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Large scale efforts to expand access to mental healthcare in low- and middle-income countries have focused on integrating mental health services into primary care settings using a task sharing approach delivered by non-specialist health workers. Given the link between mental disorders and risk of suicide mortality, treating common mental disorders using this approach may be a key strategy to reducing suicidality. The Programme for Improving Mental Health Care (PRIME) evaluated mental health services for common mental disorders delivered by non-specialist health workers at ten primary care facilities in Chitwan, Nepal from 2014 to 2016. In this paper, we present the indirect impact of treatment on suicidality, as measured by suicidal ideation, among treatment and comparison cohorts for depression and AUD using multilevel logistic regression. Patients in the treatment cohort for depression had a greater reduction in ideation relative to those in the comparison cohort from baseline to three months (OR = 0.16, 95% CI: 0.05-0.59; p = 0.01) and twelve months (OR = 0.31, 95% CI: 0.08-1.12; p = 0.07), with a significant effect of treatment over time (p = 0.02). Among the AUD cohorts, there were no significant differences between treatment and comparison cohorts in the change in ideation from baseline to three months (OR = 0.64, 95% CI: 0.07-6.26; p = 0.70) or twelve months (OR = 0.46, 95% CI: 0.06-3.27; p = 0.44), and there was no effect of treatment over time (p = 0.72). The results provide evidence integrated mental health services for depression benefit patients by accelerating the rate at which suicidal ideation naturally abates over time. Integrated services do not appear to impact ideation among people with AUD, though baseline levels of ideation were much lower than for those with depression and may have led to floor effects. The findings highlight the importance of addressing suicidality as a specific target-rather than an indirect effect-of treatment in community-based mental healthcare programs.

Background Integrating mental health services into primary care is a key strategy for reducing the mental healthcare treatment gap in low- and middle-income countries. We examined healthcare use and costs over time among individuals with depression and subclinical depressive symptoms in Chitwan, Nepal to understand the impact of integrated care on individual and health system resources. Methods Individuals diagnosed with depression at ten primary care facilities were randomized to receive a package of integrated care based on the Mental Health Gap Action Programme (treatment group; TG) or this package plus individual psychotherapy (TG + P); individuals with subclinical depressive symptoms received primary care as usual (UC). Primary outcomes were changes in use and health system costs of outpatient healthcare at 3- and 12-month follow up. Secondary outcomes examined use and costs by type. We used Poisson and log-linear models for use and costs, respectively, with an interaction term between time point and study group, and with TG as reference. Results The study included 192 primary care service users (TG = 60, TG +  P  = 60, UC = 72; 86% female, 24% formally employed, mean age 41.1). At baseline, outpatient visits were similar (− 11%, p  = 0.51) among TG + P and lower (− 35%, p  = 0.01) among UC compared to TG. Visits increased 2.30 times ( p  < 0.001) at 3 months among TG, with a 50% greater increase ( p  = 0.03) among TG + P, before returning to baseline levels among all groups at 12 months. Comparing TG + P to TG, costs were similar at baseline (− 1%, p  = 0.97) and cost changes did not significantly differ at three (− 16%, p  = 0.67) or 12 months (− 45%, p  = 0.13). Costs among UC were 54% lower than TG at baseline ( p  = 0.005), with no significant differences in cost changes over follow up. Post hoc analysis indicated individuals not receiving psychotherapy used less frequent, more costly healthcare. Conclusion Delivering psychotherapy within integrated services for depression resulted in greater healthcare use without significantly greater costs to the health system or individual. Previous research in Chitwan demonstrated psychotherapy determined treatment effectiveness for people with depression. While additional research is needed into service implementation costs, our findings provide further evidence supporting the inclusion of psychotherapy within mental healthcare integration in Nepal and similar contexts.

Objectives: To examine the association of non-pharmaceutical interventions (NPIs) with anxiety and depressive symptoms among adults and determine if these associations varied by gender and age.Methods: We combined survey data from 16,177,184 adults from 43 countries who participated in the daily COVID-19 Trends and Impact Survey via Facebook with time-varying NPI data from the Oxford COVID-19 Government Response Tracker between 24 April 2020 and 20 December 2020. Using logistic regression models, we examined the association of [1] overall NPI stringency and [2] seven individual NPIs (school closures, workplace closures, cancellation of public events, restrictions on the size of gatherings, stay-at-home requirements, restrictions on internal movement, and international travel controls) with anxiety and depressive symptoms.Results: More stringent implementation of NPIs was associated with a higher odds of anxiety and depressive symptoms, albeit with very small effect sizes. Individual NPIs had heterogeneous associations with anxiety and depressive symptoms by gender and age.Conclusion: Governments worldwide should be prepared to address the possible mental health consequences of stringent NPI implementation with both universal and targeted interventions for vulnerable groups.

Background In low- and middle-income countries (LMIC), there is a substantial gap in the treatment of mental and behavioral health problems, which is particularly detrimental to adolescents and young adults (AYA). The Common Elements Treatment Approach (CETA) is an evidence-based, flexible, transdiagnostic intervention delivered by lay counselors to address comorbid mental and behavioral health conditions, though its effectiveness has not yet been tested among AYA. This paper describes the protocol for a randomized controlled trial that will test the effectiveness of traditional in-person delivered CETA and a telehealth-adapted version of CETA (T-CETA) in reducing mental and behavioral health problems among AYA in Zambia. Non-inferiority of T-CETA will also be assessed. Methods This study is a hybrid type 1 three-arm randomized trial to be conducted in Lusaka, Zambia. Following an apprenticeship model, experienced non-professional counselors in Zambia will be trained as CETA trainers using a remote, technology-delivered training method. The new CETA trainers will subsequently facilitate technology-delivered trainings for a new cohort of counselors recruited from community-based partner organizations throughout Lusaka. AYA with mental and behavioral health problems seeking services at these same organizations will then be identified and randomized to (1) in-person CETA delivery, (2) telehealth-delivered CETA (T-CETA), or (3) treatment as usual (TAU). In the superiority design, CETA and T-CETA will be compared to TAU, and using a non-inferiority design, T-CETA will be compared to CETA, which is already evidence-based in other populations. At baseline, post-treatment (approximately 3–4 months post-baseline), and 6 months post-treatment (approximately 9 months post-baseline), we will assess the primary outcomes such as client trauma symptoms, internalizing symptoms, and externalizing behaviors and secondary outcomes such as client substance use, aggression, violence, and health utility. CETA trainer and counselor competency and cost-effectiveness will also be measured as secondary outcomes. Mixed methods interviews will be conducted with trainers, counselors, and AYA participants to explore the feasibility, acceptability, and sustainability of technology-delivered training and T-CETA provision in the Zambian context. Discussion Adolescents and young adults in LMIC are a priority population for the treatment of mental and behavioral health problems. Technology-delivered approaches to training and intervention delivery can expand the reach of evidence-based interventions. If found effective, CETA and T-CETA would help address a major barrier to the scale-up and sustainability of mental and behavioral treatments among AYA in LMIC. Trial registration ClinicalTrials.gov NCT03458039 . Prospectively registered on May 10, 2021

Background Existing implementation measures developed in high-income countries may have limited appropriateness for use within low- and middle-income countries (LMIC). In response, researchers at Johns Hopkins University began developing the Mental Health Implementation Science Tools (mhIST) in 2013 to assess priority implementation determinants and outcomes across four key stakeholder groups—consumers, providers, organization leaders, and policy makers—with dedicated versions of scales for each group. These were field tested and refined in several contexts, and criterion validity was established in Ukraine. The Consumer and Provider mhIST have since grown in popularity in mental health research, outpacing psychometric evaluation. Our objective was to establish the cross-context psychometric properties of these versions and inform future revisions. Methods We compiled secondary data from seven studies across six LMIC—Colombia, Myanmar, Pakistan, Thailand, Ukraine, and Zambia—to evaluate the psychometric performance of the Consumer and Provider mhIST. We used exploratory factor analysis to identify dimensionality, factor structure, and item loadings for each scale within each stakeholder version. We also used alignment analysis (i.e., multi-group confirmatory factor analysis) to estimate measurement invariance and differential item functioning of the Consumer scales across the six countries. Results All but one scale within the Provider and Consumer versions had Cronbach’s alpha greater than 0.8. Exploratory factor analysis indicated most scales were multidimensional, with factors generally aligning with a priori subscales for the Provider version; the Consumer version has no predefined subscales. Alignment analysis of the Consumer mhIST indicated a range of measurement invariance for scales across settings ( R 2 0.46 to 0.77). Several items were identified for potential revision due to participant nonresponse or low or cross- factor loadings. We found only one item, which asked consumers whether their intervention provider was available when needed, to have differential item functioning in both intercept and loading. Conclusion We provide evidence that the Consumer and Provider versions of the mhIST are internally valid and reliable across diverse contexts and stakeholder groups for mental health research in LMIC. We recommend the instrument be revised based on these analyses and future research examine instrument utility by linking measurement to other outcomes of interest.

We explore multi-sectoral integration as a model for scaling up evidence-based mental health and psychosocial support interventions in humanitarian settings. We introduce Self Help Plus 360, designed to support humanitarian partners across different sectors to integrate a psychosocial intervention into their programming and more holistically address population needs.

Multiple national and international trends and drivers are radically changing what biological security means for the United Kingdom (UK). New technologies present novel opportunities and challenges, and globalisation has created new pathways and increased the speed, volume and routes by which organisms can spread. The UK Biological Security Strategy (2018) acknowledges the importance of research on biological security in the UK. Given the breadth of potential research, a targeted agenda identifying the questions most critical to effective and coordinated progress in different disciplines of biological security is required. We used expert elicitation to generate 80 policy-relevant research questions considered by participants to have the greatest impact on UK biological security. Drawing on a collaboratively-developed set of 450 questions, proposed by 41 experts from academia, industry and the UK government (consulting 168 additional experts) we subdivided the final 80 questions into six categories: bioengineering; communication and behaviour; disease threats (including pandemics); governance and policy; invasive alien species; and securing biological materials and securing against misuse. Initially, the questions were ranked through a voting process and then reduced and refined to 80 during a one-day workshop with 35 participants from a variety of disciplines. Consistently emerging themes included: the nature of current and potential biological security threats, the efficacy of existing management actions, and the most appropriate future options. The resulting questions offer a research agenda for biological security in the UK that can assist the targeting of research resources and inform the implementation of the UK Biological Security Strategy . These questions include research that could aid with the mitigation of Covid-19, and preparation for the next pandemic. We hope that our structured and rigorous approach to creating a biological security research agenda will be replicated in other countries and regions. The world, not just the UK, is in need of a thoughtful approach to directing biological security research to tackle the emerging issues.

The impact of extreme low flows on the water quality of the Lower Murray River and Lower Lakes (Alexandrina and Albert) in South Australia was assessed by comparing water quality from five sites during an extreme low flow period (March 2007–November 2009) and a preceding reference period (March 2003–November 2005). Significant increases in salinity, total nitrogen, total phosphorus, chlorophyll a and turbidity were observed in the Lower Lakes during the low flow period. Consequently, water quality guidelines for the protection of aquatic ecosystems were greatly exceeded. Principal Component Analysis, empirical and mass balance model calculations suggested these changes could be attributed primarily to the lack of flushing resulting in concentration of dissolved and suspended material in the lakes, and increased sediment resuspension as the lakes became shallower. The river sites also showed significant but more minor salinity increases during the extreme low flow period, but nutrient and turbidity concentrations decreased. The most plausible reasons for these changes were decreased catchment inputs and increased influence of saline groundwater inputs. The results highlight the vulnerability of arid and semi-arid lake systems to reduced flow conditions as a result of climatic changes and/or water management decisions.

ObjectivesEfforts to improve access to healthcare in low-income countries will not achieve the maternal and child health (MCH) Sustainable Development Goals unless a concomitant improvement in the quality of care (QoC) occurs. This study measures infrastructure and QoC indicators in rural Ugandan health facilities. Valid measure of the quality of current clinical practices in resource-limited settings are critical for effectively intervening to reduce adverse maternal and neonatal outcomes.MethodsFacility-based assessments of infrastructure and clinical quality during labor and delivery were conducted in six primary care health facilities in the greater Masaka area, Uganda in 2017. Data were collected using direct observation of clinical encounters and facility checklists. Direct observation comprised the entire delivery process, from initial client assessment to discharge, and included emergency management (e.g. postpartum hemorrhage, neonatal resuscitation). Health providers were assessed on their adherence to best practice standards of care.ResultsThe quality of facility infrastructure was relatively high in facilities, with little variation in availability of equipment and supplies. However, heterogeneity in adherence to best clinical practices was noted across procedure type and facility. Adherence to crude measures of clinical quality were relatively high but more sensitive measures of the same clinical practice were found to be much lower.Conclusions for PracticeStandard indicators of clinical practice may be insufficient to validly measure clinical quality for maternal and newborn care if we want to document evidence of impact.