Adapting a transdiagnostic digital mental health intervention for use among immigrant and refugee youth in Seattle: a human-centered design approach.

Digital mental health interventions show promise in addressing mental health needs, especially among youth and marginalized communities. This study adapted the World Health Organization -developed STARS (Sustainable Technology for Adolescents to Reduce Stress) digital mental health intervention for use among youth and young adults aged 14-25 from immigrant and refugee communities in Seattle, Washington. Human-centered design methods centered around qualitative semi-structured interviews were used to contextually and culturally adapt the intervention and prioritize the needs and preferences of the intended end user. Intervention prototypes were modified and then presented to the target groups in iterative cycles until saturation was achieved. Qualitative interviews occurred in three iterations of five participants each. Modifications were documented according to the Framework for Reporting Adaptations and Modifications-Expanded (FRAME) implementation science framework. Modifications aligned with the FRAME process elements: (a) tailoring/refining, which included adapting language to less resemble digital phishing scams; (b) changes in packaging or materials, which included naming the chatbot and adopting a corresponding avatar; (c) adding/removing, which included changing existing emojis and adding additional media types including graphics interchange format images, pictures, and voice memos; (d) shortening/condensing, which included shortening the length of individual text sections as well as deleting redundant language; (e) lengthening/extending, which included allowing the user to choose to receive content catered to teenagers or to adults; and (f) loosening structure, including giving users options to skip parts of modules or to engage with additional material. The modified STARS intervention shows promise for engagement with immigrant and refugee youth in Seattle and can be examined for clinical effectiveness. Adaptations increased the relevance of content to the intended end user, expanded options for personalization and customization of the user experience, and utilized language that was age appropriate, engaging, and did not invoke feelings of stigma or distrust. Adaptations of digital mental health interventions should focus on modifications that maximize acceptability and appropriateness to intended audiences.

Digital mental health interventions like apps and online mental health tools show promise in addressing mental health needs. This study adapted the STARS (Sustainable Technology for Adolescents to Reduce Stress) digital mental health intervention for use among youth and young adults from immigrant and refugee communities in Seattle, Washington. In our study, we adapted the intervention in a way that prioritizes the preferences of the intended end user. Modifications occurred in cycles: each time modifications resulted in a new version, the version was presented to a group of participants for their feedback and further modifications. Modifications in the final version included adapting language to less resemble digital phishing scams; naming the chatbot and adopting a corresponding avatar; changing existing emojis and adding additional media types; shortening the length of individual text sections as well as deleting redundant language; allowing the user to choose content catered to teenagers or to adults; and giving users options to skip parts of modules or to engage with additional material. The modified STARS intervention shows promise for engagement with immigrant and refugee youth in Seattle and can be examined for clinical effectiveness.

Prevalence and associated factors of common mental disorders in primary care settings in Sofala Province, Mozambique.

BACKGROUND: In Mozambique, the prevalence of common mental illness in primary care is not well established. AIMS: This study aimed to assess the prevalence of, and associated factors for, common mental illness in patients accessing primary care services in three Ministry of Health clinics in Mozambique. METHOD: Adult patients were recruited from the waiting rooms of prenatal, postpartum and general out-patient consultations. A mental health professional administered a diagnostic interview to examine prevalence of major depressive disorder (MDD), generalised anxiety disorder (GAD), post-traumatic stress disorder (PTSD) and any substance misuse or dependence. Generalised linear mixed models were used to examine the odds of each disorder and sociodemographic associations. RESULTS: Of 502 patients interviewed, 74.1% were female (n = 372) and the average age was 27.8 years (s.d. = 7.4). Of all participants, 23.9% (n = 120) met diagnostic criteria for at least one common mental disorder; 8.6% were positive for MDD (n = 43), 13.3% were positive for GAD (n = 67), 4.8% were positive for PTSD (n = 24) and 4.0% were positive for any substance misuse or dependence (n = 20). Patients attending prenatal or postpartum consultations had significantly lower odds of any common mental disorder than patients attending out-patient primary care. Age was negatively associated with MDD, but positively associated with substance misuse or dependence. CONCLUSIONS: Over 20% of patients attending primary care in Mozambique may have common mental disorders. A specific focus on patients attending general out-patient visits, young people for depression, and older people and men for substance misuse/dependence would provide a targeted response to high-risk demographics.

Demonstration project of a lay counselor delivered trans-diagnostic mental health intervention for newly diagnosed HIV patients in Mozambique.

ABSTRACTCommon mental disorders (CMDs) are associated with poor HIV outcomes in low- and middle-income countries. The present study implemented a psychological therapy delivered in routine HIV care and examined its effects on HIV outcomes in Mozambique. The Common Elements Treatment Approach (CETA) was integrated into routine HIV care in Sofala, Mozambique for all newly-diagnosed HIV+ patients with CMD symptoms. HIV treatment initiation and retention were compared to overall facility averages (those enrolled in CETA + those not enrolled). Of 250 patients screened, 59% (n = 148 met the criteria for CETA enrollment, and 92.6 (n = 137) enrolled in CETA. After four CETA visits, CMD symptoms decreased >50% and suicidal ideation decreased 100%. Patients enrolling in CETA had an antiretroviral therapy initiation rate of 97.1%, one-month retention of 69.2%, and three-month retention of 82.4%. Patients in the comparison group had one-month retention of 66.0% and three-month retention of 68.0%. CETA may be a promising approach to reduce symptoms of CMDs and improve HIV care cascade outcomes in areas with high HIV prevalence.

Psychometric properties of two mental health screening tools in southeast Liberia: The Liberian Distress Screener and Patient Health Questionnaire.

Evidence suggests that locally developed and/or adapted screening tools for mental ill-health can have higher validity than directly translated tools developed in other settings. We administered the locally developed Liberian Distress Screener (LDS) and the Liberian-adapted Patient Health Questionnaire-9 (PHQ-9L) to a random sample of 142 outpatients at a regional hospital in Maryland County, Liberia. In the LDS, seven items demonstrated poor model fit and were excluded, resulting in an 11-item screener (LDS-11). Exploratory factor analysis of the 11-item screener (LDS-11) showed a single latent variable construct with significant factor loadings. Cronbach's alpha revealed good internal consistency (α = 0.81). Rasch analyses showed that "brain hot" and "heart fall down" were the most difficult idioms of distress to endorse while "things playing on the mind" was the easiest. All LDS-11 elements were associated with elevated function impairment, with "things playing on the mind," "worry too much," "head is hurting," and "heart cut/beat fast" achieving statistical significance. One item in the PHQ-9L demonstrated poor model fit and was excluded from psychometric analyses. The resultant eight-item PHQ demonstrated internal consistency (α = 0.76) and Rasch analysis revealed that "moving/talking too slowly/fast" was the most difficult item to endorse, while "not happy when doing things" was the easiest. Twelve items were significantly associated with functional impairment. Exploratory analyses reveal items that demonstrate ease and appropriateness of use for assessing mental distress in this population. Implementation research is needed to incorporate idioms of distress and screeners into Liberia's mental healthcare system.

Integrating a Transdiagnostic Psychological Intervention Into Routine HIV Care: A Mixed-Methods Evaluation of the Common Elements Treatment Approach in Mozambique.

INTRODUCTION: We integrated a transdiagnostic psychological intervention (Common Elements Treatment Approach [CETA]) into routine HIV care in Sofala, Mozambique. This task-shared program screens and treats newly diagnosed HIV+ patients with comorbid mental health symptoms. METHODS: A mixed-methods evaluation included demographics, intake screening scores, mental health symptoms, and barriers/facilitators to implementation examined through interviews. Multilevel models were used to analyze factors associated with symptom improvement and loss to follow-up (LTFU). RESULTS: From March 2019 to June 2020, 820 individuals were screened for CETA treatment; 382 (46.6%) showed clinically significant mental health symptoms and attended 1484 CETA sessions. Of CETA patients, 71.5% (n = 273/382) had general mental distress, 7.3% (n = 28) had alcohol abuse/dependence, 12.0% (n = 46) had suicidal ideation, and 3.7% (n = 14) had other violent ideation; 66.2% (n = 253) had experienced at least 1 traumatic event at intake. Mental health symptoms decreased by 74.1% (17.0 to 4.4) after 5 CETA sessions, and 37.4% of patients (n = 143) achieved a ≥50% symptom reduction from intake. LTFU was 29.1% (n = 111), but 59.5% of LTFU patients (n = 66) achieved a ≥50% symptom reduction before LTFU. Facilitators for CETA implementation included readiness for change given the unaddressed burden of mental illness. Barriers included complexity of the intervention and stigma. CONCLUSIONS: Approximately 45% of newly diagnosed HIV+ individuals in Mozambique have clinically significant mental health symptoms at diagnosis. Integrating CETA into routine HIV platforms has in-context feasibility. Future implementation studies can optimize strategies for patient retention and scale-up.

Optimizing treatment cascades for mental healthcare in Mozambique: preliminary effectiveness of the Systems Analysis and Improvement Approach for Mental Health (SAIA-MH).

Substantial investments are being made to scale-up access to mental healthcare in low- and middle-income countries, but less attention has been paid to quality and performance of nascent public-sector mental healthcare systems. This study tested the initial effectiveness of an implementation strategy to optimize routine outpatient mental healthcare cascade performance in Mozambique [the Systems Analysis and Improvement Approach for Mental Health (SAIA-MH)]. This study employed a pre-post design from September 2018 to August 2019 across four Ministry of Health clinics among 810 patients and 3234 outpatient mental health visits. Effectiveness outcomes evaluated progression through the care cascade, including: (1) initial diagnosis and medication selection; (2) enrolling in follow-up care; (3) returning after initial consultation within 60 days; (4) returning for follow-up visits on time; (5) returning for follow-up visits adherent to medication and (6) achieving function improvement. Clustered generalized linear models evaluated odds of completing cascade steps pre- vs post-intervention. Facilities prioritized improvements focused on the follow-up cascade, with 62.5% (10 of 16) monthly system modifications targeting medication adherence. At baseline, only 4.2% of patient visits achieved function improvement; during the 6 months of SAIA-MH implementation, this improved to 13.1% of patient visits. Multilevel logistic regression found increased odds of returning on time and adherent [aOR = 1.53, 95% CI (1.21, 1.94), P = 0.0004] and returning on time, adherent and with function improvement [aOR = 3.68, 95% CI (2.57, 5.44), P < 0.0001] after SAIA-MH implementation. No significant differences were observed regarding other cascade steps. The SAIA-MH implementation strategy shows promise for rapidly and significantly improving mental healthcare cascade outcomes, including the ultimate goal of patient function improvement. Given poor baseline mental healthcare cascade performance, there is an urgent need for evidence-based implementation strategies to optimize the performance of mental healthcare cascades in low- and middle-income countries.

Moderating Factors in an Anti-stigma Intervention for African American Women with HIV in the United States: A Secondary Analysis of the UNITY Trial.

African American women experience higher rates of HIV than other women in the United States, and stigma has been identified as an important determinant of engagement in HIV care. Our study examined whether key variables moderated the effect of an anti-stigma intervention on outcomes among African American women receiving treatment for HIV. Twelve potential moderators included: age, years lived with HIV, marital status, employment status, education level, PTSD diagnosis, alcohol use, social support, baseline CD4 count, baseline viral load, and number of children. Outcomes included changes in: HIV-related stigma, social support, depressive symptoms, PTSD symptoms, alcohol use, viral load, and engagement in HIV care. Results suggest that the intervention is associated with greater improvement in engagement in care among participants with PTSD or depression at baseline, and may help maintain engagement in care among participants experiencing certain mental health conditions. This provides opportunities to address discriminatory structural barriers that lead to stigma and drop-offs in HIV care.