A community case detection tool to promote help-seeking for mental health care among children and adolescents in Ugandan refugee settlements: a stepped wedge cluster randomised trial.

BACKGROUND: Strategies to promote mental health care help-seeking among children are needed, especially in low-income and middle-income countries and in complex settings. The aim of this trial was to compare a vignette-based, community-level, proactive case detection tool (CCDT) against standard awareness raising for promoting mental health help-seeking among children and adolescents. METHODS: This stepped wedge cluster randomised trial was conducted in the Bidi Bidi, Kyaka II, Kyangwali, Omugo, and Rhino refugee settlements in Uganda. Community gatekeepers received a 2-day training session on using the CCDT to proactively detect children with mental health concerns and encourage children (or their caregivers) to use the mental health-care service run by Transcultural Psychosocial Organization Uganda. At baseline, organisations implemented routine detection or mental health awareness-raising activities. At cross-over to CCDT implementation, gatekeepers used the tool in their daily activities. The primary outcome was mental health-care service use by children and adolescents. Child population size estimates at the zone level were not available. Therefore, service use was calculated using total population size. We report the effect of CCDT implementation as an incidence rate ratio (IRR), which we produced from a model that accounts for calendar time, exposure time, and person-time. IRRs were estimated for the analysis of effect over time in the per-protocol and intention-to-treat populations. The trial is registered with the ISRCTN registry, number ISRCTN19056780. FINDINGS: 28 administrative zones were selected for trial participation by October, 2021. Between Jan 1, and Nov 8, 2022, seven clusters of four zones sequentially crossed over from routine care to CCDT implementation in 1-month intervals. The CCDT was implemented by 177 trained community gatekeepers. In 9 months, 2385 children visited a mental health-care service; of these, 1118 (47%) were girls and 1267 (53%) were boys (mean age 12·18 years [SD 4.03]). 1998 children made a first or re-entry visit to a service; of these, 937 (47%) were girls and 1061 (53%) were boys (mean age 12·08 years [SD 4·06]). Compared to standard awareness-raising activities, CCDT implementation was associated with an increase in mental health-care service use in the first month after implementation (20·91-fold change [95% CI 12·87-33·99]). Despite a slight decline in service use over time in both the CCDT and pre-CCDT zones, CCDT zones maintained a time-average 16·89-fold increase (95% CI 8·15-34·99) in mental health service use. INTERPRETATION: The CCDT enabled community gatekeepers to increase mental health-care service use by children and adolescents. Vignette-based strategies rooted in the community could become a valuable contribution towards reducing the mental health-care gap among children, especially when accompanied by accessible mental health-care services. FUNDING: Sint Antonius Stichting Projects. TRANSLATIONS: For the Arabic, French and Spanish translations of the abstract see Supplementary Materials section.

Interventions to increase help-seeking for mental health care in low- and middle-income countries: A systematic review.

Mental health problems are a significant and growing cause of morbidity worldwide. Despite the availability of evidence-based interventions, most people experiencing mental health problems remain untreated. This treatment gap is particularly large in low- and middle-income countries (LMIC) and is due to both supply-side and demand-side barriers. The aim of this systematic review is to identify and synthesise the evidence on interventions to improve help-seeking for mental health problems in LMICs. The protocol was registered a priori (Registration number: CRD42021255635). We searched eight databases using terms based on three concepts: 'mental health/illness' AND 'help-seeking' AND 'LMICs'; and included all age groups and mental health problems. Forty-two papers were eligible and included in this review. Intervention components were grouped into three categories following the steps in the help-seeking process: (1) raising mental health awareness among the general population (e.g., distribution of printed or audio-visual materials), (2) identification of individuals experiencing mental health problems (e.g., community-level screening or detection), and (3) promoting help-seeking among people in need of mental health care (e.g., sending reminders). The majority of interventions (80%) included components in a combination of the aforementioned categories. Most studies report positive outcomes, yet results on the effectiveness is mixed, with a clear trend in favour of interventions with components from more than one category. Ten out of 42 studies (24%) yielded a statistically significant effect of the intervention on help-seeking; and all targeted a combination of the aforementioned categories (i.e., raising awareness, identification and help-seeking promotion). Only six studies (14%) focused on children and adolescents. Due to the limited number of robust studies done in LMICs and the heterogeneity of study designs, outcomes and components used, no definite conclusions can be drawn with regards to the effects of individual strategies or content of the interventions.

Validation of the Kriol and Belizean English Adaptation of the Revised Children's Anxiety and Depression Scale for Use With Adolescents in Belize.

PURPOSE: To validate a culturally-adapted Kriol and Belizean English version of the Revised Children's Anxiety and Depression Scale (RCADS) through comparison with clinical diagnoses made using the Kiddie Schedule of Affective Disorders and Schizophrenia. METHODS: Participants comprised of 256 adolescents aged 10-14 years and 15-19 years, who completed the adapted RCADS (10 depression items, 12 anxiety items) in one-on-one interviews, followed by a diagnostic assessment using Kiddie Schedule of Affective Disorders and Schizophrenia administered by trained clinicians. Sensitivity, specificity, positive predictive value, negative predictive value, diagnostic odds ratios, area under the curve (AUC), and Youden's Index were calculated for RCADS cutoffs and scores on the total scale and anxiety and depression subscales. RESULTS: For adolescents aged 10-14 years (n = 161), the AUC was 0.72 for the full scale, 0.67 for anxiety subscale, and 0.76 for depression subscale. For adolescents aged 15-19 years (n = 95), the AUCs were 0.82, 0.77, and 0.83. Most depression items performed well in discriminating those with and without diagnoses. Separation anxiety items performed poorly. "Thoughts of death" were common even among adolescents not meeting diagnostic criteria. The RCADS depression subscale presented the strongest psychometric properties with adolescents aged 15-19 years (at cutoff of 13, sensitivity = 0.83, specificity = 0.77, positive predictive value = 0.47, negative predictive value = 0.95, odds ratio = 15.96). CONCLUSION: The adapted RCADS-22 had acceptable categorization for adolescents aged 10-14 years and excellent categorization for adolescents aged 15-19 years; therefore, the tool is recommended for use among the latter age group. Based on sensitivity and specificity values at different cutoffs, guidance is provided to select different thresholds to suit clinical, public health, or other uses to detect and quantify adolescent depression and anxiety in Belize.

Accuracy of a Proactive Case Detection Tool for Internalizing and Externalizing Problems Among Children and Adolescents.

PURPOSE: Lack of identification and referral of children and adolescents with mental health problems contributes to the treatment gap in low- and middle-income countries, and especially in humanitarian settings. The Community Case Detection Tool (CCDT) is developed to improve community-based detection and increase help-seeking among children and adolescents in need of mental health care. The CCDT uses brief, easily understood pictorial vignettes that represent common symptoms of childhood internalizing and externalizing problems. The tool is developed for gatekeepers to support proactive detection of children in need of mental health care and to subsequently encourage help-seeking. This study evaluates the accuracy of the CCDT in detecting children and adolescents aged 6-18 years with significant mental health care needs in a conflict-affected setting: the occupied Palestinian territory. METHODS: Teachers and community workers were trained to use the CCDT. Children detected using the tool were invited for a structured clinical interview with a psychologist using the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime version, as well as the Strengths and Difficulties Questionnaire, to test the accuracy of CCDT-based detection. RESULTS: Our sample consists of 52 children positively detected as matching with one of the vignettes. Approximately three of four detected children were indicated for psychological treatment based on the clinical interview (positive predictive value = .769), and 64.6% returned 'borderline' or 'abnormal' total difficulty scores on the Strengths and Difficulties Questionnaire. CONCLUSIONS: The CCDT offers a promising low-cost solution to mitigate underdetection of mental health problems in challenging settings.

Proactive detection of people in need of mental healthcare: accuracy of the community case detection tool among children, adolescents and families in Sri Lanka.

BACKGROUND: Most children and adolescents in need of mental healthcare remain untreated even when services are available. This study evaluates the accuracy of a new tool, the Community Case Detection Tool (CCDT). The CCDT uses illustrated vignettes, two questions and a simple decision algorithm to support proactive community-level detection of children, adolescents and families in need of mental healthcare to improve help-seeking. METHODS: Trusted and respected community members in the Eastern Province of Sri Lanka used the CCDT in their daily routine. Children and families detected as potentially in need of mental healthcare based on utilizing the CCDT (N = 157, aged 6-18 years) were invited for a clinical interview by a mental health counsellor using the Mini-International Neuropsychiatric Interview for Children and Adolescents (MINI-KID). The CCDT results were compared against the results of the clinical interview. The concurrent validity and performance of the CCDT were also evaluated by comparing the CCDT outcomes against the Strengths and Difficulties Questionnaire (SDQ). RESULTS: 7 out of 10 children and families detected by community members using the CCDT were confirmed to be in need for treatment (positive predictive value [PPV] = 0.69; 0.75 when compared to the SDQ). Detections based on the family problem vignette were most accurate (PPV = 0.76), followed by the internalising problem vignette (PPV = 0.71) and the externalising problem vignette (PPV = 0.62). CONCLUSIONS: The CCDT is a promising low-cost solution to overcome under-detection of children and families in need of mental healthcare. Future research should focus on evaluating the effectiveness, as well as additional strategies to improve help-seeking.

Strengthening parenting in conflict-affected communities: development of the Caregiver Support Intervention.

BACKGROUND: There is robust evidence that compromised parenting, stemming from persistently high stress, mediates the impact of war and displacement on children's mental health and psychosocial wellbeing. Parenting interventions generally prioritize the acquisition of parenting knowledge and skills, while under-attending to parental stress and distress. This paper describes the development of the Caregiver Support Intervention (CSI), a nine-session group intervention for conflict-affected parents of children aged 3-13, that aims to strengthen parenting both indirectly, by lowering stress and improving psychosocial wellbeing among parents, and directly, by increasing knowledge and skill related to positive parenting. METHODS: We describe the multi-phase, iterative process by which we developed the CSI, and illustrate the essential role of community input in shaping the intervention and strengthening its cultural fit and perceived usefulness. We used focus group data from participants in successive cycles of implementation, feedback, and revision, as well as quantitative data and expert consultation to develop a culturally and empirically grounded intervention. RESULTS: This mixed-method, iterative approach to intervention development enabled us to develop a psychosocial intervention for conflict-affected caregivers that is feasible, acceptable, and perceived by participants as useful in addressing their own wellbeing and their parenting. Focus group data support the underlying model in which caregiver wellbeing powerfully influences parenting. CONCLUSIONS: Programs aimed at strengthening parenting in conflict-affected communities should substantively address caregiver wellbeing. An iterative approach incorporating community feedback can help ensure intervention acceptability and feasibility. We also illustrate the feasibility of involving men in parenting interventions.