Using relevance mapping methodology to design an adolescent mental health intervention in India

Background Adolescents in low and middle-income countries experience pronounced mental health needs in contexts where infrastructure and resources are scarce. While evidence-based treatment are readily available, they may not fit the unique needs of certain contexts. Objective This manuscript illustrates the systematic process of applying ‘relevance mapping’ methodology to leverage the youth mental health evidence base to identify candidate practices for inclusion in the development of a contextually appropriate psychological treatment protocol for common adolescent mental health problems in India. Methods The practice identification was informed by two datasets obtained from adolescent samples in India. The first was an epidemiological dataset from a large community sample in Goa (N = 2,048); the second incorporated ‘youth top problems’ reported by service-seeking students presenting to school counsellors in Goa and Delhi (N = 78). Problems identified in each dataset were categorized using structured codes. Problem codes and youth demographics were then indexed against a database of hundreds of evidence-based psychological treatments and their associated clinical trials. This methodology revealed the most common practice elements (discrete therapeutic strategies) and their most efficient combinations with evidence of effectiveness matching the demographics and diagnostic category (anxiety, disruptive behaviors and depression) prevalent in the planned treatment population. Results For anxiety, the most common practice elements for this age group were exposure, cognitive coping, and psychoeducation. For disruptive behaviors, the most common practices were problem-solving, goal-setting, and rapport-building. For depression, cognitive coping, behavioral activation, and psychoeducation were the most common practice elements. Conclusion These practice elements provided the treatment development team with a preliminary list of candidate content for the development of an intensive psychological treatment within a stepped care service model to address common adolescent mental health problems in schools in India

Designing Context-Specific Interventions: Maximizing Treatment Fit and Engagement in Low- and Middle-Income Countries

The gap between the need for mental health treatment and access to services is vast, especially in low- and middle-income countries (LMICs; Wang et al., 2007), and particularly among children and adolescents in these under-resourced settings (Patel et al., 2008). Closing the gap has become a public health priority in recent years (Lancet Global Mental Health Group, 2007). Task sharing and scaling up evidence-based treatments (EBTs) have been identified as two possible strategies to addressing the gap, with promising results (Singla et al., 2014). However, questions remain concerning the transportability of treatments developed in the West to populations for whom they were not initially intended, and in contexts that bear little resemblance to the highly controlled research settings in which they were conceived. The goal of this dissertation was to describe the process of building a context-sensitive, context-centered intervention using an evidence-informed design system and to evaluate user acceptability, satisfaction, and engagement. The first study used qualitative methods to document the iterative process of developing a treatment protocol in collaboration with local stakeholders and experts. Results demonstrate the central role that cultural/contextual considerations, protocol material and content, and complexity played in the design process, providing a blueprint for bringing together established treatment design principles with local knowledge to develop an intervention that is acceptable to providers and satisfying for youth participants in low-resource settings. The second study evaluated youth engagement in the intervention, as well the overall acceptability, feasibility, and fit of treatment from the youth and provider perspectives. Findings revealed that youth and providers largely perceived the treatment to be engaging, acceptable, and appropriate for the context. These results, along with participant recommendations for improvements, have the potential to inform the development of resources that promote youth engagement in the intervention. Taken together, these studies provide an inside look at the collaborative design-in-context approach of building an intervention in a low-resource setting along with users’ experience with the intervention in an initial pilot. Findings have the potential to narrow the treatment gap through promoting the development and scale up of acceptable, effective, and sustainable mental health treatments for one of the most vulnerable populations: children and adolescents in LMICs

Observed Engagement in Community Implemented Evidence-Based Practices for Children and Adolescents: Implications for Practice Delivery

ObjectiveThis observational study characterizes youth and caregiver behaviors that may pose challenges to engagement within a system-driven implementation of multiple evidence-based practices (EBPs). We examined links between Engagement Challenges and therapist EBP implementation outcomes.MethodCommunity therapists (N = 102) provided audio recordings of EBP sessions (N = 666) for youth (N = 267; 71.54%, Latinx; 51.69%, female; Mage = 9.85, Range: 1-18). Observers rated the extent to which youth and/or caregivers engaged in the following behaviors: Caregiver and/or Youth Expressed Concerns about interventions, and Youth Disruptive Behaviors. Multilevel modeling was used to identify predictors of observable Engagement Challenges, and examine associations between Engagement Challenges, and therapist-reported ability to deliver planned activities, and observer-rated extensiveness of EBP strategy delivery.ResultsAt least one Engagement Challenge was observed in 43.99% of sessions. Youth Engagement Challenges were not associated with outcomes. Caregiver Expressed Concerns were negatively associated with therapist-reported ability to carry out planned session activities (B = -.21, 95% CI[-.39-(-.02)], p < .05). However, Caregiver Expressed Concerns were positively associated with extensiveness of EBP Content strategy delivery (B = .08, 95% CI[.01-.15], p < .05).ConclusionsResults suggest that Youth Engagement Challenges have little observed impact on EBP delivery. In contrast, although therapists perceive that Caregiver Expressed Concerns derail their planned activities, Caregiver Expressed Concerns are associated with more extensive delivery of content about therapeutic interventions. Community therapists' implementation of EBPs appear unaffected by common youth in-session behavioral challenges, but future research is needed to clarify whether caregivers' concerns about interventions prompt, or are prompted by, more intensive therapist EBP content instruction

Identified needs of peripartum adolescents in Sub-Saharan Africa from 2013-2021: A mapping of domains for strengthening psychosocial interventions

Abstract: Adolescent pregnancy and early motherhood pose significant socioeconomic and health risks in Sub-Saharan Africa, leading to considerable morbidity and mortality. To learn more about the needs of this population, we reviewed 24 articles featuring 21 samples covering 12,490 adolescents from 14 countries. Our coding revealed that adolescent mothers were studied more (85.7% of samples) than pregnant adolescents (61.9%). We summarized needs as per six categories. Resource needs were most prevalent, reported by 100% of samples, followed by ecology (85.7%), mental health (76.2%), medical (61.9%), other (61.9%), and education (33.3%). The most frequently reported resource needs were low income and unemployment. Low social support, low family functioning, and exposure to negative cultural norms were ecological needs prevalent in most samples. Among mental health concerns, depression was the most commonly reported problem, whereas other problems, such as anxiety, substance use, and suicidality, were reported much less frequently. HIV-positive status was the most frequently reported medical concern. Intervention developers should consider the range of challenges when designing psychosocial services for this population

Predictors of Burnout Among Community Therapists in the Sustainment Phase of a System-Driven Implementation of Multiple Evidence-Based Practices in Children’s Mental Health

Burnout among community mental health (CMH) therapists has been associated with poorer therapist health, high agency turnover, poorer client outcomes, and compromised quality of care. Recent mandates to learn and implement multiple evidence-based practices (EBPs) within CMH settings are intended to improve the quality of community care, yet there is mixed evidence concerning the impacts on workforce burnout. The current study sought to identify correlates of therapist emotional exhaustion, a key aspect of burnout, during the sustainment phase of a system-driven implementation of multiple EBPs in children's mental health services. We hypothesized that high workload and unfavorable organizational climate would relate to therapist emotional exhaustion, but that positive experiences with EBPs adopted would relate to lower exhaustion. Although agency-level indices of organizational climate were unrelated to exhaustion, a multilevel model revealed that therapists' weekly work hours, caseload, and number of EBPs delivered were associated with increased emotional exhaustion. Additionally, activities associated with the EBP implementation efforts (e.g., hours spent in EBP-related activities, supervision or consultation, or outcome monitoring), were not associated with emotional exhaustion. Therapists' knowledge and confidence delivering EBPs and their positive perceptions of EBPs were protective against emotional exhaustion, but these perceptions did not buffer the risks associated with heavy workload. Findings point to implementation strategies to prevent burnout and associated turnover that compromise the returns on investments in EBP implementation

Supporting the implementation of written exposure therapy for posttraumatic stress disorder in an obstetrics-substance use disorder clinic in the Northeastern United States

Pregnant people with comorbid posttraumatic stress disorder (PTSD) and substance use disorder (SUD) constitute a highly vulnerable population. PTSD and SUD confer risks to both the pregnant person and the fetus, including a host of physical and mental health consequences. When PTSD and SUD co-occur, potential negative impacts are amplified, and the symptoms of each may exacerbate and maintain the other. Pregnancy often increases engagement in the healthcare system, presenting a unique and critical opportunity to provide PTSD and SUD treatment to birthing people motivated to mitigate risks of losing custody of their children. This paper presents implementation process outcomes of Written Exposure Therapy (WET), a brief, scalable, and sustainable evidence-based PTSD treatment delivered to pregnant persons receiving care in an integrated obstetrical-addiction recovery program at Boston Medical Center. Trial participants (N = 18) were mostly White, non-Hispanic (61.1%), not currently working (77.8%), had a high school or lower level of education (55.5%), had an annual household income less than $35,000 (94.4%), and were living in a substance use residential program (55.6%). We examined intervention feasibility, acceptability, appropriateness, adoption; barriers and facilitators to implementation; and feedback on supporting uptake and sustainability of the intervention using coded qualitative sources (consultation field notes [N = 47] and semi-structured interviews [N = 5]) from providers involved in trial planning and treatment delivery. Results reflected high acceptability, appropriateness, and adoption of WET. Participants described system-, provider-, and patient-level barriers to implementation, offered suggestions to enhance uptake, but did not raise concerns about core components of the intervention. Findings suggest that WET is an appropriate and acceptable PTSD treatment for this difficult-to-reach, complex population, and has the potential to positively impact pregnant persons and their children

A qualitative analysis of collaborative efforts to build a school-based intervention for multiple common adolescent mental health difficulties in India.

INTRODUCTION: In low- and middle-income countries (LMICs), the gap between need for mental health (MH) treatment and access to services is stark, particularly among children and adolescents. In service of addressing this treatment gap, the current study provides an in-depth illustration of later-stage collaborative design of a school-based, transdiagnostic MH intervention in New Delhi and Goa, India, using a combination of contextual insights from local stakeholders and knowledge derived from the global evidence base. METHODS: Using an inductive-deductive approach to qualitative thematic analysis, we examined coded data from qualitative sources related to experiences of developing and implementing an intervention prototype. These sources included notes from meetings attended by treatment development team members and providers, written feedback on protocol materials (e.g., provider manual, student handouts), field notes reflecting researcher observations, and minutes from weekly clinical supervision meetings. RESULTS: Results revealed that codes involving cultural/contextual considerations, protocol material and content, and intervention complexity arose consistently throughout treatment development and across document types, illustrating their central role in finalizing protocol design. DISCUSSION: These findings have implications for the future of mental health treatment development and implementation globally

Design process and protocol description for a multi-problem mental health intervention within a stepped care approach for adolescents in India

This paper documents the collaborative design of a mental health intervention for adolescents in India with anxiety, depression, or anger-related concerns. The process was characterized by three phases of formative activities: (1) an intensive review of the service context, (2) selection of an overall design strategy (e.g., whether to choose existing evidence-based treatments or build new treatments in context), and (3) a period of prototyping, testing, and refining. Each phase resulted in specific outputs, which were, respectively, (1) a detailed articulation of values and preferences (setting expectations for what the ideal protocol should be), (2) a set of build parameters representing a blueprint that managed strategic compromises for this context, and (3) a working protocol. We outline the steps of this design process, summarize data from an open-trial clinical case series, and illustrate the resulting working protocol, which will be tested in a future larger trial. We conclude with insights and observations likely to be relevant to protocol design activity in a variety of contexts, most particularly those in low-and-middle-income countries such as India

Mental health and psychosocial interventions integrating sexual and reproductive rights and health, and HIV care and prevention for adolescents and young people (10–24 years) in sub-Saharan Africa: a systematic scoping review

Background: Interventions targeting combined sexual and reproductive health, Human Immunodeficiency Virus (HIV) management and mental health care in sub-Saharan Africa (SSA) are few. There is a need to address common determinants of poor mental, psychosocial and sexual and reproductive health and rights (SRHR) through multimodal and multipronged interventions for adolescents. The main objective of this study was to identify whether and how interventions targeting adolescent SRHR and HIV with a focus on pregnant and parenting adolescents in SSA include mental health components and how these components and their outcomes have been reported in the literature. Methods: We carried out a two process scoping review approach between 01.04.2021 and 23.08.2022. In the first stage, we searched the PubMed database to identify studies focusing on adolescents and young people aged 10 to 24 from 2001 to 2021. We identified studies focusing on HIV and SRHR that had mental health and psychosocial aspects to the interventions. Our search yielded 7025 studies. Of these 38 were eligible based on our screening criteria that covered interventions, and on further scrutiny, using PracticeWise, an established coding system, we identified select problems and practices to provide a more granular assessment of how interventions developed for this context mapped on to specific problems. At this second stage process, we selected 27 studies for inclusion as actual interventional designs for further systematic scoping of their findings and we used the Joanna Briggs Quality Appraisal checklist to rate these studies. This review was registered within the International Prospective Register of Systematic Reviews (PROSPERO), number CRD42021234627. Findings: Our first set of findings is that when coding problems and solutions, mental health concerns were the least common category of problems targeted in these SRHR/HIV interventions; nevertheless, psychoeducation and cognitive behavioral strategies such as improved communication, assertiveness training, and informational support were offered widely. Of the 27 interventional studies included in the final review, 17 RCTs, 7 open trials, and 3 mixed designs, represented nine countries of the 46 countries in SSA. Intervention types included peer, community, family, digital, and mixed modality interventions. Eight interventions focused on caregivers and youth. Social or community ecology associated problems (being an orphan, sexual abuse, homelessness, negative cultural norms) were the most common risk factors and were more frequent than medical issues associated with HIV exposure. Our findings highlight the relevance and centrality of social issues related to adolescent mental and physical health along with the need to strengthen multimodal interventions along the lines of problems we have identified in our review. Interpretation: Combined interventions jointly addressing adolescent SRHR, HIV, and mental health have been relatively understudied, despite evidence that adverse social and community factors are rampant in this population