Expanding mental health services in low- and middle-income countries: A task-shifting framework for delivery of comprehensive, collaborative, and community-based care.

This paper proposes a framework for comprehensive, collaborative, and community-based care (C4) for accessible mental health services in low-resource settings. Because mental health conditions have many causes, this framework includes social, public health, wellness and clinical services. It accommodates integration of stand-alone mental health programs with health and non-health community-based services. It addresses gaps in previous models including lack of community-based psychotherapeutic and social services, difficulty in addressing comorbidity of mental and physical conditions, and how workers interact with respect to referral and coordination of care. The framework is based on task-shifting of services to non-specialized workers. While the framework draws on the World Health Organization's Mental Health Gap Action Program and other global mental health models, there are important differences. The C4 Framework delineates types of workers based on their skills. Separate workers focus on: basic psychoeducation and information sharing; community-level, evidence-based psychotherapeutic counseling; and primary medical care and more advanced, specialized mental health services for more severe or complex cases. This paper is intended for individuals, organizations and governments interested in implementing mental health services. The primary aim is to provide a framework for the provision of widely accessible mental health care and services.

Global priorities for climate change and mental health research.

BACKGROUND: Compared with other health areas, the mental health impacts of climate change have received less research attention. The literature on climate change and mental health is growing rapidly but is characterised by several limitations and research gaps. In a field where the need for designing evidence-based adaptation strategies is urgent, and research gaps are vast, implementing a broad, all-encompassing research agenda will require some strategic focus. METHODS: We followed a structured approach to prioritise future climate change and mental health research. We consulted with experts working across mental health and climate change, both within and outside of research and working in high, middle, and low-income countries, to garner consensus about the future research priorities for mental health and climate change. Experts were identified based on whether they had published work on climate change and mental health, worked in governmental and non-governmental organisations on climate change and mental health, and from the professional networks of the authors who have been active in the mental health and climate change space. RESULTS: Twenty-two experts participated from across low- and middle-income countries (n = 4) and high-income countries (n = 18). Our process identified ten key priorities for progressing research on mental health and climate change. CONCLUSION: While climate change is considered the biggest threat to global mental health in the coming century, tackling this threat could be the most significant opportunity to shape our mental health for centuries to come because of health co-benefits of transitioning to more sustainable ways of living. Research on the impacts of climate change on mental health and mental health-related systems will assist decision-makers to develop robust evidence-based mitigation and adaptation policies and plans with the potential for broad benefits to society and the environment.

Advancing and translating knowledge: a systematic inquiry into the 2010-2020 mental health and psychosocial support intervention research evidence base.

Background and study objectives: MHPSS is increasingly seen as a critical component to effective and responsible humanitarian programming. This review examines the extent to which MHPSS research generated since 2010 has contributed to the public health evidence base and how this has influenced and impacted programming and policy in humanitarian settings. Methods: This mixed-method study included a scoping literature review (n = 50) and a consultation process with qualitative key informant interviews (n = 19) and online survey responses (n = 52) to identify the facilitating and inhibiting factors for the two areas of inquiry and to understand the broader context in which knowledge is generated and taken up. The interviews were thematically analysed and the survey responses were descriptively analysed. Results: The review identified a rapidly growing evidence base that has evaluated a range of MHPSS interventions. However, few studies examined long-term impacts of interventions, there was limited direct evidence on outcomes for children and adolescents and whole family approaches, and there were minimal replications of the same approach that could test efficacy across settings and population groups. A general shift was identified in the consultation process away from a focus on disorder towards the more positive aspects of wellbeing. However, there remained a mismatch in many studies included in the literature review, whereby the interventions were broad, community-based but the outcome measures used still focused on changes in symptoms of mental disorders. Conclusion: The evidence base for MHPSS has grown significantly over the last 10 years. However, several knowledge gaps remain, as does the divide between research and practice. Moving forward, MHPSS intervention research needs to be more responsive to the needs on the ground.

Cortisol awakening response over the course of humanitarian aid deployment: a prospective cohort study.

Background: Internationally deployed humanitarian aid (HA) workers are routinely confronted with potentially traumatic stressors. However, it remains unknown whether HA deployment and related traumatic stress are associated with long-term changes in hypothalamic-pituitary-adrenal (HPA) axis function. Therefore, we investigated whether cortisol awakening response (CAR) decreased upon deployment and whether this was moderated by previous and recent trauma exposure and parallel changes in symptom severity and perceived social support. Methods: In this prospective study, n = 86 HA workers (68% females) completed questionnaires regarding trauma exposure, posttraumatic stress disorder (PTSD), anxiety and depressive symptoms and perceived social support, as well as salivary cortisol assessments at awakening and 30 minutes post-awakening at before, early and 3-6 months post-deployment. Results: Linear mixed models showed significantly decreased CAR (b(SE) = -.036(.011), p = .002) and awakening cortisol over time (b(SE) = -.007(.003), p = .014). The extent of awakening cortisol change was significantly moderated by interactions between previous and recent trauma exposure. Also, a steeper awakening cortisol decrease was significantly associated with higher mean anxiety and PTSD symptoms across assessments. No significant effects were found for social support. Conclusions: We observed attenuated CAR and awakening cortisol upon HA deployment, with a dose-response effect between trauma exposure before and during the recent deployment on awakening cortisol. Awakening cortisol change was associated with PTSD and anxiety symptom levels across assessments. Our findings support the need for organizational awareness that work-related exposures may have long-lasting biological effects. Further research assessing symptoms and biological measures in parallel is needed to translate current findings into guidelines on the individual level.

Antecedentes: Los trabajadores de la ayuda humanitaria desplegados internacionalmente (HA) se enfrentan rutinariamente a estresores potencialmente traumáticos. Sin embargo, aún se desconoce si el despliegue de la HA y el estrés traumático relacionado están asociados con cambios a largo plazo en la función del eje hipotalámico-pituitaria-suprarrenal (HPA). Por lo tanto, investigamos si la respuesta del cortisol al despertar (CAR, en sus siglas en inglés) disminuyó en el momento del despliegue y si esto fue moderado por una anterior o reciente exposición a un trauma y los cambios paralelos en la gravedad de los síntomas y el apoyo social percibido.Métodos: En este estudio prospectivo, x = 86 trabajadores de la HA (68% mujeres) completaron cuestionarios sobre la exposición al trauma, el trastorno de estrés postraumático (TEPT), la ansiedad y los síntomas depresivos y el apoyo social percibido, así como evaluaciones del cortisol salival al despertar y 30 minutos después del despertar, antes, durante y 3-6 meses después del despliegue.Resultados: Los modelos lineales mixtos mostraron una disminución significativa de la CAR (b(SE) = −.036(.011), p = .002) y del cortisol al despertar, en el transcurso del tiempo (b(SE) = −.007(.003), p = .014). El grado de cambio en el cortisol al despertar fue significativamente moderado por las interacciones entre la exposición anterior y reciente al trauma. Además, una disminución más pronunciada del cortisol al despertar se asoció significativamente con una mayor media de ansiedad y síntomas de TEPT en todas las evaluaciones. No se encontraron efectos significativos en cuanto al apoyo social.Conclusiones: Observamos CAR atenuado y cortisol al despertar en el despliegue de HA, con un efecto dosis-respuesta en el cortisol al despertar, entre la exposición al trauma antes y durante el reciente despliegue. El cambio de cortisol al despertar se asoció con el TEPT y los niveles de síntomas de ansiedad en todas las evaluaciones. Nuestros hallazgos apoyan la necesidad de la conciencia organizacional de que las exposiciones relacionadas con el trabajo pueden tener efectos biológicos duraderos. Se necesitan más investigaciones que evalúen los síntomas y las medidas biológicas en paralelo para traducir los hallazgos actuales en directrices a nivel individual.

Ethical standards for mental health and psychosocial support research in emergencies: review of literature and current debates.

BACKGROUND: Research in emergencies is needed to understand the prevalence of mental health and psychosocial problems and strengthen the evidence base for interventions. All research - including operational needs assessments, programme monitoring and evaluation, and formal academic research - must be conducted ethically. While there is broad consensus on fundamental principles codified in research ethics guidelines, these do not address the ethical specificities of conducting mental health and psychosocial support (MHPSS) research with adults in emergencies. To address this gap, this paper presents a review of multidisciplinary literature to identify specific ethical principles applicable to MHPSS research in emergencies. DISCUSSION: Fifty-nine sources meeting the literature review inclusion criteria were analysed following a thematic synthesis approach. There was consensus on the relevance of universal ethical research principles to MHPSS research in emergencies, including norms of participant informed consent and protection; ensuring benefit arises from research participation; researcher neutrality, accountability, and safety; and the duty to ensure research is well designed and accounts for contextual factors in emergency settings. We go onto discuss unresolved issues by highlighting six current debates relating to the application of ethics in emergency settings: (1) what constitutes fair benefits?; (2) how should informed consent be operationalised?; (3) is there a role for decision making capacity assessments?; (4) how do risk management approaches impact upon the construction of ethical research?; (5) how can ethical reflection best be achieved?, and (6) are ethical review boards sufficiently representative and equipped to judge the ethical and scientific merit of emergency MHPSS research? Underlying these debates is a systemic tension between procedural ethics and ethics in practice. In summary, underpinning the literature is a desire to ensure the protection of participants exposed to emergencies and in need of evidence-based MHPSS. However, there is a lack of agreement on how to contextualise guidelines and procedures to effectively maximise the perspectives of researchers, participants and ethical review boards. This is a tension that the field must address to strengthen ethical MHPSS research in emergencies.

A reflective learning report about the implementation and impacts of Psychological First Aid (PFA) in Gaza.

Psychological First Aid (PFA) is the recommended immediate psychosocial response during crises. As PFA is now widely implemented in crises worldwide, there are increasing calls to evaluate its effectiveness. World Vision used PFA as a fundamental component of their emergency response following the 2014 conflict in Gaza. Anecdotal reports from Gaza suggest a range of benefits for those who received PFA. Though not intending to undertake rigorous research, World Vision explored learnings about PFA in Gaza through Focus Group Discussions with PFA providers, Gazan women, men and children and a Key Informant Interview with a PFA trainer. The qualitative analyses aimed to determine if PFA helped individuals to feel safe, calm, connected to social supports, hopeful and efficacious - factors suggested by the disaster literature to promote coping and recovery (Hobfoll et al., 2007). Results show positive psychosocial benefits for children, women and men receiving PFA, confirming that PFA contributed to: safety, reduced distress, ability to engage in calming practices and to support each other, and a greater sense of control and hopefulness irrespective of their adverse circumstances. The data shows that PFA formed an important part of a continuum of care to meet psychosocial needs in Gaza and served as a gateway for addressing additional psychosocial support needs. A "whole-of-family" approach to PFA showed particularly strong impacts and strengthened relationships. Of note, the findings from World Vision's implementation of PFA in Gaza suggests that future PFA research go beyond a narrow focus on clinical outcomes, to a wider examination of psychosocial, familial and community-based outcomes.

Psychological distress, depression, anxiety, and burnout among international humanitarian aid workers: a longitudinal study.

BACKGROUND: International humanitarian aid workers providing care in emergencies are subjected to numerous chronic and traumatic stressors. OBJECTIVES: To examine consequences of such experiences on aid workers' mental health and how the impact is influenced by moderating variables. METHODOLOGY: We conducted a longitudinal study in a sample of international non-governmental organizations. Study outcomes included anxiety, depression, burnout, and life and job satisfaction. We performed bivariate regression analyses at three time points. We fitted generalized estimating equation multivariable regression models for the longitudinal analyses. RESULTS: Study participants from 19 NGOs were assessed at three time points: 212 participated at pre-deployment; 169 (80%) post-deployment; and 154 (73%) within 3-6 months after deployment. Prior to deployment, 12 (3.8%) participants reported anxiety symptoms, compared to 20 (11.8%) at post-deployment (p = 0.0027); 22 (10.4%) reported depression symptoms, compared to 33 (19.5%) at post-deployment (p = 0.0117) and 31 (20.1%) at follow-up (p = .00083). History of mental illness (adjusted odds ratio [AOR] 4.2; 95% confidence interval [CI] 1.45-12.50) contributed to an increased risk for anxiety. The experience of extraordinary stress was a contributor to increased risk for burnout depersonalization (AOR 1.5; 95% CI 1.17-1.83). Higher levels of chronic stress exposure during deployment were contributors to an increased risk for depression (AOR 1.1; 95% CI 1.02-1.20) comparing post- versus pre-deployment, and increased risk for burnout emotional exhaustion (AOR 1.1; 95% CI 1.04-1.19). Social support was associated with lower levels of depression (AOR 0.9; 95% CI 0.84-0.95), psychological distress (AOR = 0.9; [CI] 0.85-0.97), burnout lack of personal accomplishment (AOR 0.95; 95% CI 0.91-0.98), and greater life satisfaction (p = 0.0213). CONCLUSIONS: When recruiting and preparing aid workers for deployment, organizations should consider history of mental illness and take steps to decrease chronic stressors, and strengthen social support networks.

Depressive symptoms in youth heads of household in Rwanda: correlates and implications for intervention.

OBJECTIVE: To examine the level of depressive symptoms and their predictors in youth from one region of Rwanda who function as heads of household (ie, those responsible for caring for other children) and care for younger orphans. DESIGN: Cross-sectional survey SETTING: Four adjoining districts in Gigonkoro, an impoverished rural province in southwestern Rwanda. PARTICIPANTS: Trained interviewers met with the eldest member of each household (n = 539) in which a youth 24 years old or younger was caring for 1 child or more. MAIN EXPOSURE: Serving as a youth head of household. MAIN OUTCOME MEASURES: Rates and severity of depressive symptoms using the Center for Epidemiologic Studies Depression scale; measures of grief, adult support, social marginalization, and sociodemographic factors using scales developed for this study. RESULTS: Of the 539 youth heads of household, 77% were subsistence farmers and only 7% had attended school for 6 years or more. Almost half (44%) reported eating only 1 meal a day in the last week, and 80% rated their health as fair or poor. The mean score on the Center for Epidemiologic Studies Depression scale was 24.4, exceeding the most conservative published cutoff score for adolescents. Multivariate analysis revealed that reports of depressive symptoms that exceeded the clinical cutoff were associated with having 3 basic household assets or fewer, such as a mattress and a spare set of clothes (odds ratio [OR], 1.69; 95% confidence interval [CI], 1.06-2.70), eating less than 1 meal per day (OR, 1.68; 95% CI, 1.09-2.60), reporting fair health (OR, 1.32; 95% CI, 0.76-2.29) or poor health (OR, 2.33; 95% CI, 1.17-4.64), endorsing high levels of grief (OR, 2.67; 95% CI, 1.73-4.13), having at least 1 parent die in the genocide as opposed to all other causes of parental death (OR, 1.83; 95% CI, 1.10-3.04), and not having a close friend (OR, 1.91; 95% CI, 1.17-3.12). There was an interaction between marginalization from the community and alcohol use; youth who were highly marginalized and did not drink alcohol were more than 3 times more likely to report symptoms of depression (OR, 3.07; 95% CI, 1.73-5.42). When models were constructed by grouping theoretically related variables into blocks and controlling for other blocks, the emotional status block of variables (grief and marginalization) accounted for the most variance in depressive symptoms. CONCLUSIONS: Orphaned youth who head households in rural Rwanda face many challenges and report high rates of depressive symptoms. Interventions designed to go beyond improving food security and increasing household assets may be needed to reduce social isolation of youth heads of household. The effect of head-of-household depressive symptoms on other children living in youth-headed households is unknown.

Barriers to the community support of orphans and vulnerable youth in Rwanda.

A consistent theme in the literature on interventions for orphans and vulnerable children is the need for community-based care. However, a number of socio-cultural factors may impede community response. In this study, mixed methods are used to elucidate community-level barriers to care for orphans and vulnerable youth in Rwanda. Data from a large survey of youth heads of household on perceptions of marginalization from the community and the factors predicting that marginalization are considered in light of additional data from a survey of adults who volunteered to mentor these youth and focus groups with both community adults and youth heads of household. Results highlight how orphans' impoverished condition, cause of parents' death, and community perceptions of orphan behavior play a role in the marginalization of orphaned youth in Rwanda. Evidence is also offered to show that targeting humanitarian assistance to vulnerable youth may inadvertently lessen the level of community support they receive and contribute to their marginalization. The implications of these data for community-based program approaches are discussed.

Psychosocial support and marginalization of youth-headed households in Rwanda.

This research aims to characterize the psychosocial aspects of well-being among youth-headed households (YHH) in Gikongoro, Rwanda, through examination of social support and marginalization. Data is presented on perceived availability of support from relatives, an unidentified adult, peers, and other community members and an index of social marginalization. A total of 692 interviews were completed with YHH age 13-24 who are beneficiaries of a basic needs program. Sixteen percent of youth reported there was no one they felt they could go to with a problem. In times of need, only 24% felt relatives would help them, while 57% felt neighbors would offer assistance. Most youth reported significant caring relationships: 73% reported access to trusted adult who offers them advice and guidance, and most indicated close peer relationships. However, many youth also perceived a lack of community support, with 86% feeling rejected by the community and 57% feeling the community would rather hurt them than help them. Social support is a low-cost critical resource for the care of vulnerable youth and an understanding of existing social support networks would enhance the design and implementation of psychosocial and community-based care initiatives.

Infants and young children living in youth-headed households in Rwanda: Implications of emerging data.

The HIV/AIDS epidemic has already produced millions of orphans in Africa and the peak of the orphan epidemic has not yet been reached. One emerging social trend associated with premature parental death is the formation of households headed by youth aged 13-24. In Rwanda, specific sociocultural factors have supported the formation of youth-headed households (YHH) in the wake of both the 1994 genocide and the ongoing HIV/AIDS epidemic. There is no published data on the health and socioemotional functioning of children under 5 living in YHH. Survey data from 692 YHH in one region of Rwanda yielded a subsample of 89 homes which contained one or more children under 5 (n=104). These data reveal that a majority of young children living in YHH's is in fair or poor health. Heads of household themselves report high levels of depressive symptoms and social isolation; reports of emotional distress among the youngest children in the homes are associated with reports of higher symptomatology among heads of household. Findings are interpreted in light of the sociocultural context of Rwanda and the implications of the data for intervention are considered.

Psychosocial assessment for victims of violence in Peru: the importance of local participation.

This paper describes a pilot study assessing the psychosocial impact of political violence in the Peruvian Andes, utilizing a collaborative approach with local professionals and communities. The study team prioritized dialogue and information exchange with the local professional community and villagers participating in the assessment in order to raise awareness of psychosocial issues and provide education and support. Participation in the pilot study had positive therapeutic effects for villagers, and inspired ongoing discussion groups to address psychosocial problems in communities. This paper also describes a psychosocial assessment strategy utilizing qualitative methods and an adaptation of the Harvard Trauma Questionnaire in collaboration with Andean villagers. Usefulness and limitations of the data will be reviewed, in terms of cultural and context relevance, usefulness for informing interventions, and comparisons with ethnographic methodologies and other survey instruments.