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Perinatal depression has been shown to impede adherence to antiretroviral therapy (ART) and the prevention of mother-to-child transmission (PMTCT) care continuum; therefore, treating perinatal depression may result in increased viral suppression and PMTCT adherence. We examined the effects of the M-DEPTH (Maternal Depression Treatment in HIV) depression care model (including antidepressants and individual Problem Solving Therapy) on depression, maternal viral suppression and adherence to PMTCT care processes in an ongoing cluster-randomized controlled trial of 391 HIV-infected pregnant women (200 usual care; 191 intervention) with at least mild depressive symptoms enrolled across 8 antenatal care clinics in Uganda. At baseline, 68.3% had clinical depression and 41.7% had detectable HIV viral load. Adjusted repeated-measures multivariable regression models found that the intervention group was nearly 80% less likely to be clinically depressed [Adjusted OR (95% CI) 0.22 (0.05, 0.89)] at the 2-month post-pregnancy assessment, compared to the control group. However, the intervention and control groups did not differ meaningfully on maternal viral suppression, ART adherence, and other PMTCT care processes and outcomes. In this sample of women who were mostly virally suppressed and ART adherent at baseline, the depression care model had a strong effect on depression alleviation, but no downstream effects on viral suppression or other PMTCT care processes.Trial Registration NIH Clinical Trial Registry NCT03892915 (clinicaltrials.gov).

Perinatal depression is highly prevalent among women living with HIV and contributes to nonadherence to the PMTCT (prevention of mother-to-child transmission) care continuum. We examined correlates of elevated depressive symptoms and suicidality in this population.Baseline data from 391 Ugandan women enrolled in a cluster randomized controlled trial of a depression care intervention were analyzed. Adult women with confirmed sero-positive HIV status were eligible if their gestation period was ≤ 32 weeks, and they had a Patient Health Questionnaire (PHQ-9) score ≥ 5. Correlates of elevated depressive symptoms (PHQ-9 9) and moderate-to-severe suicidal ideation (more than half of the days in the prior 2 weeks) were assessed using bivariate and multivariate logistic regression models, controlling for clustering within study sites by using a random effects specification (with study site as the random effect), as well as age and education.The mean PHQ-9 score was 12.7 (SD = 5.1); 267 (68.3%) participants had elevated depressive symptoms, and 51 (13.0%) reported moderate-to-severe suicidality. In multiple logistic regression analysis, perceived provider stigma of childbearing [OR (95% CI) = 1.81 (1.16, 2.84)], greater use of negative problem-solving [OR (95% CI) = 1.09 (1.04, 1.15)], and lower general social support [OR (95% CI) = 0.50 (0.30, 0.82)] were correlated with elevated depression symptoms, while moderate-to-severe suicidal ideation was correlated with greater experience of physical interpersonal violence (IPV) and greater use of negative problem-solving.Programs aimed at improving provider support for the childbearing needs of persons living with HIV, supporting women who are experiencing IPV, and helping women to develop effective problem-solving skills and social supports may reduce symptoms of perinatal depression and help optimize PMTCT care outcomes.Clinicaltrials.gov NCT03892915 (registered March 21, 2019).

A significant treatment gap exists for mental illnesses across the world, particularly in low- and middle-income countries (LMICs). Task-sharing, a potentially scalable strategy to bridge the treatment gap, has been shown to be feasible and effective for the treatment of a range of mental illnesses. However, there is a lack of research examining lay mental health workers’ experiences in such task-sharing roles. The aim of our study was to understand the barriers and facilitators that lay health workers (LHWs) face in delivering mental healthcare. We conducted in-depth interviews with 32 lay mental health workers recruited through maximum variation sampling and 18 stakeholders leading mental health programs at a variety of non-governmental organisations across India. Interviews were semi-structured and data was analyzed using the thematic analysis approach. Results showed that LHWs perceived barriers and facilitators at three levels: individually (related to personal characteristics and family support, and in their daily work such as in relationship building and supervision), organizationally (for example, related to compensation), and societally (such as encountering gender discrimination and stigma). Each of these areas should be taken into consideration when planning and implementing task-sharing interventions for mental illnesses. As the first qualitative study to explore broad LHW experiences in mental healthcare delivery in a diverse set of programs from a LMIC, this study shows that LHW voices should be central to program design and decision-making for mental health interventions.

Non-communicable diseases (NCDs) account for the five largest contributors to burden of disease in Mexico, with diabetes representing the greatest contributor. However, evidence supporting chronic disease programmes in Mexico is limited, especially in rural communities. Compañeros En Salud (CES) partnered with the Secretariat of Health of Chiapas, Mexico to implement a novel community-based NCD treatment programme. We describe the implementation of this programme and conducted a population-based, retrospective analysis, using a difference-in-differences regression approach to estimate the impact of the programme. Specifically, we examined changes in diabetes and hypertension control rates between 2014 and 2016, comparing CES intervention clinics (n = 9) to care-as-usual at non-CES clinics (n = 806), adjusting for differences in facility-level characteristics. In 2014, the percent of diabetes patients with this condition under control was 36.9% at non-CES facilities, compared with 41.3% at CES facilities (P0.05). For hypertension patients, these figures were 45.2% at non-CES facilities compared with 56.2% at CES facilities (P = 0.02). From 2014 to 2016, the percent of patients with diabetes under control declined by 9.2% at non-CES facilities, while improving by 11.3% at non-CES facilities where the Compañeros En Salud Programa de Enfermedades Crónicas intervention was implemented (P0.001). Among hypertension patients, those with the condition under control increased by 21.5% at non-CES facilities between 2014 and 2016, compared with 16.2% at CES facilities (P0.05). Introduction of the CES model of NCD care was associated with significantly greater improvements in diabetes management between 2014 and 2016, compared with care-as-usual. Hypertension control measures were already greater at CES facilities in 2014, a difference that was maintained through 2016. These findings highlight the successful implementation of a framework for providing NCD care in rural Mexico, where a rapidly increasing NCD disease burden exists.

To evaluate the implementation of a time-driven activity-based costing analysis at five community health facilities in Haiti.Together with stakeholders, the project team decided that health-care providers should enter start and end times of the patient encounter in every fifth patient's medical dossier. We trained one data collector per facility, who manually entered the time recordings and patient characteristics in a database and submitted the data to a cloud-based data warehouse each week. We calculated the capacity cost per minute for each resource used. An automated web-based platform multiplied reported time with capacity cost rate and provided the information to health-facilities administrators.Between March 2014 and June 2015, the project tracked the clinical services for 7162 outpatients. The cost of care for specific conditions varied widely across the five facilities, due to heterogeneity in staffing and resources. For example, the average cost of a first antenatal-care visit ranged from 6.87 United States dollars (US$) at a low-level facility to US$ 25.06 at a high-level facility. Within facilities, we observed similarly variation in costs, due to factors such as patient comorbidities, patient arrival time, stocking of supplies at facilities and type of visit.Time-driven activity-based costing can be implemented in low-resource settings to guide resource allocation decisions. However, the extent to which this information will drive observable changes at patient, provider and institutional levels depends on several contextual factors, including budget constraints, management, policies and the political economy in which the health system is situated.Évaluer la réalisation d'une analyse des coûts par prestation et par durée dans cinq établissements de soins communautaires en Haïti.En collaboration avec les parties prenantes, l'équipe du projet a décidé que les prestataires de soins devraient indiquer l'heure de début et de fin de la consultation dans le dossier médical d'un patient sur cinq. Nous avons formé un responsable du recueil des données par établissement, qui a saisi manuellement les horaires ainsi que les caractéristiques des patients dans une base de données et a enregistré ces dernières dans un entrepôt de données en ligne chaque semaine. Nous avons calculé les coûts de capacité par minute pour chaque ressource utilisée. Les durées indiquées ont été multipliées par le coût de capacité unitaire à l'aide d'une plate-forme virtuelle automatisée, par laquelle ces informations ont été transmises aux administrateurs des établissements de soins.Entre mars 2014 et juin 2015, le projet a suivi les services cliniques dispensés à 7162 patients externes. Le coût des soins prodigués pour différentes affections était très variable entre les cinq établissements, en raison de l'hétérogénéité du personnel et des ressources. Par exemple, le coût moyen d'une première consultation prénatale allait de 6,87 dollars des États-Unis ($ US) dans un établissement de premier niveau à 25,06 $ US dans un établissement de haut niveau. Au sein des établissements, nous avons également observé des variations de coûts, qui étaient dues à des facteurs tels que les comorbidités des patients, le moment d'arrivée des patients, les stocks de fournitures dans les établissements et le type de consultation.Il est possible de déterminer les coûts par prestation et par durée dans les structures à faibles ressources afin d'orienter les décisions concernant l'affectation des ressources. Cependant, la mesure dans laquelle ces informations vont entraîner des changements observables au niveau des patients, des prestataires et des institutions dépend de plusieurs facteurs contextuels, notamment des contraintes budgétaires, de la gestion, des politiques et de l'économie politique dans laquelle se trouve le système de santé.Evaluar la implementación de un análisis de gastos basado en el tiempo invertido por actividad en cinco centros sanitarios comunitarios en Haití.Junto a las partes interesadas, el equipo del proyecto decidió que los profesionales sanitarios debían introducir los horarios del comienzo y el final de la consulta con el paciente en el dossier médico de uno de cada cinco pacientes. Formamos a un recopilador de datos por cada centro, que introdujo manualmente los registros de tiempo y las características de los pacientes en una base de datos, los cuales enviaba a un almacén de datos en la nube cada semana. Calculamos el coste de capacidad por minuto para cada recurso utilizado. Una plataforma automatizada en línea multiplicó el tiempo registrado por la tasa del coste de capacidad y proporcionó la información a los administradores de los centros sanitarios.Entre marzo de 2014 y junio de 2015, el proyecto registró los servicios clínicos a 7162 pacientes. El coste de la atención para condiciones específicas variaba considerablemente entre los cinco centros, debido a la heterogeneidad del personal y de los recursos. Por ejemplo, el coste medio de una primera consulta de atención prenatal variaba de 6,87 USD en un centro de bajo nivel a 25,06 USD en un centro de alto nivel. En los centros, observamos una variación similar en los costes, debido a factores como las comorbilidades de los pacientes, el tiempo de llegada del paciente, el almacenamiento de suministros en los centros y el tipo de consulta.Los gastos basados en el tiempo invertido por actividad se pueden implementar en entornos con pocos recursos para orientar la toma de decisiones sobre asignación de recursos. Sin embargo, la medida en que esta información generará cambios notables a nivel de los pacientes, profesionales e instituciones depende de varios factores contextuales, incluidas las limitaciones presupuestarias, la gestión, las políticas y la economía política en que se encuentra el sistema de salud.تقييم طريقة تطبيق التحليل الموجه بالوقت الخاص بتقدير التكاليف المعتمدة على الأنشطة في خمس منشآت صحية مجتمعية في هايتي.قرر فريق المشروع بالتعاون مع الجهات المعنية أنه يجب على مقدمي خدمات الرعاية الصحية كتابة أوقات البدء والانتهاء من استقبال المريض في كل خمسة ملفات طبية للمريض. ولقد قمنا بتدريب شخص واحد ليجمع البيانات في كل منشأة، وهو الذي يقوم بكتابة تسجيلات الوقت وخصائص المريض في قاعدة للبيانات ثم يقوم بتسليم البيانات إلى مستودع البيانات القائم على التخزين السحابي أسبوعيًا. لقد قمنا بحساب تكلفة الاستيعاب في الدقيقة لكل مورد مستخدم. قام النظام الآلي المستند إلى شبكة الإنترنت بالجمع بين الوقت المكتوب مع نسبة تكلفة الاستيعاب ثم قدم المعلومات إلى مديري المنشآت الصحية.قام المشروع في الفترة ما بين مارس/آذار من عام 2014 ويونيو/حزيران من عام 2015 بتتبع الخدمات المقدمة لـ 7162 من المرضى الخاضعين للعلاج في عيادات خارجية. وقد تباينت تكلفة الرعاية لبعض الحالات المحددة بشكلٍ واسع عبر خمس منشآت، نظرًا لتواجد عنصر عدم التجانس في مستوى توظيف طواقم العمل والموارد. على سبيل المثال، تراوح متوسط تكلفة الزيارة الأولى الخاصة برعاية الحوامل من 6.87 دولار أمريكي في منشأة منخفضة المستوى إلى 25.06 دولارًا أمريكيًا في منشأة عالية المستوى. ولقد لاحظنا وجود تباين مماثل في التكاليف داخل المنشآت، بسبب بعض العوامل مثل الاعتلالات المشتركة للمريض، ووقت وصول المريض، وتجهيز الإمدادات الطبية في المنشآت، ونوع الزيارة.يمكن تطبيق نظام التكلفة الموجهة بالوقت والمعتمدة على الأنشطة في الأماكن قليلة الموارد بهدف التأثير على قرارات تخصيص الموارد. ومع ذلك، إن الحد الذي من خلاله ستؤدي هذه المعلومات إلى إحداث تغييرات ملحوظة على مستويات المريض، ومقدم الخدمة الصحية، والمؤسسات يعتمد على عدة عوامل سياقية، حيث تشمل قيود الميزانية، والإدارة، والسياسات، والاقتصاد السياسي الذي يتعامل به النظام الصحي.旨在评估海地五个社区医疗机构实施估时作业成本法分析的情况。.项目团队与利益相关者共同决定，医疗护理提供方应该在每五名患者的医疗档案中输入接触患者的开始时间和结束时间。我们在每个机构内培训一名数据采集人员，该名人员负责在数据库中手动输入时间记录和患者特征并每周将数据提交到基于云的数据仓库中。对于采用的各项资源，我们计算每分钟的经营成本。由基于网络的自动化平台将经营成本率乘以报告的时间，并向医疗机构的管理人员提供该信息。.项目追踪了 2014 年 3 月到 2015 年 6 月间的 7162 位门诊患者的临床服务。由于人员和资源的不均衡性，这五个机构针对特定病症的护理成本相差很大。例如：第一次产前检查的平均费用由低级机构的 6.87 美元到高级机构的 25.06 美元不等。由于患者并存病、患者到达时间、机构内的库存物资以及就诊类型的不同，我们在机构内观察到了类似的成本差异。.估时作业成本法可在资源贫乏的情况下指导资源分配决策。然而，该信息将在多大程度上推动患者、提供方和机构层面发生明显的变化取决于预算限制、管理、政策和医疗系统所处政治经济背景等环境因素。.Оценить реализацию анализа расчета себестоимости по видам деятельности на основе фактора времени в пяти общинных медицинских учреждениях в Гаити.Совместно с заинтересованными сторонами проектная группа решила, что поставщики медицинских услуг должны вносить время начала и окончания приема пациента в медицинское досье каждого пятого пациента. Для каждого медицинского учреждения мы подготовили по одному сборщику данных, который вручную вводил в базу данных записи о времени приема и характеристиках пациентов и каждую неделю отправлял эти данные в облачное хранилище. Мы рассчитали себестоимость одной минуты для каждого используемого ресурса. Автоматизированная веб-платформа умножила указанное в записях время на величину себестоимости и предоставила информацию администраторам медицинских учреждений.В период с марта 2014 года по июнь 2015 года проект отслеживал оказание клинических услуг для 7162 амбулаторных пациентов. Себестоимость медицинского обслуживания для конкретных условий сильно варьировалась среди пяти медицинских учреждений из-за неоднородности кадровых и материальных ресурсов. Например, средняя себестоимость первого посещения женской консультации для дородового наблюдения варьировалась от 6,87 долл. США в медицинском учреждении низкого уровня до 25,06 долл. США в медицинском учреждении высокого уровня. На уровне медицинских учреждений мы наблюдали аналогичную вариацию себестоимости из-за таких факторов, как сопутствующие заболевания пациентов, время поступления пациентов, запасы лекарственных препаратов в медицинских учреждениях и тип посещения.Расчет себестоимости по видам деятельности на основе фактора времени может быть реализован в условиях ограниченности ресурсов для рационального распределения ресурсов. Тем не менее степень, в которой эта информация приведет к наблюдаемым изменениям на уровне пациентов, поставщиков и медицинских учреждений, зависит от нескольких контекстуальных факторов, включая бюджетные ограничения, управление, стратегии и политико-экономическую ситуацию, в которой находится система здравоохранения.

Background Despite rapid growth in the number of physicians and academic institutions entering the field of global health, there are few tools that inform global health curricula and assess physician readiness for this field. Objective To address this gap, we describe the development and pilot testing of a new tool to assess nontechnical competencies and values in global health. Competencies assessed include systems-based practice, interpersonal and cross-cultural communication, professionalism and self-care, patient care, mentoring, teaching, management, and personal motivation and experience. Methods The Global Health Delivery Competency Assessment Tool presents 15 case vignettes and open-ended questions related to situations a global health practitioner might encounter, and grades the quality of responses on a 6-point ordinal scale. We interviewed 17 of 18 possible global health residents (94%), matched with 17 residents not training in global health, for a total of 34 interviews. A second reviewer independently scored recordings of 13 interviews for reliability. Results Pilot testing indicated a high degree of discriminant validity, as measured by the instrument's ability to distinguish between residents who were and were not enrolled in a global health program (P Conclusions The tool has potential applicability to a variety of academic and programmatic activities, including evaluation of candidates for global health positions and evaluating the success of training programs in equipping practitioners for entry into this field.

An epidemic of Ebola virus disease (EVD) beginning in 2013 has claimed an estimated 11 310 lives in West Africa. As the EVD epidemic subsides, it is important for all who participated in the emergency Ebola response to reflect on strengths and weaknesses of the response. Such reflections should take into account perspectives not usually included in peer-reviewed publications and after-action reports, including those from the public sector, nongovernmental organizations (NGOs), survivors of Ebola, and Ebola-affected households and communities. In this article, we first describe how the international NGO Partners In Health (PIH) partnered with the Government of Sierra Leone and Wellbody Alliance (a local NGO) to respond to the EVD epidemic in 4 of the country's most Ebola-affected districts. We then describe how, in the aftermath of the epidemic, PIH is partnering with the public sector to strengthen the health system and resume delivery of regular health services. PIH's experience in Sierra Leone is one of multiple partnerships with different stakeholders. It is also one of rapid deployment of expatriate clinicians and logistics personnel in health facilities largely deprived of health professionals, medical supplies, and physical infrastructure required to deliver health services effectively and safely. Lessons learned by PIH and its partners in Sierra Leone can contribute to the ongoing discussion within the international community on how to ensure emergency preparedness and build resilient health systems in settings without either.

Individuals with depression show depleted concentrations of the inhibitory neurotransmitter GABA in occipital (visual) cortex, predicting weakened inhibition within their visual systems. Yet, visual inhibition in depression remains largely unexplored. To fill this gap, we examined the inhibitory process of center-surround suppression (CSS) of visual motion in depressed individuals. Perceptual performance in discriminating the direction of motion was measured as a function of stimulus presentation time and contrast in depressed individuals (n=27) and controls (n=22). CSS was operationalized as the accuracy difference between conditions using large (7.5 degrees) and small (1.5 degrees) grating stimuli. Both depressed and control participants displayed the expected advantage in accuracy for small stimuli at high contrast. A significant interaction emerged between subject group, contrast level and presentation time, indicating that alterations of CSS in depression were modulated by stimulus conditions. At high contrast, depressed individuals showed significantly greater CSS than controls at the 66 msec presentation time (where the effect peaked in both groups). The results’ specificity and dependence on stimulus features such as contrast, size and presentation time suggest that they arise from changes in early visual processing, and are not the results of a generalized deficit or cognitive bias.

BACKGROUND/OBJECTIVES: Potentially inappropriate opioid prescribing (PIP) may contribute to risk for fatal opioid overdose among older adults (age 50+). Our objective was to examine the effect of age on the likelihood of PIP exposure, as well as the effect of PIP exposure on adverse outcomes. DESIGN: Retrospective cohort study SETTING: Data from multiple state agencies in Massachusetts, 2011–2015 PARTICIPANTS: Over 3 million adult Massachusetts residents (3,078,163) who received at least one prescription opioid during the study period; approximately half (1,589,365) were older adults (age 50+). MEASUREMENTS: We measured exposure to five types of PIP: high-dose opioids, co-prescription with benzodiazepines, multiple opioid prescribers, multiple opioid pharmacies, and continuous opioid therapy without a pain diagnosis. We examined three adverse outcomes: non-fatal opioid overdose, fatal opioid overdose, and all-cause mortality. RESULTS: The rate of any PIP exposure increased with age, ranging from 2% among individuals age 18–29 to 14% among those age 50 and older. Older adults also had elevated rates of exposure to two or more different types of PIP, including 5% of adults age 50–69 and 4% of adults age 70 or older, in comparison to 2.5% of age 40–49 and lower percentages in younger age groups. Among covariates assessed, increasing age was the greatest positive predictor of PIP exposure. In analyses stratified by age, exposure to both any PIP and specific types of PIP were associated with non-fatal overdose, fatal overdose, and all-cause mortality among both younger and older adults. CONCLUSION: Older adults are more likely to be exposed to PIP, which elevates their risk for adverse events. Strategies to reduce exposure to PIP, and to improve outcomes among those already exposed, will be instrumental to addressing the opioid crisis as it manifests among older adults.

To measure the benefits to household caregivers of a psychotherapeutic intervention for adolescents and young adults living in a war-affected area.Between July 2012 and July 2013, we carried out a randomized controlled trial of the Youth Readiness Intervention--a cognitive-behavioural intervention for war-affected young people who exhibit depressive and anxiety symptoms and conduct problems--in Freetown, Sierra Leone. Overall, 436 participants aged 15-24 years were randomized to receive the intervention (n = 222) or care as usual (n = 214). Household caregivers for the participants in the intervention arm (n = 101) or control arm (n = 103) were interviewed during a baseline survey and again, if available (n = 155), 12 weeks later in a follow-up survey. We used a burden assessment scale to evaluate the burden of care placed on caregivers in terms of emotional distress and functional impairment. The caregivers' mental health--i.e. internalizing, externalizing and prosocial behaviour--was evaluated using the Oxford Measure of Psychosocial Adjustment. Difference-in-differences multiple regression analyses were used, within an intention-to-treat framework, to estimate the treatment effects.Compared with the caregivers of participants of the control group, the caregivers of participants of the intervention group reported greater reductions in emotional distress (scale difference: 0.252; 95% confidence interval, CI: 0.026-0.4782) and greater improvements in prosocial behaviour (scale difference: 0.249; 95% CI: 0.012-0.486) between the two surveys.A psychotherapeutic intervention for war-affected young people can improve the mental health of their caregivers.Mesurer les avantages pour les aidants familiaux d'une intervention psychothérapeutique destinée aux adolescents et aux jeunes adultes qui vivent dans une région touchée par la guerre.Entre juillet 2012 et juillet 2013, nous avons réalisé à Freetown, en Sierra Leone, un essai contrôlé randomisé de la Youth Readiness Intervention – une intervention cognitivo-comportementale destinée aux jeunes touchés par la guerre qui présentent des symptômes de dépression et d'anxiété ainsi que des troubles du comportement. Au total, 436 participants âgés de 15 à 24 ans ont été sélectionnés de manière aléatoire pour bénéficier soit de l'intervention (Comparés aux aidants familiaux des participants du groupe de contrôle, les aidants familiaux des participants du groupe expérimental ont fait part d'une réduction plus importante de la détresse psychique (différence d'échelle: 0,252; intervalle de confiance, IC, à 95%: 0,026-0,4782) et d'améliorations plus significatives en matière de comportement prosocial (différence d'échelle: 0,249; IC à 95%: 0.012-0.486) entre les deux études.Les interventions psychothérapeutiques destinées aux jeunes touchés par la guerre peuvent améliorer la santé mentale des aidants familiaux.Medir los beneficios para los cuidadores del hogar de una intervención psicoterapéutica para adolescentes y adultos jóvenes que viven en una zona afectada por la guerra.Entre julio de 2012 y julio de 2013, se llevaron a cabo ensayos controlados aleatorizados de la Youth Readiness Intervention (una intervención cognitivo-conductual para jóvenes afectados por la guerra que presentan síntomas de depresión y ansiedad y problemas de conducta) en Freetown, Sierra Leona. En términos generales, 436 participantes de 15 a 24 años fueron aleatorizados para recibir la intervención (En comparación con los cuidadores de los participantes del grupo de control, los cuidadores de los participantes del grupo de intervención registraron una mayor reducción en la angustia emocional (diferencia en la escala: 0,252; intervalo de confianza (IC) del 95%: 0,026–0,4782) y mayores mejoras en el comportamiento prosocial (diferencia en la escala: 0,249 (IC del 95%: 0,012–0,486) entre los dos estudios.Una intervención psicoterapéutica para los jóvenes afectados por la guerra puede mejorar la salud mental de sus cuidadores.قياس الفوائد التي تعود على مقدمي الرعاية في المنزل من خلال التدخل بالعلاج النفسي للمراهقين والشباب الذين يعيشون في منطقة متضررة من الحروب.في الفترة ما بين يوليو من عام 2012 ويوليو من عام 2013، أجرينا تجربة معشاة مضبطة بالشواهد لجاهزية الشباب بالتدخل – وهو تدخل قائم على الإدراك والسلوك للشباب المتأثرين بالحروب والذين يظهرون أعراض الاكتئاب والقلق ويثيرون مشاكل سلوكية - في فريتاون بسيراليون. وبوجه عام، تم اختيار 436 مشاركًا تتراوح أعمارهم من 15 إلى 24 سنة على نحو عشوائي لتلقي التدخل (العدد = 222) أو تلقي الرعاية المعتادة (العدد = 214). وقد أُجريت مقابلات مع مقدمي الرعاية في المنزل للمشاركين في الفرع الخاص بالتدخل (العدد = 101) أو الفرع الخاص بالمجموعة الشاهدة (العدد = 103) خلال مسح خط الأساس ثم تمت إعادة المسح مرة أخرى في حال تواجدهم (العدد = 155)، بعد مرور 12 أسبوعًا خلال مسح المتابعة. استخدمنا مقياس تقدير العبء لتقييم عبء الرعاية الذي وُضع على مقدمي الرعاية من حيث الضائقة الانفعالية والاختلال الوظيفي. وقد تم تقييم الصحة النفسية لمقدمي الرعاية – أي الاستبطان، والاختراج، والسلوك الاجتماعي الإيجابي – باستخدام مقياس أكسفورد للتوافق النفسي. تم استخدام تحاليل متعددة التحوف للاختلافات في الفارق ضمن إطار العمل لقصد العلاج، لتقدير تأثيرات العلاج.بالمقارنة مع مقدمي الرعاية للمشاركين في المجموعة الشاهدة، قام مقدمو الرعاية للمشاركين في مجموعة التدخل بالإبلاغ عن حالات انخفاض أكبر في الضائقة الانفعالية (الفرق في المقياس: 0.252؛ بنسبة أرجحية مقدارها 95%: 0.026–0.4782) وحالات تحسن أكبر في السلوك الاجتماعي الإيجابي (الفرق في المقياس: 0.249؛ بنسبة أرجحية مقدارها 95%: 0.012–0.486) بين المسحين.إن التدخل بالعلاج النفسي للشباب المتأثرين بالحروب يمكنه تحسين الصحة النفسية لمقدمي الرعاية الذين يتولون رعايتهم.旨在衡量家庭看护人从为居住在战争受灾区的青少年和青壮年提供心理治疗干预中获得的好处。.2012 年 7 月至 2013 年 7 月期间，我们针对塞拉利昂弗里敦市内受战争影响的年轻人（其显示出抑郁和焦虑症状并制造问题）展开了一次青年准备干预（即：认知-行为干预）的随机对照试验。总之，我们随机分配 436 位实验者（15-24 岁）接受干预治疗 (两次调查之间，相对于对照组实验者的看护人，干预组实验者看护人报告其抑郁情绪减少的人数更多（比例差异：0.252，95% 置信区间 (CI)：0.026–0.4782），而且其亲社会行为大大增强（比例差异：0.249，95% 置信区间 (CI)：0.012–0.486）。.对受战争影响的年轻人进行心理治疗干预可改善其看护人的心理健康。.Измерить положительное влияние психотерапевтического вмешательства, примененного в лечении подростков и молодых людей, которые проживают в регионах, затронутых войной, на состояние лиц, осуществляющих уход на дому.В период с июля 2012 г. по июль 2013 г. было проведено рандомизированное контролируемое исследование программы психосоциального вмешательства в лечении молодых людей (YRI) — когнитивно-поведенческой терапии пострадавших от войны молодых людей, у которых были выявлены симптомы депрессии и тревожного расстройства и отклонения в поведении; исследование проводилось в г. Фритаун, Сьерра-Леоне. Всего 436 участников в возрасте от 15 до 24 лет были распределены случайным образом либо в группу, в которой применялось вмешательство (По сравнению с лицами, осуществляющими уход за участниками контрольной группы, у лиц, осуществляющих уход за участниками экспериментальной группы, наблюдалось более существенное снижение показателей эмоционального расстройства (разность шкал: 0,252; 95% доверительный интервал, ДИ: 0,026–0,4782) и более существенное улучшение просоциального поведения (разность шкал: 0,249; 95% ДИ: 0,012–0,486) в период между двумя исследованиями.Психотерапевтическое вмешательство в лечении молодых людей, пострадавших от войны, может положительно повлиять на психическое здоровье лиц, осуществляющих уход за ними.

BACKGROUND One billion children live in war-affected regions of the world. We conducted the first cost-effectiveness analysis of an intervention for war-affected youth in sub-Saharan Africa, as well as a broader cost analysis. METHODS The Youth Readiness Intervention (YRI) is a behavioural treatment for reducing functional impairment associated with psychological distress among war-affected young persons. A randomized controlled trial was conducted in Freetown, Sierra Leone, from July 2012 to July 2013. Participants (n = 436, aged 15-24) were randomized to YRI (n = 222) or care as usual (n = 214). Functional impairment was indexed by the World Health Organization Disability Assessment Scale; scores were converted to quality-adjusted life years (QALYs). An 'ingredients approach' estimated financial and economic costs, assuming a societal perspective. Incremental cost-effectiveness ratios (ICERs) were also expressed in terms of gains across dimensions of mental health and schooling. Secondary analyses explored whether intervention effects were largest among those worst-off (upper quartile) at baseline. RESULTS Retention at 6-month follow-up was 85% (n = 371). The estimated economic cost of the intervention was $104 per participant. Functional impairment was lower among YRI recipients, compared with controls, following the intervention but not at 6-month follow-up, and yielded an ICER of $7260 per QALY gained. At 8-month follow-up, teachers' interviews indicated that YRI recipients observed higher school enrolment [P

Trauma from witnessing events such as bombings and killings as well as direct victimization or participation in violence has been associated with psychosocial distress and poor mental health among war-exposed children and adolescents. This study examines the relationship between caregiver mental health and child internalizing (anxiety and depression) symptoms over a 4-year period in postconflict Sierra Leone.The sample included 118 adolescent Sierra Leonean youth (73% male; mean age = 16.5 years at Time 1) and their caregivers (40% male; mean age = 39.0 at Time 1). To measure depression and anxiety symptoms, the Hopkins Symptom Checklist-25 was used with adults and the Oxford Measure of Psychosocial Adjustment - previously validated for use with children and adolescents in the region - was used to assess youth. A multivariate hierarchical linear model (HLM) for studying change within dyads was implemented to study covariation in internalizing symptoms among caregivers and youth over time; these models also included covariates at the individual, family and community levels. The relationship of caregiver mental health to child's internalizing was tested in a latent variable extension of the HLM.The latent variable extension estimated that a one standard deviation (SD) change in caregiver anxiety/depression was associated with a .43 SD change in youth internalizing (p.01) over the 4-year period. Family acceptance was negatively related to youth internalizing (p.001), while community stigma was positively associated (p.001).The findings highlight an important interplay between caregiver and child mental health within the postconflict setting and the need for psychosocial interventions to extend beyond the individual to account for family dynamics.

Face perception plays a foundational role in the social world. This perceptual ability is deficient in schizophrenia. A noise-filtering mechanism is essential for perceptual processing. It remains unclear as to whether a specific noise-filtering mechanism is implicated in the face perception problem or a general noise-filtering mechanism is involved which also mediates non-face visual perception problems associated with this psychiatric disorder. This study examined and compared the effects of external noise on the performance of face discrimination and car discrimination in schizophrenia patients (n=25) and healthy controls (n=27). Superimposing the external visual noise on face or car stimuli elevated perceptual thresholds (i.e. degraded performance levels) for both face and car discrimination. However, the effect of noise was significantly larger on face than on car discrimination, both in patients and controls. This pattern of results suggests specific vulnerability of face processing to noise in healthy individuals and those with schizophrenia.

IntroductionPartners In Health and the Malawi Ministry of Health collaborate on comprehensive HIV services in Neno, Malawi, featuring community health workers, interventions addressing social determinants of health and health systems strengthening. We conducted an observational study to describe the HIV care continuum in Neno and to compare facility-level HIV outcomes against health facilities nationally.MethodsWe compared facility-level outcomes in Neno (n=13) with all other districts (n=682) from 2013 to 2015 using mixed-effects linear regression modelling. We selected four outcomes that are practically useful and roughly mapped on to the 90-90-90 targets: facility-based HIV screenings relative to population, new antiretroviral therapy (ART)enrolments relative to population, 1-year survival rates and per cent retained in care at 1 year.ResultsIn 2013, the average number of HIV tests performed, as a per cent of the adult population, was 11.75%, while the average newly enrolled patients was 10.03%. Percent receiving testing increased by 4.23% over 3 years (PConclusionThe Neno HIV programme demonstrated significantly higher survival and retention rates compared with all other districts in Malawi. Incorporating community health workers, strengthening health systems and addressing social determinants of health within the HIV programme may help Malawi and other countries accelerate progress towards 90-90-90.

Purpose – The purpose of this paper is to examine sex differences in mental health service usage among upper-middle, lower-middle, and low-income countries (LICs). Design/methodology/approach – Data from 62 low- and middle-income countries (LAMICs) were collected with the World Health Organization – Assessment Instrument for Mental Health Systems (WHO-AIMS). Sex differences in mental health service utilization were assessed by comparing the proportion female in the general population with the proportion female treated for mental illness in five different types of mental health facility. Findings – Two-sided t-tests for significance (a=0.05) revealed a significant difference between the proportion female in the population and the proportion treated in inpatient facilities (community-based and mental hospitals) in LICs. There was also a trend toward decreased use of outpatient facilities by women in LICs (p=0.08). Lower-middle and upper-middle income countries showed no differences. In day treatment facilities for the entire sample, there was a significant difference between the proportion female in the population and the proportion treated female (weighted mean difference overall=0.10, p=0.035). Research limitations/implications – The authors found significantly reduced utilization of mental health services by women in LICs in community-based inpatient facilities and mental hospitals and a trend toward decreased use in outpatient facilities. Future studies investigating the factors contributing to the lower utilization of services by women in LICs are essential. Originality/value – This study presents the first comprehensive study of mental health service usage by sex in 62 LAMICs.

Mental health problems are linked to violence exposures such as witnessing or participating in war-related activities. Of particular concern is whether such exposure perpetuates risk of violent behavior. Externalizing problems have received limited attention in research on war-affected youth. Three waves of data (2002–2008) from a prospective longitudinal study in Sierra Leone were used to examine externalizing trajectories in 529 war-affected youth (average age 14.9 at baseline; 25% female). Of four groups, the largest represented a trajectory designated as ‘stable,’ with relatively low levels of externalizing at baseline declining slightly across the time points. Compared to the stable group, the probability of being classified in the ‘deteriorators’ group was greater among those who reported having injured/killed another person during the war and with a history of family abuse and neglect reported at T3. Membership in the ‘improvers’ group was more likely for those with higher family support and was also associated with reporting injuring/killing others during the war. A minority indicated sustained, heightened symptom levels, which was also associated with family abuse and neglect following the war. Our findings demonstrate that both traumatic war experiences and post-war experiences play vital roles in shaping adolescents' trajectories of externalizing over time.

Low-income and middle-income countries account for over 80% of the world's infectious disease burden, but

Background: Performance-based financing (PBF) has demonstrated a range of successes and failures in improving health outcomes across low- and middle-income countries. Evidence indicates that the success of PBF depends, in large part, on the model selected, in relation to a variety of contextual factors.Objective: Partners In Health∣Inshuti Mu Buzima aimed to evaluate health outcomes associated with a novel capacity-building model of PBF at health centers throughout Kirehe district, Rwanda.Design: Thirteen health centers in Kirehe district, which provide healthcare to a population of over 300,000 people, agreed to participate in a PBF initiative scheme that integrated data feedback, quality improvement coaching, peer-to-peer learning, and district-level priority setting. Health centers’ progress toward collectively agreed upon site-specific health targets was assessed every 6 months for 18 months. Incentives were awarded only when health centers met goals on all three priorities health centers had collectively agreed upon: 90% coverage of community-based health insurance, 70% contraceptive prevalence rate, and zero acute severe malnutrition cases. Improvement across all four time points and facilities was measured using mixed-effects linear regression.Findings: At 6-month follow-up, 4 of 13 health centers had met 1 target. At 12-month follow-up, 7 centers had met 1 target, and by 18-month follow-up, 6 centers had met 2 targets and 2 centers had met all 3. Average health center performance had improved significantly across the district for all three targets: mean insurance coverage increased from 68% at baseline to 93% (p

BackgroundTreatment coverage for mental disorders ranges from less than 10% to more than 90% across low- and middle-income (LAMI) countries. Studies have yet to examine whether the capacity of mental health systems might be adversely affected by the burdens of unrelated conditions such as HIV/AIDS.AimsTo examine whether the magnitude of disease burden from communicable, perinatal, maternal and nutritional conditions - commonly referred to as Group 1 diseases - is inversely associated with mental health system capacity in LAMI countries.MethodMultiple regression analyses were undertaken using data from 117 LAMI countries included in the 2011 World Health Organization (WHO) Mental Health Atlas. Capacity was defined in terms of human resources and infrastructure. Regressions controlled for effects of political stability, government health expenditures, income inequality and neuropsychiatric disease burden.ResultsHigher Group 1 disease burden was associated with fewer psychiatrists, psychologists and nurses in the mental health sector, as well as reduced numbers of out-patient facilities and psychiatric beds in mental hospitals and general hospitals (t= −2.06 to −7.68, P < 0.05).ConclusionsEvidence suggests that mental health system capacity in LAMI countries may be adversely affected by the magnitude of their Group 1 disease burden.

Three waves of data from a prospective longitudinal study in Sierra Leone were used to examine internalizing trajectories in 529 war-affected youth (ages 10-17 at baseline; 25% female). Latent class growth analyses identified four trajectories: a large majority of youth maintained lower levels of internalizing problems (41.4%) or significantly improved over time (47.6%) despite very limited access to care; but smaller proportions continued to report severe difficulties six years post-war (4.5%) or their symptoms worsened (6.4%). Continued internalizing problems were associated with loss of a caregiver, family abuse and neglect, and community stigma. Despite the comparative resilience of most war-affected youth in the face of extreme adversity, there remains a compelling need for interventions that address family- and community-level stressors.

The recognition of facial affect is a core component of social cognition and is influenced by bottom-up and top- down processes. Spatial frequency-specific processing is a fundamental mechanism underpinning visual perception that also contributes to emotion processing. Yet, it remains relatively unclear how this bottom-up process modulates analysis of affect signals. In this study, face images were manipulated via high-pass and low-pass spatial frequency filtering, and the effects of these manipulations were measured on two tasks: emotion detection and emotion perception. The detection task measured individuals' ability to detect the presence of happiness or fear when relying only upon high spatial frequency (HSF), low spatial frequency (LSF) or unfiltered (BSF) images. The perception task evaluated individuals' tendency to perceive one type of images (e.g. LSF) as happier or more fearful than another (e.g. HSF). On the detection task, individuals were better at detecting happiness in LSF images as compared to HSF images, a result not found in the fear detection condition. On the perception task, images with HSFs were perceived as significantly happier than images without HSFs, but only at low emotional salience levels. No significant effect for spatial frequency manipulation was found in the fear perception condition. Together, these results highlight the significant bottom-up role of spatial frequency content in perceiving happiness as opposed to fear and indicates the unique roles of bottom-up visual mechanisms when processing these two emotions.

Schizophrenia is associated with the inability to control and coordinate thoughts, actions, and perceptions. In conventional assessments of cognitive control, multiple sensory features of stimuli are concomitantly manipulated, introducing a confounding role of bottom-up perceptual information. To overcome this difficulty, we used an ambiguous visual stimulus (Necker cube), which allowed measurement of cognitive control with constant sensory input. Subjects (20 patients, 20 controls) were asked to control their perception of a transparent Necker cube by keeping a designated plane at the front or back of the stimulus, the position of which is perceptually bistable. Patients were highly deficient at controlling their perception of the cube. When a visual feature (the luminance contrast between a designated cube plane and the other planes) was systematically manipulated, an interaction was found whereby schizophrenia patients no longer under-performed on the highest contrast condition. These results show patients’ impairment of controlling perception in the absence of visual modulation and suggest the potential utility of perceptually based approaches to cognitive remediation in schizophrenia. (JINS, 2011, 551–556)

While many behavioral capacities decline with age, few can be readily noticed in the early stages of aging. Visual motion processing is particularly sensitive to aging; yet it is unclear whether decline in motion processing can be used to index the visual aging process in its early stages. We examined performance in 63 healthy individuals on a series of motion-related visual tasks, in a large age range (21-80 years-old). Three psychophysical tasks were used: dynamic contrast detection (a functional precursor to motion processing), contrast-based velocity discrimination (motion processing dependent upon contrast signal), and velocity discrimination (motion processing independent of contrast modulation). Additionally, cognitive ability was assessed using the WAIS-R (verbal components). Results indicated that visual motion performance began to significantly decline between the 51-60 and 61-70 age groups, and this decline was most pronounced on velocity discrimination tasks. Cognitive performance did not differ across age groups and was not correlated with performance on visual measures. This pattern of results suggests that visual motion processing may be a potential indicator of early aging within the visual system.

IntroductionThis protocol concerns the implementation and evaluation of an intervention designed to realign the existing cadre of community health workers (CHWs) in Neno district, Malawi to better support the care needs of the clients they serve. The proposed intervention is a ‘Household Model’ where CHWs will be reassigned to households, rather than to specific patients with HIV and/or tuberculosis (TB).Methods and analysisUsing a stepped-wedge, cluster-randomised design, this study investigates whether high HIV retention rates can be replicated for non-communicable diseases (NCDs), and the model’s impact on TB and paediatric malnutrition case finding, as well as the uptake of family planning and antenatal care. Eleven sites (health centres and hospitals) were arranged into six clusters (average cluster population 21 800). Primary outcomes include retention in care for HIV and chronic NCDs, TB case finding, paediatric malnutrition case finding, and utilisation of early and complete antenatal care. Clinical outcomes are based on routinely collected data from the Ministry of Health’s District Health Information System 2 and an OpenMRS electronic medical record supported by Partners In Health. Additionally, semistructured qualitative interviews with various stakeholders will assess community perceptions and context of the Household Model.Ethics and disseminationEthics approval has been obtained from the Malawian National Health Science Research Committee (#16/11/1694) in Lilongwe, Malawi; Partners Healthcare Human Research Committee (#2017P000548/PHS) in Somerville, Massachusetts; and the Biomedical and Scientific Research Ethics Sub-Committee (REGO-2017–2060) at the University of Warwick in Coventry, UK. Dissemination will include manuscripts for peer-reviewed publication as well as a full report detailing the findings of the intervention for the Malawian Ministry of Health.Trial registration numberNCT03106727.Primary sponsorPartners In Health | Abwenzi Pa Za Umoyo P.O. Box 56, Neno, Malawi. Protocol Version 4, March 2018.

Healthy females outperform males on face recognition. Relative to healthy individuals, schizophrenia patients are impaired on face perception tasks. Yet, it is unclear whether the female advantage found in healthy controls is preserved in females with schizophrenia. In the present study, we compared male and female patients and healthy controls on two basic face perception tasks – detection and identity discrimination. In the detection task, subjects located an upright or inverted line-drawn face (or a tree) embedded within a larger line-drawing. In the identity discrimination task, subjects determined which of two side-by-side face images matched an earlier presented face image. Healthy females were significantly more accurate than healthy males on face detection, but not on identity discrimination. However, female patients were not more accurate than male patients on either task. On both upright face detection and face identity discrimination, healthy controls significantly outperformed patients. Patients’ performance on face detection was closely associated with tree detection and IQ scores, as well as level of psychosis. This pattern of results suggests that a female advantage in basic face perception is no longer available in schizophrenia, and that this absence may be related to a generalized deficit factor, which acts to level performance across sexes, and putative changes in sex-related neurobiological differences associated with schizophrenia.

Visual sensitivity decreases with age, and this presumably has an impact on face recognition. However, the relationship between aging in basic visual processing and in the sensory and cognitive mechanisms mediating face recognition is not well understood. Face detection, a foundational step in recognizing faces, relies primarily on sensory information. This study measured the ability to detect facial configuration and contrast detection in young (59 years). Performance on both face detection and contrast detection was moderately degraded in the middle-aged group compared with the young group and was further degraded in elderly adults. Face detection was correlated strongly with contrast sensitivities, but only weakly with verbal IQ. The results suggest that face detection ability begins to reduce in early aging, and is associated with spatiotemporal visual processing. Copyright 2009, Oxford University Press.

Face recognition involves several physiological and psychological processes, including those in visual, cognitive and affective domains. Studies have found that schizophrenia patients are deficient at recognizing facial emotions, yet visual and cognitive processing of facial information in this population has not been systematically examined. In this study, we examined visual detection, perceptual discrimination and working memory of faces as well as non-face visual objects in patients. Visual detection was measured by the accuracy when detecting the presence of a briefly displayed face, image which contained only the basic configural information of a face. Perceptual discrimination was measured by discriminability scores for individual facial identity images, in which the degree of similarity between images was systematically varied via morphing. Working memory was measured by the discriminability scores when two comparison face images were separated by 3 or 10 seconds. All measurements were acquired using a psychophysical method (two-alternative forced choice). Relative to controls, patients showed significantly reduced accuracy in visual detection of faces (p=0.003), moderately degraded performance in perceptual discrimination of faces (p=0.065), and significantly impaired performance in working memory of faces (p

The way schizophrenia patients perceive the world is largely mysterious. Understanding and appreciating the visual world begins with the perception of basic visual features, which is altered in this mental disorder. Yet, the roles basic visual features play in functional activities such as appreciation of art are unclear. This study examined the effects of visual feature manipulation on beauty perception of art in schizophrenia patients (n=29) and in normal controls (n=30). Three pieces of art - The Starry Night (Van Gogh), Mona Lisa (Da Vinci) and a natural landscape photograph (anonymous) - were manipulated in terms of their coloration (removal of color), spatial frequency content (low or high-frequency pass) and visual noise level (with added noise). Subjects judged the beauty of the original and visual-feature-manipulated artworks by rating each piece individually (1 to 7) and by ranking all pieces from most to least beautiful. For the three original art pieces, averaged ratings and rankings were similar in patients and controls. However, when the visual features of the original pieces were manipulated, changes in the beauty ratings were significantly smaller in patients. The reduced sensitivity to visual feature manipulations suggests that the modulation of basic visual signals, often used for vivid and dynamic expressions in art, may be under-appreciated in schizophrenia.

Objective: Youth in war-affected regions are at risk for poor psychological, social, and educational outcomes. Effective interventions are needed to improve mental health, social behavior, and school functioning. This randomized controlled trial tested the effectiveness of a 10-session cognitive-behavioral therapy (CBT)–based group mental health intervention for multisymptomatic war-affected youth (aged 15–24 years) in Sierra Leone. Method: Waraffected youth identified by elevated distress and impairment via community screening were randomized (stratified by sex and age) to the Youth Readiness Intervention (YRI) (n ¼ 222) or to a control condition (n ¼ 214). After treatment, youth were again randomized and offered an education subsidy immediately (n ¼ 220) or waitlisted (n ¼ 216). Emotion regulation, psychological distress, prosocial attitudes/behaviors, social support, functional impairment, and posttraumatic stress disorder (PTSD) symptoms were assessed at pre- and postintervention and at 6-month follow-up. For youth in school, enrollment, attendance, and classroom performance were assessed after 8 months. Linear mixed-effects regressions evaluated outcomes. Results: The YRI showed significant postintervention effects on emotion regulation, prosocial attitudes/behaviors, social support, and reduced functional impairment, and significant follow-up effects on school enrollment, school attendance, and classroom behavior. In contrast, education subsidy was associated with better attendance but had no effect on mental health or functioning, school retention, or classroom behavior. Interactions between education subsidy and YRI were not significant. Conclusion: YRI produced acute improvements in mental health and functioning as well as longer-term effects on school engagement and behavior, suggesting potential to prepare war-affected youth for educational and other opportunities. Clinical trial registration information–Trial of the Youth Readiness Intervention (YRI); http://clinicaltrials.gov; NCT01684488 J. Am. Acad. Child Adolesc. Psychiatry, 2014;53(12):1288–1297. Key Words: youth, intervention, mental health, war-affected, randomized controlled trial