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The goals of this project are twofold: First, this project will examine the measurement invariance of the Level of Personality Functioning Scale - Brief Form 2.0 (LPFS-BF 2.0) across a broad range of countries (35 countries) and languages (20 languages), as well as the measurement invariance of the World Health Organization’s Quality of Life Brief Scale (WHOQOL-BREF; WHOQOL Group, 1998), the Personality Disorder Severity ICD-11 scale (PDS-ICD-11; Bach et al., 2021), and the Tightness-Looseness Scale (TLS; Gelfand et al., 2011). The latter measurement invariance investigations are included in this project for the purposes of (a) assessing the suitability of these measures for describing and comparing our samples; (b) assessing their appropriateness as outcome criteria to be used when evaluating the predictive invariance of the LPFS-BF 2.0; and (c) offering evidence pertaining to these instruments’ applicability for international research and application. The second goal of this project is to examine the LPFS-BF 2.0’s predictive invariance regarding three established constructs. The specific constructs were selected based on their well-established associations with personality dysfunction and include quality of life (e.g., Cramer et al., 2006), personality disorder severity (e.g., Bach & Anderson, 2020), and history of mental health services (e.g., Cruitt et al., 2019).

Evidence-based assessment (EBA) increases access to care and has a demonstrated potential to improve patient outcomes when used appropriately. EBA might be of great value in low- and middle-income countries (LMIC) where trained personnel is scarce as it can help inform decision making. While EBA is clearly recommended by clinical guidelines and mostly seen as positive by mental health care workers, EBA remains largely underused. The ‘Mental Health Information Reporting Assistant’ (https://mhira.app) is an open source software developed together with clinicians, software developers and researchers from Tanzania, Chile and Kosovo under consideration of different settings. Our hypothesis is that the implementation of MHIRA will increase usage of EBA.

Objective: Gender differences have been reported in schizophrenia and suggested that later onset, predominant affective symptoms and better functioning are reported in women, while there is a higher prevalence with more severe negative symptoms and a higher comorbidity for substance abuse in men. However, since the majority of data comes from high-income countries, it is almost unknown whether gender differences exist in people with schizophrenia from socially and economically diverse contexts. The objective of this study is to explore gender differences in socio-demographic and clinical characteristics in a sample of people with schizophrenia in Kosovo, a low- and middle-income country (LMIC). Materials and methods: The study included 101 patients with schizophrenia recruited from community services. Data on demographics, socio-economic characteristics, use of psychological therapy, and medication was collected through direct interviews. Clinical symptoms were assessed by using a combination of self-rated and researcher-rated measures. Gender differences were examined using chi-square test, independent sample t-tests, and univariate analysis of variance. Results: The sample was composed of 31.7% (n=32) women. Most demographic characteristics did not differ by gender, apart from marital status (a higher proportion of women were separated; p=0.010). Women presented with more depressive (p=0.010) and paranoid symptoms (p=0.011), and attended psychological therapy less frequently (50% women vs 80% men; p=0.014). For both genders, attending psychological therapy was associated with lower negative symptoms (p=0.002). Conclusion: Women with schizophrenia had worse clinical presentation compared with men, and reported lower psychological therapy attendance. More research is needed to better describe schizophrenia in LMICs, and to understand whether access to mental health services, particularly psychological therapy, is attributable to clinical or contextual factors. Offering psychological therapy to people with schizophrenia of either gender could alleviate the burden of negative symptoms.&nbsp

Additional file 2.

Additional file 3.

Additional file 1.

Additional file 4. Codes used for coding.

Additional file 3. Topic Guides.

Additional file 1 DIALOG+ App. Figure 1. A visual representation of how DIALOG+ app displays the 11 life domain ratings, allowing comparison of ratings with those from previous sessions. The ticks on the right mark the domains selected for further discussion in the four-step solution-focused approach (DIALOG+ Manual, https://dialog.elft.nhs.uk/East London, accessed 7 July 2020). Figure 2. A visual representation of the DIALOG+ screen showing the four-step solution-focused approach (DIALOG+ Manual, https://dialog.elft.nhs.uk/East London, accessed 7 July 2020).

Additional file 2. Reporting checklist for qualitative study. Based on the SRQR guidelines.

Background: There are limited resources for improving mental health care across Europe, especially in Low-and-Middle-Income Countries (LMICs) in South-eastern Europe with fewer specialist staff and less funding. Scaling up psychosocial interventions that utilise available time and resources more effectively could improve care for people with psychosis in these settings. One intervention is DIALOG+, delivered via an app on a tablet computer: patients identify life areas to improve and clinicians use a solution-focussed process to help improve these areas. This intervention was piloted across mental healthcare systems in European LMICs, and focus groups were conducted to explore whether such interventions could use available resources effectively to improve care for psychosis in these settings. Methods: Eleven focus groups were conducted with clinicians and patients with psychosis who used the intervention over three months during the pilot study, in Bosnia and Herzegovina, Kosovo United Nations Resolution, Montenegro, North Macedonia and Serbia. The Theoretical Domains Framework (TDF), which describes factors affecting engagement with healthcare interventions, structured topic guides and guided analysis. Codes from the data were mapped onto the TDF, analysed to identify barriers and facilitators, translated into English and checked for inter-rater reliability. Results: 25 clinicians and 23 patients participated in focus groups. Clinicians’ barriers included limited time for sessions and difficulties working with acutely psychotic patients. Patients’ barriers were burden of greater concentration when engaging with DIALOG+ and feeling tense or disturbed during the sessions. Facilitators included motivation to use DIALOG+, positive opinions shared by others, perceived benefits for practice and improving clinician-patient conversations, relationships and care. Conclusions: Barriers to using psychosocial interventions could be overcome even if resources cannot be increased. Despite limited time and other barriers to using DIALOG+, perceived benefits to practice and clinician-patient relationships suggest that psychosocial interventions can use available resources effectively to improve care for psychosis.

Objectives: This study explores the changes in coping mechanisms used by Syrian refugee families in Istanbul to cope with multilevel stressors over 9-months.Background: Turkey is the worldu2019s largest refugee hosting country with 3.6 million Syrian refugees. The development and elaboration of explanatory models of both stressors and coping at the family level over time can help to inform practical mental health and psychosocial interventions for families in low resource settings. Materials and Methods: We conducted initial and 9-month follow up interviews with 30 Syrian refugee families. Data was coded and analyzed with Atlas/ti.Results and Conclusions: The initial assessment identified 22 family stressors in three domains (Surviving war and border crossing; Living in Istanbul; Parenting in Istanbul). Stressors related to war experience were less pressing compared to concerns over financial issues, schooling of children and assimilation to new culture in second assessment. Seventeen family coping mechanisms were identified initially in four domains (Flexible and Reciprocal Family Organization; Hopeful Family Beliefs and Communication; Staying Connected with Family in Syria and in Exile; Making the Best of Living in a New Country). Families decreased in connecting with family in Syria and exile compared to coping mechanisms in other domains such as women empowerment, spouse support, hoping for better future for children, be optimistic and feeling at home in Turkey. Over time, stressors related to the war in Syria diminished whereas displacement stressors increased. These changes over time in stressors and coping strategies can help inform family focused interventions that address current family stressors by strengthening current family coping strategies.

Objectives: This study explores perspectives and attitudes of clinicians, policymakers, patients and caregivers on technology-assisted psycho-social intervention for patients with schizophrenia in 5 countries of South Eastern Europe SEE (Bosnia & Herzegovina, Kosovo*, Montenegro, North-Macedonia and Serbia) prior to cluster randomized clinical trial of its effectiveness.Background: Psychotic disorders like schizophrenia are severe and complex mental health disorders that can cause a long-term disability. Schizophrenia represents a major health burden in low and middle-income countries (LMIC) who often have limited treatment resources. Implementation of a technology-assisted, low-cost intervention such as DIALOG+, which utilizes existing personnel and social resources, could lower the existing burden of schizophrenia in LMIC.Materials and Methods: Study findings are based on data from 43 focus groups (8 clinicians, 8 policymakers, 9 patients and 7 caregivers) conducted in 5 SEE countries. In each focus group facilitators presented standardized DIALOG + presentation and asked perspectives of participants on DIALOG+. Data was coded and analysed using Atlas-Ti Software.Results and Conclusions: The data analysis from focus groups identified in total 14 perceived potential difficulties, 21 perceived potential gains and 36 perceived potential facilitators to DIALOG+ implementation presented separately for clinicians, policymakers, patients and carers. Dialog+ is perceived as feasible and welcomed by clinicians, policymakers, patients and carers. The findings also identified some potential difficulties in implementation of Dialog + which could be addressed prior to effectiveness study. Findings indicate some differences among populations with are worthwhile in implementation of the treatment. Study also briefly discusses the challenges of conducting qualitative study in multi-country studies.