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Background and Hypothesis Cognitive difficulties significantly burdened people with schizophrenia (PWS). However, cognitive assessment is often unavailable in low- and middle-income counties (LMICs) due to a lack of validated and culturally adapted cognitive assessment tools. In this study, we developed and evaluated a culturally sensitive cognitive battery for PWS in Ethiopia. Study Design This study was conducted in three phases. First, we selected appropriate tests through an instrument selection procedure and created a new battery. Then, we rigorously adapted the tests using culturally competent procedures, including cognitive interviewing and expert meetings. Finally, we tested the new battery in 208 PWS and 208 controls. We evaluated its psychometric properties using advanced statistical techniques, including Item Response Theory (IRT). Study Results The Ethiopian Cognitive Assessment battery for Schizophrenia (ECAS) was developed from three different batteries. Participants reported tests were easy to complete, and the raters found them easy to administer. All tests had good inter-rater reliability, and the composite score had very high test-retest reliability (ICC = 0.91). One-factor structure better represented the data with excellent internal consistency (α = .81). ECAS significantly differentiated PWS from controls with 77% sensitivity and 62% specificity at a Z-score ≤0.12 cut-off value. IRT analysis suggested that the battery functions best among moderately impaired participants (difficulty between −0.06 and 0.66). Conclusions ECAS is a practical, tolerable, reliable, and valid assessment of cognition. ECAS can supplement current assessment tools in LAMICs for PWS and can be used to measure cognitive intervention outcomes.

[...]the model of care was designed to respect the TFH approach to healing while seeking to address concerns about harmful practices through a rights-based approach. [...]the trial explicitly tested the value of collaboration over and above separate training programmes for TFHs and PHCWs. [...]that there is evidence that collaborative models can work in one setting, we next need hybrid effectiveness-implementation trials incorporating theory-informed measurement of relevant contextual features across a range of settings.8 This approach will contribute to building a body of evidence to tell us what works for whom, how, and in what context.9 The mental health response to the COVID-19 pandemic must include TFHs,10 providing an opportunity to evaluate models of collaborative shared care.

Background Burnout is characterized by physical and emotional exhaustion from long-term exposure to emotionally demanding work. Burnout affects interpersonal skills, job performance, career satisfaction, and psychological health. However, little is known about the burden of burnout among healthcare providers in sub-Saharan Africa. Methods Relevant articles were identified through a systematic review of PubMed, Web of Science (Thomson Reuters), and PsycINFO (EBSCO). Studies were selected for inclusion if they examined a quantitative measure of burnout among healthcare providers in sub-Saharan Africa. Results A total of 65 articles met our inclusion criteria for this systematic review. Previous studies have examined burnout in sub-Saharan Africa among physicians ( N  = 12 articles), nurses ( N  = 26), combined populations of healthcare providers ( N  = 18), midwives ( N  = 2), and medical or nursing students ( N  = 7). The majority of studies assessed burnout using the Maslach Burnout Inventory. The highest levels of burnout were reported among nurses, although all healthcare providers showed high burnout. Burnout among healthcare providers is associated with their work environments, interpersonal and professional conflicts, emotional distress, and low social support. Conclusions Available studies on this topic are limited by several methodological challenges. More rigorously designed epidemiologic studies of burnout among healthcare providers are warranted. Health infrastructure improvements will eventually be essential, though difficult to achieve, in under-resourced settings. Programs aimed at raising awareness and coping with burnout symptoms through stress management and resilience enhancement trainings are also needed.

Depression may negatively affect stroke outcomes and the progress of recovery. However, there is a lack of updated comprehensive evidence to inform clinical practice and directions of future studies. In this review, we report the multidimensional impact of depression on stroke outcomes. Data sources. PubMed, PsycINFO, EMBASE, and Global Index Medicus were searched from the date of inception. Eligibility criteria. Prospective studies which investigated the impact of depression on stroke outcomes (cognition, returning to work, quality of life, functioning, and survival) were included. Data extraction. Two authors extracted data independently and solved the difference with a third reviewer using an extraction tool developed prior. The extraction tool included sample size, measurement, duration of follow-up, stroke outcomes, statistical analysis, and predictors outcomes. Risk of bias. We used Effective Public Health Practice Project (EPHPP) to assess the quality of the included studies. Eighty prospective studies were included in the review. These studies investigated the impact of depression on the ability to return to work (n = 4), quality of life (n = 12), cognitive impairment (n = 5), functioning (n = 43), and mortality (n = 24) where a study may report on more than one outcome. Though there were inconsistencies, the evidence reported that depression had negative consequences on returning to work, functioning, quality of life, and mortality rate. However, the impact on cognition was not conclusive. In the meta-analysis, depression was associated with premature mortality (HR: 1.61 (95% CI; 1.33, 1.96)), and worse functioning (OR: 1.64 (95% CI; 1.36, 1.99)). Depression affects many aspects of stroke outcomes including survival The evidence is not conclusive on cognition and there was a lack of evidence in low-income settings. The results showed the need for early diagnosis and intervention of depression after stroke. The protocol was pre-registered on the International Prospective Register of Systematic Review (PROSPERO) (CRD42021230579).

ObjectiveThis study aimed at testing the significance of mediating and moderating roles of sense of coherence, adaptive coping styles and social support in the relationship between exposure to trauma and psychological symptoms in a refugee population in sub-Saharan Africa.MethodsA cross-sectional survey design was employed to collect data. The study was carried out in Mai Aini refugee camp in Ethiopia. A total of 562 adult Eritrean refugees aged 18–74 years were selected randomly to screen for depression and post-traumatic stress disorder (PTSD) symptoms and to examine associated factors. Data were collected using the premigration and postmigration living difficulties checklist, Center for Epidemiologic Studies Depression (CES-D) scale, Primary Care PTSD Screener, coping style scale, Sense of Coherence scale and Oslo Social Support scale. Path modelling was used to test the mediation and moderation effects of prespecified factors.ResultsPremigration living difficulties were associated directly with symptoms of PTSD (β=0.09, p<0.05), and associated indirectly with PTSD symptoms in paths through duration of stay in the camp, sense of coherence, postmigration living difficulties, task-oriented coping style and depressive symptoms (β=0.26, p<0.01). Premigration and postmigration living difficulties were associated directly with depressive symptoms with standardised estimate of β=0.35(p<0.001) and β=0.23(p<0.05), respectively. Postmigration living difficulties were associated indirectly with PTSD through paths of sense of coherence, task-oriented coping style and depressive symptoms (β=0.13; p<0.01). Social support moderated the effect of postmigration living difficulties on depressive symptoms (p<0.05). Emotion-oriented coping style moderated the effect of premigration threat for abuse on PTSD (β=−0.18, p<0.001) and depressive (β=−0.12, p<0.01) symptoms, as well as moderating threat to life on PTSD symptoms (β=−0.13, p<0.001).ConclusionsSense of coherence and task-oriented coping style showed a partial mediating effect on the association between exposure to trauma and symptoms of PTSD. An emotion-oriented coping style and social support moderated the effect of premigration and postmigration living difficulties, respectively. Fostering social support, task-oriented and emotion-oriented coping styles may be beneficial for these refugees.

BackgroundDepression is among the top mental health problems with a major contribution to the global burden of disease. This study aimed at identifying the latent factor structure and construct validity of the Center for Epidemiologic Studies Depression (CES-D) Scale.Participants and settingA cross-sectional survey of 562 adults aged 18 years and above who were randomly selected from the Eritrean refugee community living in the Mai-Aini refugee camp, Ethiopia.MeasuresThe CES-D Scale, Primary Care PTSD (PC-PTSD) screener, premigration and postmigration living difficulties checklist, Oslo Social Support Scale (OSS-3), Sense of Coherence Scale (SoC-13), Coping Style Scale and fast alcohol screening test (FAST) were administered concurrently. Confirmatory factor analysis was employed to test prespecified factor structures of CES-D.ResultFirst-order two factors with second-order common factor structure of CES-D (correlated error terms) yielded the best fit to the data (Comparative Fit Index =0.975; root mean square error of approximation=0.040 [90% CI 0.032 to 0.047]). The 16 items defining depressive affect were internally consistent (Cronbach’s α=0.932) and internal consistency of the 4 items defining positive affect was relatively weak (Cronbach’s α=0.703). These two latent factors have a weaker standardised covariance estimate of 33% (24% for women and 40% for men), demonstrating evidence of discriminant validity. CES-D is significantly associated with measures of adversities, specifically, premigration living difficulties (r=0.545, p<0.001) and postmigration living difficulties (r=0.47, p<0.001), PC-PTSD (r=0.538, p<0.001), FAST (r=0.197, p<0.001) and emotion-oriented coping (r=0.096, p˂0.05) providing evidence of its convergent validity. It also demonstrated inverse association with measures of resilience factors, specifically, SoC-13 (r=−0.597, p<0.001) and OSS-3 (r=−0.319, p<0.001). The two correlated factors model of CES-D demonstrated configural, metric, scalar, error variance and structural covariance invariances (p>0.05) for both men and women.ConclusionsUnlike previous findings among Eritreans living in USA, second-order two factors structure of CES-D best fitted the data for Eritrean refugees living in Ethiopia; this implies that it is important to address culture for the assessment and intervention of depression.

Poor governance has been identified as a barrier to effective integration of mental health care in low- and middle-income countries. Governance includes providing the necessary policy and legislative framework to promote and protect the mental health of a population, as well as health system design and quality assurance to ensure optimal policy implementation. The aim of this study was to identify key governance challenges, needs and potential strategies that could facilitate adequate integration of mental health into primary health care settings in low- and middle-income countries. Key informant qualitative interviews were held with 141 participants across six countries participating in the Emerging mental health systems in low- and middle-income countries (Emerald) research program: Ethiopia, India, Nepal, Nigeria, South Africa, and Uganda. Data were transcribed (and where necessary, translated into English) and analysed thematically using frame-work analysis, first at the country level, then synthesized at a cross-country level. While all the countries fared well with respect to strategic vision in the form of the development of national mental health policies, key governance strategies identified to address challenges included: strengthening capacity of managers at sub-national levels to develop and implement integrated plans; strengthening key aspects of the essential health system building blocks to promote responsiveness, efficiency and effectiveness; developing workable mechanisms for inter-sectoral collaboration, as well as community and service user engagement; and developing innovative approaches to improving mental health literacy and stigma reduction. Inadequate financing emerged as the biggest challenge for good governance. In addition to the need for overall good governance of a health care system, this study identifies a number of specific strategies to improve governance for integrated mental health care in low- and middle-income countries. La mauvaise gouvernance a été identifiée comme un obstacle à l’intégration effective des soins de santé mentale dans les pays à revenu faible ou à revenu intermédiaire. La gouvernance comprend le cadre politique et législatif nécessaire pour promouvoir et protéger la santé mentale d’une population, ainsi que l’élaboration d’un système de santé et d’assurance de qualité afin d’assurer une mise en œuvre optimale des politiques. L’objectif de la présente étude est d’identifier les principaux défis, les besoins et les stratégies potentielles de gouvernance qui peuvent faciliter une intégration adéquate de la santé mentale dans les établissements de soins de santé primaires des pays à revenu faible ou à revenu intermédiaire. Des entrevues qualitatives avec des témoins privilégiés ont été réalisées avec 141 personnes dans six pays protagonistes du programme de recherche sur les systèmes émergents de santé mentale dans les pays à revenu faible ou intermédiaire (Emerald): l’ Éthiopie, l’Inde, le Népal, le Nigeria, l’Afrique du Sud et l’Ouganda. Les données ont été transcrites (et, le cas échéant, traduites en anglais) et analysées thématiquement à l’aide de l’analyse du cadre, d’abord au niveau des pays, puis synthétisées au niveau transfrontalier. Si tous les pays ont obtenu des résultats positifs en ce qui concerne la vision stratégique sous forme de mise œuvre de politiques nationales de santé mentale, les principales stratégies de gouvernance identifiées pour relever les défis sont les suivantes: renforcement des capacités des gestionnaires aux niveaux infranationaux afin d’élaborer et de mettre en œuvre des plans intégrés; consolidation des aspects clés des blocs essentiels du système de santé pour promouvoir la réactivité, l’efficacité et la productivité; développement de mécanismes efficaces de collaboration intersectorielle, ainsi que l’engagement de la communauté et des utilisateurs des services; et développement de modèles d’approches novatrices pour mieux se familiariser à la santé mentale et réduire la stigmatisation. L’insuffisance des financements constitue le plus grand défi à la bonne gouvernance. Outre la nécessité d’une bonne gouvernance globale du système de soins de santé, la présente étude identifie un certain nombre de stratégies spécifiques permettant d’améliorer la gouvernance des soins intégrés de santé mentale dans les pays à revenu faible ou à revenu intermédiaire. 治理不善是中低收入国家实现精神卫生保健有效整合的障 碍。治理包括提供必要的政策和法律框架来促进和保护人群 精神卫生, 以及通过卫生体系设计和质量保证来确保最佳政策 实施。本研究目的是辨明关键的治理挑战、需求和潜在策略, 有助于中低收入国家将精神卫生整合至初级保健中。关键知 情人定性访谈的对象共141名, 均参与了中低收入国家新兴精 神卫生体系 （Emerald） 研究项目。这些访谈对象来自六个 国家：埃塞俄比亚、印度、尼泊尔、尼日利亚、南非和乌干 达。转录访谈数据 （必要时翻译成英文）, 采用框架分析方法 分析主题, 首先进行国家层面分析, 然后整合至跨国家分析。 在战略方面, 所有国家均表现良好, 制定了全国精神卫生政策, 关键的治理策略解决以下问题：加强地方管理者制定和实施 整合规划的能力；强化基本卫生体系模块的关键部分, 以提高 反应性、效率和有效性；建立可操作的部门间合作机制, 提高 社区和服务使用者参与度；形成创新方法, 提高精神卫生知识 水平, 减少污名化。研究显示筹资不足是治理的最大挑战。除 卫生保健体系整体治理良好外, 本研究还明确了一些中低收入 国家改善治理、整合精神卫生保健的具体策略。 La mala gobernanza ha sido identificada como una barrera para la integración efectiva de la atención de salud mental en los países de ingresos bajos y medios. La gobernanza incluye proporcionar el marco político y legislativo necesario para promover y proteger la salud mental de una población, así como el diseño del sistema de salud y la garantía de la calidad para asegurar una implementación óptima de políticas. El objetivo de este estudio fue identificar los desafíos, necesidades y estrategias claves de la gobernanza, que podrían facilitar la integración adecuada de la salud mental en la atención primaria en los países de ingresos bajos y medios. Se realizaron entrevistas cualitativas con 141 informantes claves de seis países participantes en el programa de investigación de los sistemas emergentes de salud mental en países de bajos y medios ingresos (‘Emerald’): Etiopía, India, Nepal, Nigeria, Sudáfrica y Uganda. Los datos se transcribieron (y donde fue necesario, traducidos al inglés) y se analizaron temáticamente usando el análisis del marco, primero a nivel de país, luego se sintetizaron entre países. Si bien todos los países obtuvieron buenos resultados con respecto a la visión estratégica en la forma de desarrollo de las políticas nacionales de salud mental, las estrategias claves de gobernanza identificadas para abordar los desafíos incluyeron: el fortalecimiento de la capacidad de los gerentes a niveles subnacionales para desarrollar e implementar los planes integrados; el fortalecimiento de los aspectos claves de los elementos esenciales del sistema de salud para promover la capacidad de respuesta, la eficiencia y la eficacia; el desarrollo de mecanismos viables para la colaboración intersectorial, así como el compromiso de los usuarios en la comunidad y los servicios; y el desarrollo de enfoques innovadores para mejorar la alfabetización en salud mental y la reducción del estigma. Una financiación inadecuada surgió como el mayor desafío para la buena gobernanza. Además de la necesidad general de una buena gobernanza de un sistema de salud, este estudio identifica una serie de estrategias específicas para mejorar la gobernanza de la atención integral de salud mental en los países de ingresos bajos y medios.

To assess the effect of food insecurity on perinatal depression in rural Ethiopia. We used a prospective cohort in which food insecurity was considered as primary exposure and perinatal depression as an outcome. Food insecurity at baseline (in the period of 8-24 weeks of pregnancy) was measured using the Household Food Insecurity Access Scale (HFIAS), and perinatal depression at follow-up (in 32-36 weeks of pregnancy) was measured using a Patient Health Questionnaire (PHQ-9). We used multivariable regression to assess the effect of food insecurity on the prevalence of perinatal depression. We explored food insecurity's direct and indirect impacts on perinatal depression using structural equation modelling (SEM). This paper used data from the Butajira Nutrition, Mental Health and Pregnancy (BUNMAP) cohort established under the Butajira Health and Demographic Surveillance Site (BHDSS). Seven hundred and fifty-five pregnant women. Among the study participants, 50 % were food-insecure, and about one-third were depressed at 32-36 follow-up. In SEM, higher values of baseline food insecurity, depressive symptoms and state-trait anxiety (STA) were positively and significantly associated with perinatal depression. The direct impact of food insecurity on perinatal depression accounts for 42 % of the total effect, and the rest accounted for the indirect effect through baseline depression (42 %) and STA (16 %). The significant effect of food insecurity at baseline on perinatal depression and the indirect effect of baseline food insecurity through baseline anxiety and depression in the current study implies the importance of tailored interventions for pregnant women that consider food insecurity and psychosocial problems.

Background The World Health Organization Disability Assessment Schedule (WHODAS-2.0) has been adapted and validated in several cultures, but data on performance in the African context are lacking. The aim of the study was to evaluate the validity and psychometric properties of the WHODAS-2.0 among people with severe mental disorders (SMD) and their caregivers in a rural African setting. Methods The content validity of the 36 item WHODAS was assessed using free listing and pile sorting in 36 community members. Cognitive interviewing was conducted with 20 people with SMD and 20 caregivers to assess comprehensibility. Convergent validity and sensitivity to change were evaluated in a facility-based cohort study of new or acutely relapsed cases of people with SMD ( n  = 150) and their caregivers ( n  = 150) consecutively recruited from a psychiatric clinic. A repeat assessment was conducted in a sub-sample ( n  = 84) after 6 weeks. Confirmatory factor analysis was used to evaluate construct validity in people with SMD ( n  = 250) and their caregivers ( n  = 250). Results Internal consistency of the items of the overall scale and each domain ranged from very good (alpha = 0.82) to excellent (alpha = 0.98). Scores on the WHODAS-2.0 correlated highly with a locally developed measure of functioning ( r  = 0.88) and moderately with clinical symptom severity ( r  = 0.52). The WHODAS- 2.0 was sensitive to treatment changes (effect size = 0.50). As hypothesized, the six sub-scales loaded highly onto the general disability factor and each item loaded significantly onto their respective domains. The factor loadings of each item in the one factor model of the brief version of WHODAS (12 item) were also high. For both 12- and 36-item scales the goodness of fit indices, were close to, but outside of, recommended ranges. The caregiver data of both the 36 and 12 item versions had similar psychometric properties, but higher mean values and better responsiveness to change. Conclusions Our study showed that both the 12 and 36 item versions of the WHODAS 2.0 have acceptable validity and psychometric properties and can be used as a cross-cultural measure; however, careful and rigorous adaptation is required for rural African settings.

Developing evidence for the implementation and scaling up of mental healthcare in low- and middle-income countries (LMIC) like Ethiopia is an urgent priority. To outline a mental healthcare plan (MHCP), as a scalable template for the implementation of mental healthcare in rural Ethiopia. A mixed methods approach was used to develop the MHCP for the three levels of the district health system (community, health facility and healthcare organisation). The community packages were community case detection, community reintegration and community inclusion. The facility packages included capacity building, decision support and staff well-being. Organisational packages were programme management, supervision and sustainability. The MHCP focused on improving demand and access at the community level, inclusive care at the facility level and sustainability at the organisation level. The MHCP represented an essential framework for the provision of integrated care and may be a useful template for similar LMIC.