of-care. We integrated different disease-related knowledge bodies to construct a comprehensive, machine interpretable diseasomics knowledge-graph that includes the Disease Ontology, disease symptoms, SNOMED CT, DisGeNET, and PharmGKB data. The resulting disease-symptom network comprises knowledge from the Symptom Ontology, electronic health records (EHR), human symptom disease network, Disease Ontology, Wikipedia, PubMed, textbooks, and symptomology knowledge sources with 84.56% accuracy. We also integrated spatial and temporal comorbidity knowledge obtained from EHR for two population data sets from Spain and Sweden respectively. The knowledge graph is stored in a graph database as a digital twin of the disease knowledge. We use node2vec (node embedding) as digital triplet for link prediction in disease-symptom networks to identify missing associations. This diseasomics knowledge graph is expected to democratize the medical knowledge and empower non-specialist health workers to make evidence based informed decisions and help achieve the goal of universal health coverage (UHC). The machine interpretable knowledge graphs presented in this paper are associations between various entities and do not imply causation. Our differential diagnostic tool focusses on signs and symptoms and does not include a complete assessment of patient's lifestyle and health history which would typically be necessary to rule out conditions and to arrive at a final diagnosis. The predicted diseases are ordered according to the specific disease burden in South Asia. The knowledge graphs and the tools presented here can be used as a guide.

Rural health workers' perspectives and experience with an online educational program in behavioural activation: A thematic analysis.

Cognitive behavioural therapy (CBT) is an effective treatment for depression. There are established education programmes which prepare specialist mental health workers to practice CBT. CBT is a complex treatment requiring intensive preparation and clinical skill to deliver. An alternative and simpler psychological treatment, behavioural activation (BA), may be as effective as CBT. An advantage of BA over CBT is that you do not need to be a specialist mental health worker nor require lots of training to deliver it. The relative simplicity of BA and the brief education required for workers to deliver it may increase access to psychological treatments for depression. In 2020, we developed an online educational programme in BA targeting non-specialist healthcare workers. In this paper, we wanted to understand healthcare workers' perceptions and experiences of completing a professional certificate programme which prepares them to deliver BA for people living with depression. We report the feedback from seven non-specialist mental health workers who completed the online education programme in BA. Twelve workers were invited to enrol on the programme, of which four declined. All but one of the eight participants lived and worked in rural South Australia. A thematic analysis of the interview data identified three themes: Course was simple to follow, Ease of integration into clinical practice and Ongoing support and supervision. The overall meta-theme was 'Easy to train and easy to apply'. Participants reported that the online training prepared them to practice BA and they were able to apply the skills in their clinical practice. Future work needs to examine if online training for healthcare workers in BA translates to clinical outcomes for people living with depression.

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.

Psychosocial interventions for depression delivered by non-mental health specialists to people living with HIV/AIDS in low- and middle-income countries: A systematic review

BackgroundDepression commonly co-exists with human immunodeficiency virus (HIV), but in low- and middle-income countries (LMICs), where the HIV burden is greatest, mental health resources are limited. These settings may benefit from psychosocial interventions delivered to people living with HIV/AIDS (PLWH) by non-mental health specialists. We aimed to systematically review randomised controlled trials (RCTs) that investigated the effectiveness of psychosocial interventions delivered by non-mental health specialists to prevent depression in PLWH in LMICs.MethodsWe used a comprehensive electronic search strategy to identify RCTs of any stage, including pilot studies, which reported on the effectiveness of a psychosocial intervention on depression among adults living with HIV/AIDS in a LMIC setting. Screening, study selection and data extraction was completed independently by two authors. We assessed risk of bias using the Cochrane risk of bias (RoB) tool and performed a narrative synthesis.ResultsWe identified 3431 studies, from which we included 15 studies corresponding to 14 RCTs and a total of 3997 PLWH. Eleven studies were parallel RCTs, one was a stepped-wedged RCT, one was a full factorial RCT, one was a three-arm RCT and four were pilot studies. Studies were generally small, with eight including depression as a primary outcome. All but four trials included men and women and most studies followed participants for less than one year. Twelve trials had at least one domain in which there was a high risk of bias, with the remaining two trials having at least one domain of concern, due to lack of reporting of items. In 12 studies people in the intervention arm had statistically significantly (P < 0.05) lower or more reduced depressive symptom scores, or were less likely to have major depression, at final follow-up than people in the control group.ConclusionsPsychosocial interventions delivered by non-specialist mental health workers may be effective in preventing or reducing depression in PLWH in LMICs. However, existing studies are small with a relatively short follow-up period and have methodological limitations. Future trials should address these shortcomings, establish whether intervention effects are clinically meaningful and investigate cost-effectiveness.

Proceedings of the 17th Annual International INEBRIA Conference

Proceedings of the 17th Annual International INEBRIA Conference

An evaluation of mental health capacity building among Community Rehabilitation Officers in Malawi: A mixed-methods case study

BackgroundThe World Health Organisation's Mental Health Gap Action Programme (mhGAP) training has been delivered throughout sub-Saharan Africa to enhance health workers' capacity to provide mental health care. mhGAP training evaluations typically assess one or two soft skills, namely trainee confidence to identify, manage, and refer people with mental illness, and their attitudes towards people with mental illness. This research expands on these evaluations by assessing changes in Community Rehabilitation Officers' (CROs) knowledge and self-efficacy to identify, manage, and refer people with mental illness, in addition to their confidence and attitudes. The relationship between changes in CROs' attitudes and changes in their knowledge, confidence, and self-efficacy, and perceptions of CROs' capacity in delivering community mental health care are also explored. Material and methodsIn this mixed-methods study, fifty-seven CROs who participated in mhGAP training in Malawi were assessed on knowledge, confidence, and self-efficacy in delivering mental health care and their attitude towards mental illness. Two programme managers and seven facilitators were interviewed to investigate their perception of CROs' mental health care delivery capacity post-training. ResultsOnly CROs' confidence and self-efficacy scores improved post-training. No relationship was found between changes in attitude scores and knowledge, confidence, and self-efficacy scores. Programme managers and facilitators identified instances where training positively impacted CROs’ delivery of mental health care. However, they questioned its long-term sustainability. ConclusionsmhGAP training was found to enhance CRO confidence and self-efficacy in Malawi. Thus, mhGAP training may help in improving the confidence and self-efficacy of non-specialist health workers in this context. How mhGAP training impacts changes in knowledge and attitudes towards mental health requires further exploration. CROs' sustainable provision of mental health care in resource-constrained contexts needs to be addressed. Findings add to the evidence on the impact of mhGAP training in building health workers’ mental health care delivery capacity.

Assessment and validation of the Community Maternal Danger Score algorithm

BackgroundHigh rates of maternal mortality in low-and-middle-income countries (LMICs) are associated with the lack of skilled birth attendants (SBAs) at delivery. Risk analysis tools may be useful to identify pregnant women who are at risk of mortality in LMICs. We sought to develop and validate a low-cost maternal risk tool, the Community Maternal Danger Score (CMDS), which is designed to identify pregnant women who need an SBA at delivery.MethodsTo design the CMDS algorithm, an initial scoping review was conducted to identify predictors of the need for an SBA. Medical records of women who delivered at the Federal Medical Centre in Makurdi, Nigeria (2019–2020) were examined for predictors identified from the literature review. Outcomes associated with the need for an SBA were recorded: caesarean section, postpartum hemorrhage, eclampsia, and sepsis. A maternal mortality ratio (MMR) was determined. Multivariate logistic regression analysis and area under the curve (AUC) were used to assess the predictive ability of the CMDS algorithm.ResultsSeven factors from the literature predicted the need for an SBA: age (under 20 years of age or 35 and older), parity (nulliparity or grand-multiparity), BMI (underweight or overweight), fundal height (less than 35 cm or 40 cm and over), adverse obstetrical history, signs of pre-eclampsia, and co-existing medical conditions. These factors were recorded in 589 women of whom 67% required an SBA (n = 396) and 1% died (n = 7). The MMR was 1189 per 100,000 (95% CI 478–2449). Signs of pre-eclampsia, obstetrical history, and co-existing conditions were associated with the need for an SBA. Age was found to interact with parity, suggesting that the CMDS requires adjustment to indicate higher risk among younger multigravida and older primigravida women. The CMDS algorithm had an AUC of 0.73 (95% CI 0.69–0.77) for predicting whether women required an SBA, and an AUC of 0.85 (95% CI 0.67–1.00) for in-hospital mortality.ConclusionsThe CMDS is a low-cost evidence-based tool that uses 7 risk factors assessed on 589 women from Makurdi. Non-specialist health workers can use the CMDS to standardize assessment and encourage pregnant women to seek an SBA in preparation for delivery, thus improving care in countries with high rates of maternal mortality.

Role of accredited social health activists in treatment of persons with severe mental illness in the community.

Role of accredited social health activists in treatment of persons with severe mental illness in the community.