Integrating human‐centred design into the development of an intervention to improve the mental wellbeing of young women in the perinatal period: the Catalyst project

Background Mental wellbeing during pregnancy and the year after birth is critical to a range of maternal and infant outcomes. Many mental health interventions fail to incorporate stakeholder perspectives. The Catalyst Project aimed to work with key stakeholders in Mozambique to develop interventions and delivery strategies which were in-line with existing evidence and the needs, goals, and priorities of those both directly and indirectly involved in its success. Methods A qualitative, human-centred design approach was utilised. Focus-group discussions, individual interviews, and observations with young women (aged 16–24 years), their families, community leaders, service providers and government were used to better understand the needs, priorities and challenges to mental wellbeing of young women. These findings were triangulated with the literature to determine priority challenges to be addressed by an intervention. Stakeholder workshops were held to identify potential solutions and co-develop an intervention and delivery strategy. Results The 65 participants comprised 23 young pregnant women or new mothers, 12 family members, 19 service providers and 11 staff from the Ministry of Health. Participants highlighted significant uncertainty related to living situations, financial status, education, social support, and limited knowledge of what to expect of the impact of pregnancy and parenting. Family and community support were identified as an important need among this group. The Mama Felíz (Happy Mama) programme was developed with stakeholders as a course to strengthen pregnancy, childbirth and child development knowledge, and build positive relationships, problem-solving and parenting skills. In addition, family sessions address wider cultural and gender issues which impact adolescent maternal wellbeing. Conclusions We have developed an intervention to reduce the risk of poor maternal mental health and gives young mothers hope and skills to make a better life for them and their children by packaging information about the risk and protective factors for maternal mental disorders in a way that appeals to them, their families and service providers. By using human-centred design to understand the needs and priorities of young mothers and the health and community systems in which they live, the resulting intervention and delivery strategy is one that stakeholders view as appropriate and acceptable

Technology and implementation science to forge the future of evidence-based psychotherapies: the PRIDE scale-up study

Objective: To report the interim results from the training of providers in evidence-based psychotherapies (EBPs) and use of mobile applications. Design and setting: The Partnerships in Research to Implement and Disseminate Sustainable and Scalable Evidence (PRIDE) study is a cluster-randomised hybrid effectiveness-implementation trial comparing three delivery pathways for integrating comprehensive mental healthcare into primary care in Mozambique. Innovations include the use of EBPs and scaling-up of task-shifted mental health services using mobile applications. Main outcome measures: We examined EBP training attendance, certification, knowledge and intentions to deliver each component. We collected qualitative data through rapid ethnography and focus groups. We tracked the use of the mobile applications to investigate early reach of a valid screening tool (Electronic Mental Wellness Tool) and the roll out of the EBPs PARTICIPANTS: Psychiatric technicians and primary care providers trained in the EBPs. Results: PRIDE has trained 110 EBP providers, supervisors and trainers and will train 279 community health workers in upcoming months. The trainings improved knowledge about the EBPs and trainees indicated strong intentions to deliver the EBP core components. Trained providers began using the mobile applications and appear to identify cases and provide appropriate treatment. Conclusions: The future of EBPs requires implementation within existing systems of care with fidelity to their core evidence-based components. To sustainably address the vast mental health treatment gap globally, EBP implementation demands: expanding the mental health workforce by training existing human resources; sequential use of EBPs to comprehensively treat mental disorders and their comorbid presentations and leveraging digital screening and treatment applications. Keywords: adult psychiatry; anxiety disorders; depression & mood disorders; schizophrenia & psychotic disorders; substance misuse. © Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ

Perception of lay counselors on the impact of depression on people living with HIV in follow-up in primary healthcare in Mozambique

Introdução: A Human Immunodeficiency Virus Síndrome de Imunodeficiência Adquirida (HIV/SIDA) é epidémica na África subsaariana, em geral, e em Moçambique em particular, constituindo uma grande sobrecarga para a saúde pública. O HIV/SIDA está, geralmente, associado a problemas de saúde mental, com principal enfoque para a depressão. Embora o tratamento do HIV/SIDA tenha sido expandido ao nível da atenção primária de saúde, o apoio psicossocial e intervenções em saúde mental para estes pacientes ainda não são abrangentes, principalmente devido a escassez dos recursos humanos especializados. Atualmente, o apoio psicossocial prestado por conselheiros de saúde é reconhecidamente importante para a adesão ao tratamento e melhoria do suporte social do doente HIV+ porém a deteção de problemas de saúde mental, como a depressão, ainda carecem de instrumentos e modelos de intervenção para seu tratamento. Várias modalidades de tratamentos da depressão baseados em evidência, envolvendo profissionais de saúde não especializados e leigos, foram testadas com sucesso em países em desenvolvimento. O aconselhamento interpessoal (AIP) é um método breve baseado em evidências utilizado para o tratamento de depressão concebido para ser administrado por profissionais não especializados em saúde mental ao nível da atenção primária. Neste estudo avaliamos a perceção dos conselheiros leigos sobre o impacto da depressão nas pessoas vivendo com HIV/SIDA, em seguimento ao nível da atenção primária em Moçambique. Objetivos: O presente projeto, visa avaliar a perceção dos conselheiros leigos sobre impacto da depressão em pacientes HIV+ em seguimento nos cuidados primários em Moçambique. Método: Foi realizado um estudo misto quali-quantitativo exploratório sobre os conhecimentos, atitudes e práticas dos conselheiros e outros provedores em relação a depressão e seu manejo nos pacientes adultos portadores de HIV ao nível dos cuidados primários. Este estudo foi precedido do estudo de validação de instrumento de rastreio de doença mental com 1469 participantes dos quais 409 eram HIV+. Foram aplicadas 107 entrevistas qualitativas com perguntas abertas e um questionário semiestruturado traduzido em português brasileiro com recurso ao Questionário de Atitude sobre a Depressão (Depression Attitude Questionnaire) – DAQ. Conclusões: O presente estudo demonstra a importância de integração de rastreio de depressão e outras doenças mentais nos cuidados primários e no contexto de tratamento do HIV. Essa integração deve ser acompanhada pela capacitação de conselheiros leigos que atuam no apoio psicossocial tanto para identificação e intervenção para casos de depressão para melhor adesão ao tratamento antirretroviral.Introduction: HIV/AIDS is epidemic in sub-Saharan Africa, in general, and in Mozambique in particular, constituting a great burden for public health. HIV/AIDS is generally associated with mental health problems, with a main focus on depression. Although HIV/AIDS treatment has been expanded at the level of primary health care, psychosocial support and mental health interventions for these patients are still not comprehensive, mainly due to the scarcity of specialized human resources. Currently, psychosocial support is provided by health counselors and is recognized as important for adherence to treatment and improvement of the social support of HIV+ patients, however, for the detection of mental health problems, such as depression, instruments and intervention models are still lacking. treatment. Several evidence-based treatment modalities for depression, involving non specialist and lay health professionals, have been successfully tested in developing countries. Interpersonal counseling (IPC) is a brief, evidence-based method used for the treatment of depression designed to be administered by non-specialist mental health professionals at the primary care level. In this study we assess lay counselors' perceptions of the impact of depression on people living with HIV/AIDS at the primary care level in Mozambique Objectives: The present project aims to assess the perception of lay counselors on the impact of depression on HIV+ patients undergoing follow-up in primary care in Mozambique. Method: An exploratory qualitative-quantitative mixed study was conducted on the knowledge, attitudes and practices of counselors and other providers regarding depression and its management in adult HIV patients at the primary care level. This study was preceded by the validation study of a mental illness screening instrument with 1469 participants of which 409 were HIV+. 107 qualitative interviews were applied with open questions and a semi-structured questionnaire translated into Brazilian Portuguese using the Depression Attitude Questionnaire – DAQ. Conclusions: The present study demonstrates the importance of integrating screening for depression and other mental illnesses in primary care and in the HIV treatment context. This integration must be accompanied by the training of lay counselors who work in psychosocial support both for identification and intervention for cases of depression for better adherence to antiretroviral treatment

Association between mental disorders and adherence to antiretroviral treatment in health facilities in two Mozambican provinces in 2018: a cross-sectional study

Introduction: Lower adherence to antiretroviral treatment (ART) has been found among people with HIV (PWH) who have comorbid mental disorders like depression and alcohol use in Sub-Saharan African. However, there has been less exploration with regards to other mental disorders. Methods: This study assessed the association of multiple mental disorders and adherence to ART based on the data from primary/tertiary health care facilities in Maputo and Nampula, Mozambique. We administered a sociodemographic questionnaire, Mini International Neuropsychiatric Interview (MINI) Plus 4.0.0 adapted for use in Mozambique to assess mental conditions, and a 3-item self-report to measure ART adherence. Results: 395 HIV-positive (self-report) participants on ART, with an average age of 36.7 years (SD = 9.8), and 30.4% were male. The most common mental disorders were major depressive disorder (27.34%) followed by psychosis (22.03%), suicidal ideation/behavior (15.44%), and alcohol-use disorder (8.35%). Higher odds of missing at least one dose in the last 30 days (OR = 1.45, 95% CI: 1.01, 2.10) were found in participants with any mental disorder compared to those without a mental disorder. The highest levels of non-adherence were observed among those with drug use disorders and panic disorder. Conclusions: In Mozambique, PWH with any co-occurring mental conditions had a lower probability of ART adherence. Integrating comprehensive mental health assessment and treatment and ART adherence interventions tailored to PWH with co-occurring mental disorders is necessary to attain optimal ART adherence and reach the UNAIDS ART target

Lay HIV counselors' knowledge and attitudes toward depression: a mixed-methods cross-sectional study at primary healthcare centers in Mozambique

Introduction: Depression is the most common mental disorder among people living with HIV/AIDS and has a negative impact on HIV treatment outcomes. Training lay HIV counselors to identify and manage depression may contribute to improved patient access and adherence to treatment, and reduce stigma and discrimination among lay health workers toward both HIV and depression. The purpose of this study was to assess the current knowledge and attitudes of lay HIV counselors toward managing depression in primary care in Mozambique. Methods: We conducted a mixed-methods cross-sectional study to assess depression-related knowledge and attitudes among lay HIV counselors in 13 primary healthcare facilities in Mozambique. We used the quantitative Depression Attitude Questionnaire (DAQ) scale, followed by open-ended questions to further explore three key DAQ domains: the nature of depression, treatment preferences, and professional attitudes or reactions. Results: The sample included 107 participants (77.6% female, mean age: 32.3 years, sd = 7.4). Most (82.2%) had less than a high/technical school education. Findings suggested that some HIV counselors had knowledge of depression and described it as a cluster of psychological symptoms (e.g., deep sadness, anguish, apathy, isolation, and low self-esteem) sometimes leading to suicidal thoughts, or as a consequence of life stressors such as loss of a loved one, abuse, unemployment or physical illness, including being diagnosed with HIV infection. HIV counselors identified talking to trusted people about their problems, including family and/or counseling with a psychotherapist, as the best way for patients to deal with depression. While acknowledging challenges, counselors found working with patients with depression to be rewarding. Conclusion: Lay health counselors identified HIV and psychosocial issues as key risk factors for depression. They believed that the treatment approach should focus on social support and psychotherapy

Protocol for intervention development to improve adolescent perinatal mental health in Kenya and Mozambique: The INSPIRE project

Introduction Mental health interventions have traditionally been developed by clinicians and researchers without the meaningful engagement and partnership with those who would receive, deliver, and fund them. Recent progress has highlighted the importance of the co-design of interventions, through stakeholder participation, as a means of increasing the integration of mental health interventions into existing health, education, and social care systems. This protocol describes the pre-implementation phase of the INSPIRE (Innovative approaches to adolescent perinatal wellbeing) project which aims to identify challenges, and design and test interventions to promote mental wellbeing and good mental health of adolescent girls during pregnancy and the year after birth with local stakeholders in Kenya and Mozambique. Methods A participatory approach that blends human-centred design, systems thinking, and implementation science methods will be used to engage adolescents (aged 15–19 years), their families, and other stakeholders who can influence implementation efforts, in planning and preparing interventions. First, an understanding of context, barriers, and opportunities related to adolescent perinatal mental health will be elicited through individual interviews, focus group discussions, and observations. This will be complemented by a scoping review of relevant interventions. The research team will identify contextual insights relating to adolescent and system characteristics, strengths, and challenges. These will be shared with and refined by stakeholders. Thematic analysis will be conducted to describe the experiences of adolescent girls, and barriers and enablers to maintaining good mental health. The former will be triangulated with the Context and Implementation of Complex Intervention (CICI) framework. Causal loop diagrams will be developed to illustrate the individual and system-level variables which influence adolescent perinatal mental health. Stakeholder workshops will be used to identify priorities, brainstorm potential interventions, develop a program theory, and prototype an intervention and implementation strategies. Intervention acceptability, appropriateness, and feasibility will be assessed, and a theory of change map finalized. Results To date the study has recruited 169 participants to complete individual interviews, focus group discussions and observation activities. Conclusions It is anticipated that the use of a participatory and systematic approach to the development of an intervention to improve mental health, will improve its perceived appropriateness, acceptability, and feasibility among key stakeholders. This may, in turn, significantly improve its availability, uptake, and sustainability