Article

Model for Service Delivery for Developmental Disorders in Low-Income Countries

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Abstract

As in many low-income countries, the treatment gap for developmental disorders in rural Pakistan is near 100%. We integrated social, technological, and business innovations to develop and pilot a potentially sustainable service for children with developmental disorders in 1 rural area. Families with developmental disorders were identified through a mobile phone-based interactive voice response system, and organized into "Family Networks." "Champion" family volunteers were trained in evidence-based interventions. An Avatar-assisted Cascade Training and information system was developed to assist with training, implementation, monitoring, and supervision. In a population of ∼30 000, we successfully established 1 self-sustaining Family Network consisting of 10 trained champion family volunteers working under supervision of specialists, providing intervention to 70 families of children with developmental disorders. Each champion was responsible for training and providing ongoing support to 5 to 7 families from his or her village, and the families supported each other in management of their children. A pre-post evaluation of the program indicated that there was significant improvement in disability and socioemotional difficulties in the child, reduction in stigmatizing experiences, and greater family empowerment to seek services and community resources for the child. There was no change in caregivers' well-being. To replicate this service more widely, a social franchise model has been developed whereby the integrated intervention will be "boxed" up and passed on to others to replicate with appropriate support. Such integrated social, technological, and business innovations have the potential to be applied to other areas of health in low-income countries.

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... Our earlier work in the same study settings has established that community-based female family volunteers can deliver evidence-based mental health care in community settings to bridge the mental health treatment gap [15][16][17]. Previously, we had converted the mhGAP guidelines into training videos for caregivers of children with developmental disorders and hosted them on a tablet device [18]. We trained non-specialist female family volunteers to deliver this technology-assisted parent skills training and pilot tested the intervention with 70 families with children with developmental disorders. ...
... We trained non-specialist female family volunteers to deliver this technology-assisted parent skills training and pilot tested the intervention with 70 families with children with developmental disorders. This model of service delivery was found to be acceptable, feasible, and resulted in improving child outcomes [18]. Based upon these preliminary findings, we scaled up the program and evaluated its implementation to explore how technologyassisted task sharing at scale impacts training, fidelity, reach, and adoption [19]. ...
... As the intervention content was adapted into a training application with "real-life" narratives [18] both the consumers and providers rated the program as highly appropriate and in keeping with the local traditions and cultural values (the mean score of consumers on the appropriateness domain was 24.62 ± 4.17 and 31.8 ± 4.62 for providers). The consumers perceived that the program was a good way to address their and their child's problems (2.43 ± 0.71). ...
Article
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Background As in many low-income countries, the treatment gap for developmental disorders in Pakistan is nearly 100%. The World Health Organization (WHO) has developed the mental Health Gap Intervention guide (mhGAP-IG) to train non-specialists in the delivery of evidence-based mental health interventions in low-resource settings. However, a key challenge to scale-up of non-specialist-delivered interventions is designing training programs that promote fidelity at scale in low-resource settings. In this case study, we report the experience of using a tablet device-based application to train non-specialist, female family volunteers in leading a group parent skills training program, culturally adapted from the mhGAP-IG, with fidelity at scale in rural community settings of Pakistan. Methods The implementation evaluation was conducted as a part of the mhGAP-IG implementation in the pilot sub-district of Gujar Khan. Family volunteers used a technology-assisted approach to deliver the parent skills training in 15 rural Union Councils (UCs). We used the Proctor and RE-AIM frameworks in a mixed-methods design to evaluate the volunteers’ competency and fidelity to the intervention. The outcome was measured with the ENhancing Assessment of Common Therapeutic factors (ENACT), during training and program implementation. Data on other implementation outcomes including intervention dosage, acceptability, feasibility, appropriateness, and reach was collected from program trainers, family volunteers, and caregivers of children 6 months post-program implementation. Qualitative and quantitative data were analyzed using the framework and descriptive analysis, respectively. Results We trained 36 volunteers in delivering the program using technology. All volunteers were female with a mean age of 39 (± 4.38) years. The volunteers delivered the program to 270 caregivers in group sessions with good fidelity (scored 2.5 out of 4 on each domain of the fidelity measure). More than 85% of the caregivers attended 6 or more of 9 sessions. Quantitative analysis showed high levels of acceptability, feasibility, appropriateness, and reach of the program. Qualitative results indicated that the use of tablet device-based applications, and the cultural appropriateness of the adapted intervention content, contributed to the successful implementation of the program. However, barriers faced by family volunteers like community norms and family commitments potentially limited their mobility to deliver the program and impacted the program’ reach. Conclusions Technology can be used to train non-specialist family volunteers in delivering evidence-based intervention at scale with fidelity in low-resource settings of Pakistan. However, cultural and gender norms should be considered while involving females as volunteer lay health workers for the implementation of mental health programs in low-resource settings.
... There is considerable stigma and discrimination affecting children with developmental disorders and their families. Thus, the treatment gap for developmental disorders in rural Pakistan is almost 100% [7,8]. The Ministry of Health in Pakistan is implementing the WHO mhGAP in primary health care settings to bridge the treatment gap for priority mental health conditions including childhood developmental disorders in Pakistan. ...
... As a part of mhGAP implementation in a pilot sub-district of Rawalpindi, Pakistan, we converted the WHO mhGAP guidelines into training videos for caregivers of children with developmental disorders and hosted them on a tablet device. Family Volunteers (FVs) were trained to deliver this training to the caregivers of children with developmental disorders [7]. The training videos were interactive, allowing family volunteers and members to discuss each scenario in the context of their own lives and develop individualised management plans for their children. ...
... To pilot test the intervention, we identified and trained 10 family volunteers in implementing technology assisted, evidence-based, WHO mhGAP guidelines with 70 families and children with developmental disorders. The program was found to be feasible, acceptable and resulted in change in child's outcomes [7]. ...
Article
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Background Globally, there is a large documented gap between needs of families and children with developmental disorders and available services. We adapted the World Health Organization’s mental health Gap-Intervention Guidelines (mhGAP-IG) developmental disorders module into a tablet-based android application to train caregivers of children with developmental disorders. We aimed to evaluate the effectiveness of this technology-assisted, family volunteers delivered, parents’ skills training intervention to improve functioning in children with developmental disorders in a rural community of Rawalpindi, Pakistan. Methods In a single-blinded, cluster randomized controlled trial, 30 clusters were randomised (1:1 ratio) to intervention (n = 15) or enhanced treatment as usual (ETAU) arm (n = 15). After screening, 540 children (18 participants per cluster) aged 2–12 years, with developmental disorders and their primary caregivers were recruited into the trial. Primary outcome was child’s functioning, measured by Childhood Disability Assessment Schedule for Developmental Disorders (DD-CDAS) at 6-months post-intervention. Secondary outcomes were parents’ health related quality of life, caregiver-child joint engagement, socio-emotional well-being of children, family empowerment and stigmatizing experiences. Intention-to-treat analyses were done using mixed-models adjusted for covariates and clusters. Results At 6-months post-intervention, no statistically significant mean difference was observed on DD-CDAS between intervention and ETAU (mean [SD], 47.65 [26.94] vs. 48.72 [28.37], Adjusted Mean Difference (AMD), − 2.63; 95% CI − 6.50 to 1.24). However, parents in the intervention arm, compared to ETAU reported improved health related quality of life (mean [SD] 65.56 [23.25] vs. 62.17 [22.63], AMD 5.28; 95% CI 0.44 to 10.11). The results were non-significant for other secondary outcomes. Conclusions In the relatively short intervention period of 6 months, no improvement in child functioning was observed; but, there were significant improvements in caregivers’ health related quality of life. Further trials with a longer follow-up are recommended to evaluate the impact of intervention. Trial registration Clinicaltrials.gov, NCT02792894. Registered April 4, 2016, https://clinicaltrials.gov/ct2/show/NCT02792894
... The Mental Health Gap Action Programme (mhGAP) Intervention Guide (IG) was developed by WHO in 2010 to increase mental health capacity in primary care and community-based settings by training nonspecialists, such as PCPs, thus improving service access for a wider population (12). mhGAP-based training has been implemented in several countries in the EMR, including Afghanistan (13,14), Egypt (13), Iraq (15), Lebanon (13,16), Libya (13), Pakistan (13,17,18), Qatar (13), Sudan (19), Syrian Arab Republic (13,15), and Tunisia (20). The training has been used in the Region to enhance the mental health capacity of for example physicians, social workers, nurses, community health workers, family volunteers, psychosocial staff of humanitarian agencies, and pregnant women (13)(14)(15)(16)(17)(18)(19)(20). ...
... mhGAP-based training has been implemented in several countries in the EMR, including Afghanistan (13,14), Egypt (13), Iraq (15), Lebanon (13,16), Libya (13), Pakistan (13,17,18), Qatar (13), Sudan (19), Syrian Arab Republic (13,15), and Tunisia (20). The training has been used in the Region to enhance the mental health capacity of for example physicians, social workers, nurses, community health workers, family volunteers, psychosocial staff of humanitarian agencies, and pregnant women (13)(14)(15)(16)(17)(18)(19)(20). ...
... For the scale-up of the training programme, a cascade model was used. A cascade model refers to "a series of training processes, each occurring as the result of the one before" (27) and is used to help diffuse expertise in the mental health sector (17,(28)(29)(30)(31). Specifically, a former local trainer for the first implementation of the mhGAP-based programme trained psychiatrists from the 4 Faculties of Medicine in Tunisia (Tunis, Sfax, Monastir and Sousse) in the mhGAP modules. ...
Article
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The Mental Health Gap Action Programme (mhGAP) Intervention Guide was developed to support evidence-based training offered to nonspecialists to further encourage the integration of mental health into primary care and community-based settings. This training programme was implemented in many countries of the Eastern Mediterranean Region (EMR). Tunisian primary care physicians were offered an mhGAP-based training programme as a pilot in 2016 and it was evaluated using an 18-month exploratory trial and implementation analysis. Pilot findings informed the scale-up of a mental health training programme that began in January 2020 by recommending amendments to mental health policy, informing training content, further operationalizing the National Strategy for Mental Health Promotion, and encouraging the sustainability of the training’s effects through a cascade model. Our lessons learned may be useful to other countries of the EMR, invested in furthering the training of primary care physicians/other nonspecialists, as well as the integration of mental health into primary care settings.
... To overcome these challenges, we developed an integrated model of service delivery (incorporating social, technological and business innovations ( Fig. 1) for children with developmental disorders and delays in low resource settings (Hamdani et al. 2015). An android application was developed to incorporate the WHO mhGAP-IG diagnostic and management guidelines and WHO PST for developmental disorders and delays in a standardised way. ...
... The model was found to be feasible, acceptable and resulted in change in client outcomes. The proof of concept of the integrated model of service delivery has already been published (Hamdani et al. 2015). ...
... (2) Can the WHO PST programme improve child's social communication and joint engagement with caregivers, improve child's social and emotional well-being, improve family empowerment, and result in better caregiver's health related quality of life? (3) Can the integrated model of service delivery for developmental disorders and delays (Hamdani et al. 2015) serve as a scalable method of delivering WHO PST programme in low resource settings? (4) What factors can inhibit and promote the large-scale implementation of WHO PST programme for developmental disorders and delays? ...
Article
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Background Development disorders and delays are recognised as a public health priority and included in the WHO mental health gap action programme (mhGAP). Parents Skills Training (PST) is recommended as a key intervention for such conditions under the WHO mhGAP intervention guide. However, sustainable and scalable delivery of such evidence based interventions remains a challenge. This study aims to evaluate the effectiveness and scaled-up implementation of locally adapted WHO PST programme delivered by family volunteers in rural Pakistan. Methods The study is a two arm single-blind effectiveness implementation-hybrid cluster randomised controlled trial. WHO PST programme will be delivered by ‘family volunteers’ to the caregivers of children with developmental disorders and delays in community-based settings. The intervention consists of the WHO PST along with the WHO mhGAP intervention for developmental disorders adapted for delivery using the android application on a tablet device. A total of 540 parent-child dyads will be recruited from 30 clusters. The primary outcome is child's functioning, measured by WHO Disability Assessment Schedule – child version (WHODAS-Child) at 6 months post intervention. Secondary outcomes include children's social communication and joint engagement with their caregiver, social emotional well-being, parental health related quality of life, family empowerment and stigmatizing experiences. Mixed method will be used to collect data on implementation outcomes. Trial has been retrospectively registered at ClinicalTrials.gov (NCT02792894). Discussion This study addresses implementation challenges in the real world by incorporating evidence-based intervention strategies with social, technological and business innovations. If proven effective, the study will contribute to scaled-up implementation of evidence-based packages for public mental health in low resource settings. Trial registration Registered with ClinicalTrials.gov as Family Networks (FaNs) for Children with Developmental Disorders and Delays. Identifier: NCT02792894 Registered on 6 July 2016.
... The devastating floods of 2010 led to thousands of people losing of their homes, and caused destruction to houses, roads, schools and health facilities [20,21]. A recent community-based cross-sectional survey of 349 pregnant women in Swat showed that the prevalence of current psychological distress was 38.1 % [22]. Mental health impacts of conflict are often severe [8,23] and may not be depicted in the national statistics. ...
... An artist has converted the characters into "Avatars" (graphic image representing each character) (Fig. 1), which were used to voice the narrative scripts. Our group had successfully used this methodology of Technology-assisted Cascade Training (TACT) for training parents of children with developmental disorders [22]. The TACTS has also used case scenarios and role plays to reinforce key messages and training skills. ...
Article
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Background Rates of perinatal depression in low and middle income countries are reported to be very high. Perinatal depression not only has profound impact on women’s health, disability and functioning, it is associated with poor child health outcomes such as pre-term birth, under-nutrition and stunting, which ultimately have an adverse trans-generational impact. There is strong evidence in the medical literature that perinatal depression can be effectively managed with psychological treatments delivered by non-specialists. Our previous research in Pakistan led to the development of a successful perinatal depression intervention, the Thinking Healthy Program (THP). The THP is a psychological treatment delivered by community health workers. The burden of perinatal depression can be reduced through scale-up of this proven intervention; however, training of health workers at scale is a major barrier. To enhance access to such interventions there is a need to look at technological solutions to training and supervision. Methods/design This is a non-inferiority, single-blinded randomized controlled trial. Eighty community health workers called Lady Health Workers (LHWs) working in a post-conflict rural area in Pakistan (Swat) will be recruited through the LHW program. LHWs will be randomly allocated to Technology-assisted Cascade Training and Supervision (TACTS) or to specialist-delivered training (40 in each group). The TACTS group will receive training in THP through LHW supervisors using a tablet-based training package, whereas the comparison group will receive training directly from mental health specialists. Our hypothesis is that both groups will achieve equal competence. Primary outcome measure will be competence of health workers at delivering THP using a modified ENhancing Assessment of Common Therapeutic factors (ENACT) rating scale immediately post training and after 3 months of supervision. Independent assessors will be blinded to the LHW allocation status. Discussion Women living in post-conflict areas are at higher risk of depression compared to the general population. Implementation of evidence-based interventions for depression in such situations is a challenge because health systems are weak and human resources are scarce. The key innovation to be tested in this trial is a Technology-assisted Cascade Training and Supervision system to assist scale-up of the THP. Trial registration Registered with ClinicalTrials.gov as GCC-THP-TACTS-2015, Identifier: NCT02644902.
... Building on our previous work in this area (Hamdani et al. 2015), we used a multimedia androidbased training Application. Training materials were converted into narrative scripts in the Urdu language by a panel of THP trainers. ...
... and understanding about mental disorders as compared to control groups. A pre-post study evaluated of an online course to enhance health professionals' knowledge about the clinical management of alcohol misuse in Brazil demonstrated significant improvement in knowledge about the clinical management of alcohol-related problems(Pereira et al. 2015b).Hamdani et al. (2015) tested the effectiveness of training lay individuals (volunteer family members of children with developmental disorders) in behavioral management skills in rural Pakistan, and found technology-assisted training feasible and effective in improving outcomes of children with developmental disorders. Our findings are consistent with and add ...
Article
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Background The Thinking Healthy Programme (THP) is an evidence-based psychological intervention endorsed by the World Health Organization, tailored for non-specialist health workers in low- and middle-income countries. However, training and supervision of large numbers of health workers is a major challenge for the scale-up of THP. We developed a ‘Technology-Assisted Cascaded Training and Supervision system’ (TACTS) for THP consisting of a training application and cascaded supervision delivered from a distance. Methods A single-blind, non-inferiority, randomized controlled trial was conducted in District Swat, a post-conflict area of North Pakistan. Eighty community health workers (called Lady Health Workers or LHWs) were randomly assigned to either TACTS or conventional face-to-face training and supervision by a specialist. Competence of LHWs in delivering THP post-training was assessed by independent observers rating a therapeutic session using a standardized measure, the ‘Enhancing Assessment of Common Therapeutic factors’ (ENACT), immediately post-training and after 3 months. ENACT uses a Likert scale to score an observed interaction on 18 dimensions, with a total score of 54, and a higher score indicating greater competence. Results Results indicated no significant differences between health workers trained using TACTS and supervised from distance v. those trained and supervised by a specialist face-to-face ( mean ENACT score M = 24.97, s.d. = 5.95 v . M = 27.27, s.d. = 5.60, p = 0.079, 95% CI 4.87–0.27) and at 3 months follow-up assessment ( M = 44.48, s.d. = 3.97 v . M = 43.63, s.d. = 6.34, p = 0.53, CI −1.88 to 3.59). Conclusions TACTS can provide a promising tool for training and supervision of front-line workers in areas where there is a shortage of specialist trainers and supervisors.
... One method of doing so is through the use of Interactive Voice Response (IVR) systems, commonly used in ICTD projects. Within the field of mental health, IVR systems have been used in rural Pakistan [43] to help identify families with a child with a developmental disorder, in Bolivia to administer a self-care service to people with moderate depression [53], and in Rwanda to connect young mothers to mental health resources [17]. ...
... Section 3.1, Culture-Based Interactions (5) When designing digital interventions for mental distress, it is important to consider whether your intervention needs to be accessible to people from lower socioeconomic statuses and lower levels of literacy to be successful, as the treatment gap is the highest among people from that demographic [99]. Projects from ICTD such as IVR systems have been shown to have high rates of success outside of mental health [17,43,53]. Section 3.2, Resource-Based Interactions (6) Stigma against mental distress and illness is a huge disincentivizing factor with regards to whether people choose to seek help. ...
Conference Paper
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Mental illness is rapidly gaining recognition as a serious global challenge. Recent human-computer interaction (HCI) research has investigated mental health as a domain of concern, but is yet to venture into the Global South, where the problem exhibits a more complex, intersectional nature. In this paper, we review work on mental health in the Global South and present a case for HCI for Development (HCI4D) to look at mental health-both because it is an inarguably important area of concern in itself, and also because it impacts the efficacy of HCI4D interventions in other domains. We consider the role of cultural and resource-based interactions towards accessibility challenges and continuing stigma around mental health. We also identify participants' mental health as a constant consideration for HCI4D and present best practices for measuring and incorporating it. As an example, we demonstrate how both the process and the lens of aspirations-based design, a recently proposed approach for HCI4D research and design, may benefit from the consideration of mental health concerns. Our paper thus recommends a path forward for considering mental health in HCI4D, potentially leading to new research directions in addition to enriching existing ones.
... However, critiques proposed that task sharing may not always be acceptable and feasible in lower resource contexts: non-specialists may not feel competent to deliver certain tasks for example [20]. There are several examples of interventions for DDs developed or adapted for use in LMICs [21,22], including a caregiver intervention using family networks in Pakistan [23]; a lay health worker delivered programme for autism in India [24], and two parent-mediated interventions in India and Pakistan [24][25][26][27]. ...
Article
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There are increasing efforts to scale up services globally for families raising children with developmental disabilities (DDs). Existing interventions, often developed in high income, Western settings, need substantial adaptation before they can be implemented in different contexts. The aim of this study was to explore perspectives on the role that context plays in the adaptation and implementation of interventions targeting caregivers of children with DDs across settings. The study question was applied to the Caregiver Skills Training (CST) programme of the World Health Organization specifically, as well as to stakeholder experiences with caregiver interventions more broadly. Two focus group discussions (FGDs; n = 15 participants) and 25 individual semi-structured interviews were conducted. Participants were caregivers of children with DDs and professionals involved in adapting or implementing the CST across five continents and different income settings. Data were analysed thematically. Four main themes were developed: 1) Setting the scene for adaptations; 2) Integrating an intervention into local public services; 3) Understanding the reality of caregivers; 4) Challenges of sustaining an intervention. Informants thought that contextual adaptations were key for the intervention to fit in locally, even more so than cultural factors. The socio-economic context of caregivers, including poverty, was highlighted as heavily affecting service access and engagement with the intervention. Competing health priorities other than DDs, financial constraints, and management of long-term collaborations were identified as barriers. This study validates the notion that attention to contextual factors is an essential part of the adaptation of caregiver interventions for children with DDs, by providing perspectives from different geographical regions. We recommend a stronger policy and research focus on contextual adaptations of interventions and addressing unmet socio-economic needs of caregivers.
... Cross-cultural exploration and comparison of the cultural and socioeconomic factors that may affect the transference of clinical information I Increase access to services Develop and evaluate culturally and contextually appropriate service delivery models suitable for low-resource settings, for example using nonspecialist training facilitators as currently tested in Pakistan (Hamdani et al., 2017;Hamdani, Minhas, Iqbal, & Rahman, 2015). ...
Article
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Autism research is heavily skewed toward western high‐income countries. Culturally appropriate screening and diagnostic instruments for autism are lacking in most low‐ and middle‐income settings where the majority of the global autism population lives. To date, a clear overview of the possible cultural and contextual factors that may affect the process of identifying and diagnosing individuals with autism spectrum disorders (ASD) is missing. This study aims to outline these factors by proposing a conceptual framework. A multidisciplinary review approach was applied to inform the development of the conceptual framework, combining a systematic review of the relevant autism research literature with a wider literature search spanning key texts in global mental health, cultural psychiatry, cross‐cultural psychology, and intellectual disability research. The resulting conceptual framework considers the identification, help‐seeking, and diagnostic process at four interrelated levels: (a) the expression; (b) recognition; (c) interpretation; and (d) reporting of autism symptoms, and describes the cultural and contextual factors associated with each of these levels, including cultural norms of typical and atypical behavior, culture‐specific approaches to parenting, mental health literacy, cultural beliefs, attitudes and stigma, as well as the affordability, availability, accessibility, and acceptability of services. This framework, mapping out the cultural and contextual factors that can affect the identification, help‐seeking, and diagnosis of ASD may function as a springboard for the development of culturally appropriate autism screening and diagnostic instruments, and inform future cross‐cultural autism research directions. The framework also has relevance for clinicians and policy makers aiming to improve support for underserved autism populations worldwide. Autism Res 2020, 13: 1029‐1050. © 2020 International Society for Autism Research, Wiley Periodicals, Inc. Lay Summary The vast majority of autism research is conducted in western high‐income settings. We therefore know relatively little of how culture and context can affect the identification, help‐seeking, and diagnosis of autism across the globe. This study synthesizes what is known from the autism research literature and a broader literature and maps out how culture and context may affect (a) the expression, (b) recognition, (c) interpretation, and (d) reporting of autism symptoms.
... To contrast the Irish situation with one in a much poorer country which has few or no practitioners available in rural areas; an example of innovative practices in Pakistan was presented at the workshop. Through a dial-up system parents could get a good estimate of the likelihood that their child had a disability; and through an avatar and community support service (with no practitioners physically present) they could be provided with an intervention, which is producing promising results (Hamdani et al, 2015). The idea of presenting this example of practice was to illustrate that there are very different approaches to assessment and intervention; and this is something that should stimulate fresh thinking in the Irish context. ...
Technical Report
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Review with practical recommendations for increasing access to services for youth with disabilities in Ireland
... Within health and social care settings the method is more commonly referred to as 'train the trainers' (TTT). It is an approach that has been utilised, for example, in studies of the dissemination and implementation of new interventions to support caregivers after a stroke [1]; to train general practitioners in novel clinical skills for managing people with medically unexplained symptoms [2]; and in the implementation of other evidence-based clinical interventions [3][4][5]. It has also been employed to enable acquisition of the skills required to appraise the evidence base [6]. ...
Article
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Background: 'Cascade training' or 'train-the-trainers' has been widely utilised in the dissemination of information and expertise in health and social care, but with little examination of the work required for optimal delivery. National suicide prevention strategies commonly include such training initiatives. Methods: A qualitative study to characterise the work, according to the concepts of Normalization Process Theory, required to disseminate STORM, a model of suicide prevention training across Scotland, and then implement it within organisations. This utilised a cascade style 'train-the trainers' intervention delivered as part of the Choose Life suicide prevention strategy in Scotland during 2008-11. Semi-structured interviews were carried out with 19 training facilitators, 30 of their group participants within organisations and 11 local managers within health boards in Scotland. Results: Crucial to the process of a cascade training approach to implementing suicide prevention within an organisation was the multi-layered activity of constructing coherence of the intervention at every level in order to prevent dilution of the training. This necessitated collaborative work within and between groups of actors- managers, facilitators and participants. Where facilitators were effectively engaged in their role, confident in their ability to train, supported by supervision and possessed the leadership skills to engage both with participants and their local context to deliver training, there was evidence of both successful delivery and embedding within the organisation. However, there was little systematic evidence of institutional level appraisal- crucial to truly implementing a novel intervention within the system - despite efforts at local managerial engagement. Conclusions: Successful cascade or train-the-trainer implementation of an intervention requires extensive collaborative work to take place between and within groups of actors at all levels of an organization from those working at policy level to the 'coalface'. A priori application of Normalization Process Theory, to specify aims and goals for the necessary work to be carried out between different groups of actors, would assist in embedding a novel working practice at all levels. Future national training strategies for suicide prevention should address what is required to establish a flourishing culture of high-quality skills acquisition and development within healthcare organisations.
... Cross-cultural exploration and comparison of the cultural and socioeconomic factors that may affect the transference of clinical information I Increase access to services Develop and evaluate culturally and contextually appropriate service delivery models suitable for low-resource settings, for example using nonspecialist training facilitators as currently tested in Pakistan (Hamdani et al., 2017;Hamdani, Minhas, Iqbal, & Rahman, 2015). ...
Preprint
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Autism research is heavily skewed towards western high-income countries. Culturally appropriate screening and diagnostic instruments for autism are lacking in most low- and middle-income settings where the majority of the global autism population lives. To date, a clear overview of the possible cultural and contextual factors that may affect the process of identifying and diagnosing individuals with ASD is missing. This study aims to outline these factors by proposing a conceptual framework. A multidisciplinary review approach was applied to inform the development of the conceptual framework, combining a systematic review of the relevant autism research literature with a wider literature search spanning key texts in global mental health, cultural psychiatry, cross-cultural psychology and intellectual disability research. The resulting conceptual framework considers the identification and diagnostic process at four interrelated levels: i) the expression, ii) recognition, iii) interpretation and iv) reporting of autism symptoms, and describes the cultural and contextual factors associated with each of these levels, including cultural norms of typical and atypical behaviour, culture-specific approaches to parenting, mental health literacy, cultural beliefs, attitudes and stigma, as well as the affordability, availability, accessibility and acceptability of services. This framework, mapping out the cultural and contextual factors that can affect the identification and diagnosis of ASD, may function as a springboard for the development of culturally appropriate autism screening and diagnostic instruments, and inform future cross-cultural autism research directions. The framework also has relevance for clinicians and policy makers aiming to improve support for underserved autism populations worldwide.
... Task-sharing approaches that provide abbreviated training to less specialized providers for the delivery of evidencebased screening, care, and support interventions can help bridge the resource gap. Researchers in Pakistan screened a large rural community by distributing written descriptions of developmental disorders that included motivational messages and by administering the Ten Questions Screen for disability using an interactive voice response system[34]. Children who screened positive were eligible to work with a network of families equipped with " family champion volunteers " trained in evidence-based interventions outlined in the WHO Mental Health Gap Action Program's (mhGAP) intervention guide. ...
Article
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1. The United Nations Sustainable Development Goals and the UN Convention on the Rights of the Child (CRC) envision an inclusive society in which health and education contribute to the well-being of all. To achieve this vision, children with developmental delays and behavioral, cognitive, mental, and neurological disabilities need greater access to health care, early childhood care and development services, and education. 2. Improved population-level detection, alongside screening, assessment, and linkage to evidence-based, intersectoral services in the first years of life, can help maximize capabilities and increase the chances of social inclusion for children with developmental delays and disabilities. 3. Educational programs for children with delays and disabilities whose service delivery structure supports the ability of parents to work should be encouraged so that parents can participate in achieving children’s educational goals while also meeting their financial needs. 4. Parents and caregivers who receive training in psychosocial interventions and ongoing support can help children with delays and disabilities thrive in family contexts. 5. Family mental health influences the developmental trajectory of children. Ensuring that parents and caregivers have access to affordable, quality mental health services helps to prevent poor outcomes for children. 6. Rigorous evaluation, continuous quality improvement, and regular monitoring of the programmatic outcomes of services and policy approaches targeting children and caregivers would inform their implementation and serve to disseminate lessons learned from successful policy and program implementation.
... The data for this validation study were collected as a part of an implementation research trial embedded within the scaled-up implementation of WHO mhGAP-based Parent Skills Training (PST) programme in rural Pakistan (Hamdani et al., 2017). The host organization has a database of about 3000 families and children with developmental disorders as a part of the host organization's service delivery to the community (Hamdani et al., 2015). For the purpose of the cluster randomized controlled trial (cRCT), a sample size of 540 parent-child dyads from 30 clusters (18 parent-child dyads per cluster) was required to evaluate the impact of PST programme (Hamdani et al., 2017). ...
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Background Developmental disorders (DDs) in children are a priority condition and guidelines have been developed for their management within low-resource community settings. However, a key obstacle is lack of open access, reliable and valid tools that lay health workers can use to evaluate the impact of such programmes on child outcomes. We adapted and validated the World Health Organization's Disability Assessment Schedule for children (WHODAS-Child), a lay health worker-administered functioning-related tool, for children with DDs in Pakistan. Methods Lay health workers administered a version of the WHODAS-Child to parents of children with DDs ( N = 400) and without DDs ( N = 400), aged 2–12 years, after it was adapted using qualitative study. Factor analysis, validity, reliability and sensitivity to change analyses were conducted to evaluate the psychometric properties of the adapted outcome measure. Results Among 800 children, 58% of children were male [mean ( s.d. ) age 6.68 ( s.d. = 2.89)]. Confirmatory Factor Analysis showed a robust factor structure [χ ² /df 2.86, RMSEA 0.068 (90% CI 0.064–0.073); Tucker–Lewis Index (TLI) 0.92; Comparative Fit Index (CFI) 0.93; Incremental Fit Index (IFI) 0.93]. The tool demonstrated high internal consistency ( α 0.82–0.94), test–retest [Intra-class Correlation Coefficient (ICC) 0.71–0.98] and inter-data collector (ICC 0.97–0.99) reliabilities; good criterion ( r −0.71), convergent ( r −0.35 to 0.71) and discriminative [M ( s.d. ) 52.00 ( s.d. = 21.97) v . 2.14 ( s.d. = 4.00); 95% CI −52.05 to −47.67] validities; and adequate sensitivity to change over time (ES 0.19–0.23). Conclusions The lay health worker administrated version of adapted WHODAS-Child is a reliable, valid and sensitive-to-change measure of functional disability in children aged 2–12 years with DDs in rural community settings of Pakistan.
... Most included papers used a subset of mhGAP-IG modules, with depression, psychosis, drug and alcohol use disorders, epilepsy and suicide being the most common 10 17-20 ; three focused on developmental and behavioural disorders. 12 13 21 Course durations varied from 3 hours training for teachers about attention deficit hyperactivity disorder, followed by a 1.5-hour booster session, 13 to 5 full days 'base course' followed by the mhGAP 'standard course' 16 or 40 hours child psychiatry training over 2 weeks. 21 Most training lasted 2-3 days, combining didactic lecture teaching with videos, role plays, communication exercises and discussions. ...
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Question Despite mental, neurological and substance use (MNS) disorders being highly prevalent, there is a worldwide gap between service need and provision. WHO launched its Mental Health Gap Action Programme (mhGAP) in 2008, and the Intervention Guide (mhGAP-IG) in 2010. mhGAP-IG provides evidence-based guidance and tools for assessment and integrated management of priority MNS disorders in low and middle-income countries (LMICs), using clinical decision-making protocols. It targets a non-specialised primary healthcare audience, but has also been used by ministries, non-governmental organisations and academics, for mental health service scale-up in 90 countries. This review aimed to identify evidence to date for mhGAP-IG implementation in LMICs. Study selection and analysis We searched MEDLINE, Embase, PsycINFO, Web of Knowledge/Web of Science, Scopus, CINAHL, LILACS, SciELO/Web of Science, Cochrane, Pubmed databases and Google Scholar for studies reporting evidence, experience or evaluation of mhGAP-IG in LMICs, in any language. Data were extracted from included papers, but heterogeneity prevented meta-analysis. Findings We conducted a systematic review of evidence to date, of mhGAP-IG implementation and evaluation in LMICs. Thirty-three included studies reported 15 training courses, 9 clinical implementations, 3 country contextualisations, 3 economic models, 2 uses as control interventions and 1 use to develop a rating scale. Our review identified the importance of detailed reports of contextual challenges in the field, alongside detailed protocols, qualitative studies and randomised controlled trials. Conclusions The mhGAP-IG literature is substantial, relative to other published evaluations of clinical practice guidelines: an important contribution to a neglected field.
... A recent pilot study in Bangladesh found that socialization of parents with an ASD child in a rural setting through training sessions was associated with positive outcomes (Blake et al., 2017). There is an existing model involving the parent/caregiver to support people with development disorders in low resource communities (Hamdani et al., 2015) validating our concept to incorporate community support. However, our recommendation emphasizes on utilization of existing countrywide infrastructure used for vaccination programs for initial screening of ASD, and use of ICT technology to connect to specialist if required after initial screening. ...
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We provide specific recommendations for addressing autism spectrum disorder (ASD) in developing countries from the viewpoint of Bangladesh. Developing countries lack necessary healthcare facilities, skilled professionals and resources to deal with rising burden of ASD. This underscores the need for developing strategies that could work within cultural and economic barrier. We propose an innovative model for primary screening of ASD by utilizing well-established nationwide vaccination program in Bangladesh. Moreover, ICT-based intervention should be promoted to adapt best practices found elsewhere in the local context. Our recommendations would also be useful for other resource-limited countries.
... Evidence highlights that IVR has proven to be a reliable and inexpensive tool in mobile healthcare. For instance, IVR has been applied in low-and middle-income countries for remote education of health personal, for example in the field of family planning [22], for diagnostic and treatment support [23], to enhance medical adherence [24], for the management and monitoring of psychiatric conditions and mental health [25,26] as well as for education and behaviour change communication in the field of sexually transmitted infections [27] and chronic diseases [28]. The results of our study contribute essential empirical findings to the neglected area of mHealth user acceptance in sub-Saharan Africa. ...
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Objectives: To investigate and determine the factors that enhanced or constituted barriers to the acceptance of an mHealth system which was piloted in Asante-Akim North District of Ghana to support healthcare of children. Methods: Four semi-structured focus group discussions were conducted with a total of 37 mothers. Participants were selected from a study population of mothers who subscribed to a pilot mHealth system which used an interactive voice response for its operations. Data were evaluated using qualitative content analysis methods. In addition a short quantitative questionnaire assessed systems usability (SUS). Results: Results revealed 10 categories of factors that facilitated user-acceptance of the interactive voice response (IVR) system including quality of care experience, health education and empowerment of women. The 8 categories of factors identified as barriers to user-acceptance included the lack of human interaction, lack of update and training on the electronic advices provided, and lack of social integration of the system into the community. The usability (SUS median: 79.3; range: 65-97.5) of the system was rated acceptable. Conclusions: The principles of the tested mHealth system could be of interest during infectious disease outbreaks, such as Ebola or Lassa fever, when there might be a special need for disease-specific health information within populations. This article is protected by copyright. All rights reserved.
... The capacity of health care professionals in LMICs to provide education and therapy are limited by the scarce knowledge and human resources for neurological and developmental paediatric care (Hamdani et al., 2015). Mothers perceived that health services were busy and lacked knowledge about CP, its management and treatment. ...
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Background Accurate diagnosis of cerebral palsy (CP) high-risk status is now possible in infants less than six months corrected age. Parents play a central role in providing nurturing care and implementing early intervention approaches. To design interventions tailored to needs of parents and understand how to improve parental support, this study aimed to understand the influences shaping parent experiences with an infant at high-risk of CP in West Bengal, India. Methods and procedures This phenomenological qualitative study was conducted with parents of infants at high-risk of CP in West Bengal, India. Individual in-depth interviews explored experiences with health providers, supports for caregiving and challenges of parenting. Interviews were conducted in English with concurrent translation and analysed using thematic analysis. Outcomes and results Main themes included: limited finances and social networks shape decisions and caregiving practices; trust in the formal health care system; views of disability including explanations for their infant’s condition and expectations for the child’s future, and everyday adaptations required to meet infants’ needs. Conclusions and implications Low cost models of early intervention may alleviate the financial burden and stress on families. Dependence on health care professionals for care management is a barrier to family-delivered approaches to care.
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Article
Early acknowledgment of developmental difficulties in young children strengthens both preventive and therapeutic approaches. Despite their feasibility, early intervention services are limited in Low-and-Middle-Income (LAMI) countries compared to highincome countries. The aim of this study was to examine the evidence for early childhood intervention programs for developmental difficulties in children below five years in LAMI countries through a systematic review and meta-analysis. In this background, original studies published in peer-reviewed journals from 2010-2019 and focused on developmental difficulties including delays and deviances; randomized research design with a clear description of the intervention and measurable outcomes, and conducted in LAMI were considered for the systematic review. Electronic databases, including ProQuest, PubMed, Ovid, EBSCOhost, and Google Scholar, were searched using a combination of specific keywords. PRISMA guidelines were followed to include the studies. Each of the selected studies was assessed for quality before applying appropriate statistics to synthesize the data. Fourteen publications were identified from 2,697 publications for the systematic review out of which four were found compatible for a meta-analysis. The studies reviewed were conducted in Bangladesh, India, Pakistan, Uganda, Vietnam, and Zambia. A meta-analysis of four studies provided considerable evidence for the effects of early developmental intervention. This systematic review provides an evidence for early childhood intervention programs in LAMI countries. Implications of these findings for the early childhood programs are discussed in this article.
... Several studies recruited subjects cross-sectionally or longitudinally in cohorts from international surveys (e.g., European Study on the Epidemiology of Mental Disorders -ESEMeD [176,177,182,195 Thirty percent (n ¼ 244) of the selected studies did not report which version of WHODAS 2.0 was administered. [38-44, 47, 49, 50, 58-64,67-69,72,74,75,78,80,83,85,87,91,93-95,97-99,102,106-108, 122,132,155,158,168-170,174,175,181,183,184,190,192,195,197,199, 200, 204, 208, 211, 222, 225, 229, [27,139,[828][829][830][831] Three percent (n ¼ 24) of the selected studies administered the World Mental Health (WMH) Survey Initiative version, WMH-WHODAS. [104,133,161,[176][177][178][179]193,201,202,[205][206][207]216,321,355,397,416,429,671,730,[832][833][834] The WMH Survey Initiative is a project organized by the Assessment, Classification, and Epidemiology (ACE) Group at the WHO and its purpose is to obtain accurate information about the prevalence and correlates of mental disorders, substance use disorder, and behavioral disorders in countries in all WHO regions (http://www.hcp.med.harvard. ...
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Purpose: This systematic review examines research and practical applications of the World Health Organization Disability Assessment Schedule (WHODAS 2.0) as a basis for establishing specific criteria for evaluating relevant international scientific literature. The aims were to establish the extent of international dissemination and use of WHODAS 2.0 and analyze psychometric research on its various translations and adaptations. In particular, we wanted to highlight which psychometric features have been investigated, focusing on the factor structure, reliability, and validity of this instrument. Method: Following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) methodology, we conducted a search for publications focused on “whodas” using the ProQuest, PubMed, and Google Scholar electronic databases. Results: We identified 810 studies from 94 countries published between 1999 and 2015. WHODAS 2.0 has been translated into 47 languages and dialects and used in 27 areas of research (40% in psychiatry). Conclusions: The growing number of studies indicates increasing interest in the WHODAS 2.0 for assessing individual functioning and disability in different settings and individual health conditions. The WHODAS 2.0 shows strong correlations with several other measures of activity limitations; probably due to the fact that it shares the same disability latent variable with them. Implications for Rehabilitation WHODAS 2.0 seems to be a valid, reliable self-report instrument for the assessment of disability. The increasing interest in use of the WHODAS 2.0 extends to rehabilitation and life sciences rather than being limited to psychiatry. WHODAS 2.0 is suitable for assessing health status and disability in a variety of settings and populations. A critical issue for rehabilitation is that a single “minimal clinically important .difference” score for the WHODAS 2.0 has not yet been established.
... The importance of this approach is exemplifi ed by the rapid scale-up between 2000 and 2009 of more than 120 cash transfer programmes in LMICs, growing from 28•3 million benefi ciaries in 2001 to 129•4 million in 2010 (appendix pp [59][60][61][62][63][64][65][66][67][68][69][70]. Lessons learned are that the main drivers of expansion of cash transfer programmes included political commitment and popularity, operational ease, advances in information technology and banking, rigorous evidence that they are eff ective, and support from international organisations. ...
Article
Building on long-term benefits of early intervention (Paper 2 of this Series) and increasing commitment to early childhood development (Paper 1 of this Series), scaled up support for the youngest children is essential to improving health, human capital, and wellbeing across the life course. In this third paper, new analyses show that the burden of poor development is higher than estimated, taking into account additional risk factors. National programmes are needed. Greater political prioritisation is core to scale-up, as are policies that afford families time and financial resources to provide nurturing care for young children. Effective and feasible programmes to support early child development are now available. All sectors, particularly education, and social and child protection, must play a role to meet the holistic needs of young children. However, health provides a critical starting point for scaling up, given its reach to pregnant women, families, and young children. Starting at conception, interventions to promote nurturing care can feasibly build on existing health and nutrition services at limited additional cost. Failure to scale up has severe personal and social consequences. Children at elevated risk for compromised development due to stunting and poverty are likely to forgo about a quarter of average adult income per year, and the cost of inaction to gross domestic product can be double what some countries currently spend on health. Services and interventions to support early childhood development are essential to realising the vision of the Sustainable Development Goals.
... Online communities represent an oppor tunity to promote mental wellbeing and enable people with mental health conditions to feel less alone and to find support from others with shared experiences. Family members can also access important resources such as social support, recommended coping strategies, and selfhelp programmes delivered online or through mobile phone platforms-for example, for developmental disorders, 173 mood and anxiety problems (the Depression and Bipolar Support Alliance), and for dementia (WHO's iSupport). ...
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Background: Rates of perinatal depression in low and middle income countries are reported to be very high. Perinatal depression not only has profound impact on women's health, disability and functioning, it is associated with poor child health outcomes such as pre-term birth, under-nutrition and stunting, which ultimately have an adverse trans-generational impact. There is strong evidence in the medical literature that perinatal depression can be effectively managed with psychological treatments delivered by non-specialists. Our previous research in Pakistan led to the development of a successful perinatal depression intervention, the Thinking Healthy Program (THP). The THP is a psychological treatment delivered by community health workers. The burden of perinatal depression can be reduced through scale-up of this proven intervention; however, training of health workers at scale is a major barrier. To enhance access to such interventions there is a need to look at technological solutions to training and supervision. Methods/design: This is a non-inferiority, single-blinded randomized controlled trial. Eighty community health workers called Lady Health Workers (LHWs) working in a post-conflict rural area in Pakistan (Swat) will be recruited through the LHW program. LHWs will be randomly allocated to Technology-assisted Cascade Training and Supervision (TACTS) or to specialist-delivered training (40 in each group). The TACTS group will receive training in THP through LHW supervisors using a tablet-based training package, whereas the comparison group will receive training directly from mental health specialists. Our hypothesis is that both groups will achieve equal competence. Primary outcome measure will be competence of health workers at delivering THP using a modified ENhancing Assessment of Common Therapeutic factors (ENACT) rating scale immediately post training and after 3 months of supervision. Independent assessors will be blinded to the LHW allocation status. Discussion: Women living in post-conflict areas are at higher risk of depression compared to the general population. Implementation of evidence-based interventions for depression in such situations is a challenge because health systems are weak and human resources are scarce. The key innovation to be tested in this trial is a Technology-assisted Cascade Training and Supervision system to assist scale-up of the THP.
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Introduction In low-income and middle-income countries, it is estimated that one in every three preschool-age children are failing to meet cognitive or socioemotional developmental milestones. Thailand has implemented a universal national developmental screening programme (DSPM) for young children to enable detection of developmental disorders and early intervention that can improve child health outcomes. DSPM implementation is being hampered by low attendance at follow-up appointments when children fail the initial screening. Methods Action research, using qualitative methods was conducted with 19 caregivers, 5 health workers and 1 chief at two Health Promotion Hospitals to explore the factors affecting attendance at follow-up appointments. Transcripts and notes were analysed using descriptive content analysis. Findings were then discussed with 48 health workers, managers, researchers and policymakers. Results The high workload of health workers during busy vaccination clinics, and inadequate materials prevented clear communication with caregivers about the screening, how to stimulate child development and the screening result. Caregivers, particularly grandparents, had a lack of understanding about how to stimulate child development, and did not fully understand failed screening results. Caregivers felt blamed for not stimulating their child’s development, and were either worried that their child was severely disabled, or they did not believe the screening result and therefore questioned its usefulness. This led to a lack of attendance at follow-up appointments. Conclusion Task-sharing, mobile health (mhealth), community outreach and targeted interventions for grandparent caregivers might increase awareness about child development and screening, and allow health workers more time to communicate effectively. Sharing best practices, communication training and mentoring of DSPM workers coupled with mhealth job aids could also improve caregiver attendance at follow-up. Engagement of caregivers in understanding the barriers to attendance at follow-up and engagement of stakeholders in the design and implementation of interventions is important to ensure their effectiveness.
Article
Aims (1) To determine the feasibility of involving parents as key partners in school mental health activities; (2) to determine whether educating parents on mental health treatment Gap Intervention Guideline (mhGAP‐IG) section on children leads to enhanced parent perception of mental health symptoms in their children; and (3) to determine context appropriate social demographic predictors of the parental awareness following the psychoeducation using the mhGAP‐IG children version. Methods Consenting parents completed the Child Behaviour Checklist (CBCL) and the Brief Problem Monitor for Parents (BPM‐P) about their children at baseline and at 6 months post‐baseline respectively. Immediately after post‐baseline, they received psychoeducation on the importance of mental well‐being in children and how to recognize symptoms of mental disorders, using the mhGAP‐IG section on children. This psychoeducation was the intervention between baseline and 6 months post‐baseline. We analysed means of mental disorder symptoms and prevalence of the various mental syndromes/problems on the CBCL/BPM‐P scores to determine the statistical significance of the changes between baseline and 6 months. Results Overall, there was significant increase (P < 0.05) in the symptoms mean scores and prevalence of syndromes/problems between baseline and 6 months post‐psychoeducation. However, there were some differences between urban and rural settings and in some parents and children socio‐demographics and gender that should be considered in individual cases. Conclusion It is feasible to include parents in school mental health programmes as key stakeholders. The mhGAP‐IG section on children is a good tool for psychoeducation. However, there are predictors of outcomes that need further research.
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Kanne and Bishop's (2020) Editorial Perspective 'The Autism waitlist crisis and remembering what families need' offers a strong argument to provide greater access to high-quality assessments for Autism Spectrum Disorder (ASD). They note, correctly, that due to increasing numbers of referrals practitioners are under increasing pressure to provide quicker or abbreviated evaluations, that some cases are extremely complex and require considerable expertise to assess, and that a good assessment is a good investment in effective intervention. I agree with these points but also want to highlight some difficulties and dilemmas associated with the assessment of ASD; and to argue that improving access to assessments and interventions through the use of nonspecialists and new technologies may be a promising direction.
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Purpose: A contribution to the Italian adaptation of the original English version of the World Health Organization Disability Assessment Schedule 2.0 for children and youth (WHODAS-Child), proxy-administered among children with autism spectrum disorder (ASD) without intellectual disability. Materials and methods: Observational and retrospective study with within-dependent variables by cross-sectional sampling on psychometric properties (internal consistency and construct/criterion validity) of the 36- and 7-item versions of the Italian WHODAS-Child. The original English version was translated into Italian, also considering the Italian version of the WHODAS 2.0 for adults. The Italian questionnaire was then translated back into English. All authors compared the original and back-translated English versions. The sample was collected among parents and clinicians of 100 children with ASD. To assess convergent/divergent validity, the Autism Diagnostic Observational Schedule (ADOS) was also administered. Results: Cronbach's α for both versions' total scores was good. WHODAS-Child also showed a positive correlation with the three DSM-5 levels of impairment. A pattern of correlations with the ADOS was found for all domains of the WHODAS-Child except for the mobility and self-care domains. Conclusions: The WHODAS-Child Italian proxy-administered version has the potential to be a reliable and valid tool to measure functional impairment in children with ASD. Implications for rehabilitationWorld Health Organization Disability Assessment Schedule 2.0 for children and youth (WHODAS-Child) has shown to be sensitive in detecting children and youth functioning in the domains of activity and participation.WHODAS-Child Italian version seems to be a reliable and valid tool to measure the functional impairment in children with autism spectrum disorder.A critical issue for rehabilitation is that a single "minimal clinically important difference" score for the WHODAS-Child has not yet been established.
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Background The Mental Health Gap Action Programme (mhGAP) supports engagement of non-specialists in mental health services in Low- and Middle-Income countries. Given this aim, assessment of the effectiveness of approaches under its remit is warranted. Aims We evaluated mhGAP approaches relating to child and adolescent mental health, focusing on provider / child outcomes, and barriers / facilitators of implementation. Methods Thirteen databases were searched for reviews and primary research on mhGAP roll out for child and adolescent mental health. Results Twelve studies were reviewed. Provider-level outcomes were restricted to knowledge gains, with limited evidence of other effects. Child-level outcomes included improved access to care, enhanced functioning and socio-emotional well-being. Organisational factors, clients and providers? attitudes and expectations, and transcultural considerations were barriers. Conclusions Further attention to the practical and methodological aspects of implementation of evaluation may improve the quality of evidence of the effectiveness of approaches under its remit. https://link.springer.com/article/10.1007/s10597-022-00981-3
Article
Purpose This study examined whether the 12-item self-administered World Health Organization Disability Assessment Schedule (WHODAS) 2.0 demonstrated measurement invariance between young adolescents aged 10–16 years with a physical illness and older adolescents aged 15–19 years from the general population. Materials and methods Young adolescent data come from the baseline wave of the Multimorbidity in Youth across the Life-course study (n = 117) and older adolescent data come from the Canadian Community Health Survey-Mental Health (n = 1851). Multiple-group confirmatory factor analysis was used to test measurement invariance. WHODAS 2.0 scores were compared across morbidity subgroups using multiple regression. Results Measurement invariance of the WHODAS 2.0 was demonstrated: (χ²=635.2(144), p<.001; RMSEA = 0.059 (0.054, 0.064); CFI = 0.967; TLI = 0.970; and, SRMR = 0.068). Adjusting for data source, sex, race, immigrant status, and household income, WHODAS 2.0 scores were associated with morbidity status in a dose–response manner: physical illness only (B = 1.50, p<.001), mental illness only (B = 2.92, p<.001), and physical–mental comorbidity (B = 4.44, p<.001). Conclusions Measurement invariance of the WHODAS 2.0 suggests that young adolescents interpret the items and disability construct similarly to older adolescents – a group that previously demonstrated measurement invariance with an adult sample. The 12-item self-administered WHODAS 2.0 may be used to measure disability across the life-course. • IMPLICATIONS FOR REHABILITATION • The 12-item self-administered WHODAS 2.0 is one of the most widely used measures of disability and functioning. • Measurement invariance of the WHODAS 2.0 suggests that young adolescents interpret the items and disability construct similarly to older adolescents and adults in Canada. • Researchers and health professionals can be confident that differences in 12-item self-administered WHODAS 2.0 scores are real and meaningful. • The 12-item self-administered WHODAS 2.0 may be used to measure disability across the life-course.
Article
Purpose This study investigated the psychometric properties of the 12-item proxy-administered World Health Organization Disability Assessment Schedule (WHODAS) 2.0 in young children with chronic physical illness in Canada. Materials and methods Data come from the Multimorbidity in Youth across the Life-course, a longitudinal study of Canadian youth with physical illnesses (n = 263). Baseline parent-reported data from children (2–9 years, n = 143) and adolescents (10–16 years, n = 117) were analyzed. Wilcoxon’s tests examined differences in WHODAS 2.0 scores between subgroups. Internal consistency was estimated, and confirmatory factor analysis modeled the WHODAS 2.0 factor structure. Regression modeling examined if the WHODAS 2.0 could discriminate between children with vs. without mental comorbidity. Results Differences were found between children and adolescents regarding self-care and getting along, and for the item on emotional affect. Inter-item correlations were similar between subgroups and internal consistency was strong for children (α = 0.90) and adolescents (α = 0.93). The factor structure of the WHODAS 2.0 was confirmed; parameter estimates were similar between subgroups. The association between mental comorbidity and disability did not differ by age – comorbidity was associated with greater disability (β = 5.87, p < 0.01). Conclusions The 12-item proxy-administered WHODAS 2.0 appears valid and reliable in young children with physical illness and can be used in this population. • Implications for rehabilitation • The 12-item proxy-administered WHODAS 2.0 has acceptable inter-item correlations and internal consistency in young Canadian children with chronic physical illness, and its factor structure is consistent with previous reports • Expansion of its use in measuring disability in young children provides the opportunity to use the WHODAS 2.0 across the life-course, facilitating the interpretation of changes in disability over time or in response to treatment • Additional research is needed to determine responsiveness to change and the minimal clinically important difference of the WHODAS 2.0 in this population
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This paper reports on the development and preliminary field-testing of a new inventory designed to capture experiences of stigma from the perspective of those who are stigmatized. The Inventory of Stigma Experiences is composed of two scales: one measuring the scope of stigma experienced in different life domains (10 items), and the other assessing psychosocial impact (7 items). Preliminary field-testing was conducted on 88 participants from a variety of hospital, community mental health, and advocacy agencies who reported a range of serious and persistent mental disorders, most with past admissions to psychiatric institutions and general hospital psychiatric units. A significant proportion were also actively involved in outpatient community mental health programs at the time of the survey. However, less than half reported that their mental health had improved over the past year. Reliability coefficients were strong for both scales – .83 for the Stigma Experiences Scale and .91 for the Stigma Impact Scale – indicating high internal consistency and reliability. A statistically significant but moderate correlation between the scales indicated that they were measuring largely different but related phenomena.
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The 5-item World Health Organization Well-Being Index (WHO-5) is among the most widely used questionnaires assessing subjective psychological well-being. Since its first publication in 1998, the WHO-5 has been translated into more than 30 languages and has been used in research studies all over the world. We now provide a systematic review of the literature on the WHO-5. We conducted a systematic search for literature on the WHO-5 in PubMed and PsycINFO in accordance with the PRISMA guidelines. In our review of the identified articles, we focused particularly on the following aspects: (1) the clinimetric validity of the WHO-5; (2) the responsiveness/sensitivity of the WHO-5 in controlled clinical trials; (3) the potential of the WHO-5 as a screening tool for depression, and (4) the applicability of the WHO-5 across study fields. A total of 213 articles met the predefined criteria for inclusion in the review. The review demonstrated that the WHO-5 has high clinimetric validity, can be used as an outcome measure balancing the wanted and unwanted effects of treatments, is a sensitive and specific screening tool for depression and its applicability across study fields is very high. The WHO-5 is a short questionnaire consisting of 5 simple and non-invasive questions, which tap into the subjective well-being of the respondents. The scale has adequate validity both as a screening tool for depression and as an outcome measure in clinical trials and has been applied successfully across a wide range of study fields. © 2015 S. Karger AG, Basel.
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There are at least 50 million children with an intellectual or developmental disorder in South Asia. The vast majority of these children have no access to any service and there are no resources to develop such services. We aimed to explore a model of care-delivery for such children, whereby volunteer family members of affected individuals could be organized and trained to form an active, empowered group within the community that, a) using a task-sharing approach, are trained by specialists to provide evidence-based interventions to their children; b) support each other, with the more experienced FaNs i.e. family networks, providing peer-supervision and training to new family members who join the group; and c) works to reduce the stigma associated with the condition. We used qualitative methods to explore carers' perspectives about such a care-delivery model. The key findings of this research are that there is a huge gap between the needs of the carers and available services. Carers would welcome a volunteer-led service, and some community members would have time to volunteer. Raising community awareness in a culturally sensitive manner prior to launching such a service and linking it to the community health workers programme would increase the likelihood of success. Gender-matching would be important. It would be possible to form family networks around the more motivated volunteers, with support from local non-governmental organizations. The carers were receptive to the use of technology to assist the work of the volunteers as well as for networking. We conclude that family volunteers delivering evidence-based packages of care after appropriate training is a feasible system that can help reduce the treatment gap for childhood intellectual and developmental disorders in under-served populations.
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Cultural adaptations of evidence-based psychological treatments (PTs) are important to enhance their universal applicability. The aim of this study was to review systematically the literature on adaptations of PTs for depressive disorders for ethnic minorities in Western countries and for any population in non-Western countries to describe the process, extent and nature of the adaptations and the effectiveness of the adapted treatments. Method Controlled trials were identified using database searches, key informants, previous reviews and reference lists. Data on the process and details of the adaptations were analyzed using qualitative methods and meta-analysis was used to assess treatment effectiveness. Twenty studies were included in this review, of which 16 were included in the meta-analysis. The process of adaptation was reported in two-thirds of the studies. Most adaptations were found in the dimensions of language, context and therapist delivering the treatment. The meta-analysis revealed a statistically significant benefit in favor of the adapted treatment [standardized mean difference (SMD) -0.72, 95% confidence interval (CI) -0.94 to -0.49]. Cultural adaptations of PTs follow a systematic procedure and lead primarily to adaptations in the implementation of the treatments rather than their content. Such PTs are effective in the treatment of depressive disorders in populations other than those for whom they were originally developed.
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Overview: The World Health Organization Disability Assessment Schedule for children (WHODAS-Child) is a disability assessment instrument based on the WHO's International Classification of Functioning, Disability and Health for children and youth. It is modified from the original adult version specifically for use with children. The aim of this study was to assess the WHODAS-Child structure and metric properties in a community sample of children with and without reported psychosocial problems in rural Rwanda. Methods: The WHODAS-Child was first translated into Kinyarwanda through a detailed committee translation process and back-translation. Cognitive interviewing was used to assess the comprehension of the translated items. Test-retest reliability was assessed in a group of 64 children. The translated WHODAS-Child was then administered to a final sample of 367 children in southern Kayonza district in rural southeastern Rwanda within a larger psychosocial assessment battery. The latent structure was assessed through confirmatory factor analysis. Reliability was evaluated in terms of internal consistency (Cronbach's alpha) and test-retest reliability (Pearson's correlation coefficient). Construct validity was explored by examining convergence between WHODAS-Child scores and mental disorder status, and divergence of WHODAS-Child scores with protective factors and prosocial behaviors. Concordance between parent and child scores was also assessed. Results: The six-factor structure of the WHODAS-Child was confirmed in a population sample of Rwandan children. Test-retest and inter-rater reliability were high (r = .83 and ICC = .88). WHODAS-Child scores were moderately positively correlated with presence of depression (r = .42, p<.001) and post-traumatic stress disorder (r = .31, p<.001) and moderately negatively correlated with prosocial behaviors (r = .47, p<.001). The Kinyarwanda version of the WHODAS-Child was found to be a reliable and acceptable self-report tool for assessment of functional impairment among children largely referred for psychosocial problems in the study district in rural Rwanda. Further research in low-resource settings and with more general populations is recommended.
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A novel behavioural screening questionnaire, the Strengths and Difficulties Questionnaire (SDQ), was administered along with Rutter questionnaires to parents and teachers of 403 children drawn from dental and psychiatric clinics. Scores derived from the SDQ and Rutter questionnaires were highly correlated; parent-teacher correlations for the two sets of measures were comparable or favoured the SDQ. The two sets of measures did not differ in their ability to discriminate between psychiatric and dental clinic attenders. These preliminary findings suggest that the SDQ functions as well as the Rutter questionnaires while offering the following additional advantages: a focus on strengths as well as difficulties; better coverage of inattention, peer relationships, and prosocial behaviour; a shorter format; and a single form suitable for both parents and teachers, perhaps thereby increasing parent-teacher correlations.
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