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Low- and middle-income countries (LMICs) face high burden of common mental disorders (CMDs). Most of the evidence for the Collaborative Care (CC) model effectiveness comes from high-income countries (HICs) and may not generalise to LMICs. A systematic review was conducted to assess effectiveness of CC for CMDs in LMICs. We searched eight-databases, two trial registries (2011-November 2023). Randomised controlled trials (RCTs) of adults (≥18 years) with depression/anxiety diagnosis, reporting remission/change in symptom severity were eligible. Random effects meta-analyses were conducted for: short-(0–6 months), medium-(7–12 months), long-(13–24 months), and very long-term (≥25 months) follow-up. Quality was assessed with Cochrane RoB2 tool. PROSPERO registration: CRD42022380407. Searches identified 7494 studies, 12 trials involving 13,531 participants were included; nine had low-risk of bias. CC was more effective than usual care for depression: dichotomous outcomes (short-term, 7 studies, relative risk (RR) 1.39, 95%CI 1.31, 1.48; medium-term, 6 studies, RR 1.35, 95%CI 1.28, 1.43); and continuous outcomes (short-term, 8 studies, standardised mean difference (SMD) −0.51, 95%CI −0.80, −0.23; medium-term, 8 studies, SMD −0.59, 95%CI −1.00, −0.17). CC was found to be effective at long-term (one study), but not at very long-term. Improvement in anxiety outcomes with CC (2 studies, 340 participants) reported up to 12-months; improvements in quality-of-life were not statistically significant (3 studies, 796 participants, SMD 0.62, 95%CI −0.10, 1.34). Pooled estimates showed high heterogeneity. In LMICs, CC was more effective than usual care for improving depression outcomes at short and medium-term follow-up. A similar improvement was found for anxiety outcomes, but evidence is limited. • Collaborative Care shows effectiveness for treatment of common mental disorders. • Effectiveness established even in the presence of physical comorbidity. • Delivery through task shifting by trained non-mental health workers is effective. • Future research to focus on implementation in low- and middle-income countries [ABSTRACT FROM AUTHOR]

AbstractThe COVID-19 crisis severely impacted healthcare centers in the pandemic’s epicenter. The shortage of healthcare workers (HCW) frequently utilized for complex interventions in the intensive care unit (ICU), such as proning for acute respiratory distress syndrome (ARDS), inspired a team of ICU professionals to implement a task-shifting initiative. Thirty-three HCW from various departments participated in the training. The interdisciplinary team performed multiple proning sessions on 90 patients with COVID-19-related ARDS. Participants indicated that the training session equipped them with adequate skills to safely prone patients. The training emphasized effective teamwork and communication while also increasing trainees’ awareness of proning benefits. [ABSTRACT FROM AUTHOR]

Introduction: Occupational therapy has been underdeveloped and often neglected in the global health workforce agenda, contrasting with the global rise of population needs for services. The World Federation of Occupational Therapists (WFOT) is utilizing a research-based, multi-step process for developing a Global Strategy for strengthening the occupational therapist workforce. A multi-pronged scoping review, situational analysis, and expert input process enabled the drafting of a provisional Global Strategy. Here, feedback on that draft from representatives of WFOT member organizations was obtained and analyzed as one key intermediate step toward shaping the in-developing Strategy's content and structure. Methods: Two-phased, mixed-methods consultation consisting of: (1) online survey with score ratings and comments on the utility of each strategy and (2) four in-person focus groups discussions on low-scoring items involving a total of 76 representatives of WFOT member organizations. The focus group discussions were analyzed using an inductive thematic analysis approach. Results: Strategies involving 'task shifting/task sharing' or the 'harmonization of workforce data-collection requirements' received the lowest scores in the initial survey and were thereby addressed in the focus groups discussions. The overarching theme of the focus groups was the need to: "clarify, specify, and contextualize the strategies", including: (1) "clarify the terminology and specify the application", for example, describe the meaning of task shifting, specify which tasks can (and cannot) be shifted and to whom, to address concerns regarding scope-of-practice, service demand, and safety; and (2) "outline the context of need and the context for the implementation" of the strategies, elucidating why the strategies are needed and how they can be feasibly implemented across the different jurisdictional contexts. Conclusion: Within a mixed-methods consultation, WFOT representatives identified challenging topics on the draft workforce strategies and suggested methods to improve the Global Strategy, its acceptability, and implementation. The terms 'task shifting/task sharing' raised the greatest discussion among the profession leaders, when the strategy was not sufficiently clarified, specified, or contextualized. [ABSTRACT FROM AUTHOR]

Abstract Introduction Occupational therapy has been underdeveloped and often neglected in the global health workforce agenda, contrasting with the global rise of population needs for services. The World Federation of Occupational Therapists (WFOT) is utilizing a research-based, multi-step process for developing a Global Strategy for strengthening the occupational therapist workforce. A multi-pronged scoping review, situational analysis, and expert input process enabled the drafting of a provisional Global Strategy. Here, feedback on that draft from representatives of WFOT member organizations was obtained and analyzed as one key intermediate step toward shaping the in-developing Strategy’s content and structure. Methods Two-phased, mixed-methods consultation consisting of: (1) online survey with score ratings and comments on the utility of each strategy and (2) four in-person focus groups discussions on low-scoring items involving a total of 76 representatives of WFOT member organizations. The focus group discussions were analyzed using an inductive thematic analysis approach. Results Strategies involving ‘task shifting/task sharing’ or the ‘harmonization of workforce data-collection requirements’ received the lowest scores in the initial survey and were thereby addressed in the focus groups discussions. The overarching theme of the focus groups was the need to: “clarify, specify, and contextualize the strategies”, including: (1) “clarify the terminology and specify the application”, for example, describe the meaning of task shifting, specify which tasks can (and cannot) be shifted and to whom, to address concerns regarding scope-of-practice, service demand, and safety; and (2) “outline the context of need and the context for the implementation” of the strategies, elucidating why the strategies are needed and how they can be feasibly implemented across the different jurisdictional contexts. Conclusion Within a mixed-methods consultation, WFOT representatives identified challenging topics on the draft workforce strategies and suggested methods to improve the Global Strategy, its acceptability, and implementation. The terms ‘task shifting/task sharing’ raised the greatest discussion among the profession leaders, when the strategy was not sufficiently clarified, specified, or contextualized.

BACKGROUND: A key question in implementation science is how to balance adaptation and fidelity in translating interventions to new settings. There is growing consensus regarding the importance of planned adaptations to deliver interventions in contextually sensitive ways. However, less research has examined ad-hoc adaptations, or those that occur spontaneously in the course of intervention delivery. A key question is whether ad-hoc adaptations ultimately contribute to or detract from intervention goals. This study aimed to (a) identify ad-hoc adaptations made during delivery of a family therapy intervention and (b) assess whether they promoted or interrupted intervention goals. METHODS: Tuko Pamoja (Swahili: We are Together) is an evidence-informed family therapy intervention aiming to improve family dynamics and mental health in Kenya. Tuko Pamoja employs a task-shifting model, delivered by lay counselors who are afforded a degree of flexibility in presenting content and in practices they use in sessions. We used transcripts of therapy sessions with 14 families to examine ad-hoc adaptations used by counselors. We first identified and characterized ad-hoc adaptations through a team-based code development, coding, and code description process. Then, we evaluated to what extent ad-hoc adaptations promoted the principles and strategies of the intervention (TP-promoting), disrupted them (TP-interrupting), or neither (TP-neutral). To do this, we first established inter-coder agreement on application of these categories with verification by the intervention developer. Then, coders categorized ad-hoc adaptation text segments as TP-promoting, TP-interrupting, or TP-neutral. RESULTS: Ad-hoc adaptations were frequent and included (in decreasing order): incorporation of religious content, exemplars/role models, community dynamics and resources, self-disclosure, and metaphors/proverbs. Ad-hoc adaptations were largely TP-promoting (49%) or neutral (39%), but practices were TP-interrupting 12% of the time. TP-interrupting practices most often occurred within religious content and exemplars/role models, which were also the most common practices overall. CONCLUSION: Extra attention is needed during planned adaptation, training, and supervision to promote intervention-aligned use of common ad-hoc adaptation practices. Discussing them in trainings can provide guidance for lay providers on how best to incorporate ad-hoc adaptations during delivery. Future research should evaluate whether well-aligned ad-hoc adaptations improve therapeutic outcomes. TRIAL REGISTRATION: Pilot trial registered at clinicaltrials.gov (C0058).

ABSTRACTBackground: Trauma exposure prevalence and consequent post-traumatic stress disorder among South African adolescents are significant. Sleep disturbances are among the most frequently reported difficulties faced by those dealing with PTSD. The current study examined the feasibility and preliminary efficacy of the South African Adolescence Group Sleep Intervention on PTSD symptom severity and sleep disturbance.Method: Sixty-one adolescents with PTSD diagnoses and sleep disturbance were randomly assigned (1:1) to one individual and four group sessions of a sleep intervention (SAASI) or a control group. Participants completed the Child PTSD symptom scale for DSM5 (CPSS-5) and the Pittsburgh Sleep Quality Index (PSQI) among other sleep and psychiatric measures. The trial was registered on the Pan African Trial Registry (PACTR202208559723690).Results: There was a significant but similar decrease in PSQI scores in both groups over time indicating no overall intervention effect (Wald test = −2.18, p = .029), mean slope = −0.2 (95% CI: −0.37 to −0.02) (p = .583). On the CPSS-5, interaction between groups was also not significant (p = .291). Despite this overall finding, the mean difference in CPSS-SR-5 scores increased over time, with the difference between groups post-treatment -9.10 (95%CI: −18.00 to −0.21), p = .045 and the 1-month follow-up contrast - 11.22 (95%CI: −22.43 to −0.03), p = .049 suggesting that PTSD symptom severity decreased more in the intervention group than the control group. The dropout rate was higher than expected for both the intervention (n = 10; 32%) and control (n = 8; 26.7%) groups. Dropout were mostly school commitments or travel related.Conclusions: Early findings suggest a trend towards dual improvement in sleep quality and PTSD symptom severity in adolescents with a sleep disturbance and PTSD receiving a group sleep intervention (SAASI). Further investigation in a properly powered RCT with detailed retention planning is indicated.

In the United States, schools provide a large portion of child and adolescent mental health services; however, systems are restricted by resource and workforce shortages while the need for services steadily increases. This discrepancy leads to unmanageable caseloads for providers and reduced access to quality services for youth, and highlights a need to expand the school-based workforce to meet student needs. Herein, we propose a novel mental health service-delivery framework to offset these challenges by integrating mentors within the context of multitiered systems of support (MTSS) through task-shifting. We review and synthesize the literature in community and school psychology on the promises and challenges of youth mentoring and MTSS. We discuss the importance of diversifying school psychology, including the importance of increasing access to and benefit from educational supports for minoritized students, and the promise of mentoring within this context. We propose that by systematically integrating youth mentoring within MTSS there are several systems-level and individual-level benefits for youth, school staff, and mentoring nonprofits. We conclude by providing ethical, evaluation, and implementation considerations surrounding the proposed model. Impact Statement Restructuring the school-based mental health workforce by integrating community mentors into MTSS frameworks provides an innovative, powerful way to engage with diverse student populations. We propose a novel model that expands and strengthens this workforce, thereby increasing the quality and reach of school-based services. [ABSTRACT FROM AUTHOR]

Objective: Increasing effectiveness and sustainability of universal school‐based eating disorder prevention is needed. This study adapted two existing selective prevention programmes for universal delivery, investigating feasibility, acceptability, and preliminary effects when delivered by trained teachers to classes of mixed‐gender adolescents. Method: A three‐arm controlled pilot study with Year 9 students (N = 288; Mage = 13.61 SDage =.50). Three schools in south Wales and south‐west England were allocated to mindfulness‐based intervention (MBI), dissonance‐based intervention (DBI), or classes‐as‐usual (CAU) control. Self‐reported eating disorder risk factors were collected at baseline, 6‐week post‐intervention, and 2‐month follow‐up. Focus groups were conducted post‐intervention. Results: Delivery and evaluation were feasible, allowing for flexibility in scheduling, with good retention. Student and teacher ratings indicated moderate acceptability of both interventions, with recommendations for refinement. Mixed model analyses, controlling for baseline, showed significant effects of condition across post‐intervention and follow‐up for body esteem (DBI > CAU; Cohen's d =.34) and positive affect (MBI > CAU, d =.58). For girls only, both MBI and DBI improved body satisfaction and internalization, and the MBI additionally resulted in improved weight and shape concerns, negative affect, and life disengagement (d's =.39–1.12), across post‐intervention and follow‐up. Discussion: Selective eating disorder prevention programmes based on cognitive dissonance and mindfulness can be delivered universally in schools, by teachers, allowing for appropriate flexibility necessary for real world implementation. Moderate acceptability indicates areas for improving content and delivery; positive effects on key outcomes are encouraging. These findings provide support for further robust evaluation. Public Significance: Existing universal eating disorder prevention is limited by small effects and reliance on highly trained facilitators. This study is the first to adapt mindfulness‐ and dissonance‐based interventions for delivery by teachers, to adolescents of all genders in a classroom setting. Delivery was largely feasible and acceptable, and both interventions showed significant effects across key risk factors for eating disorders, with larger effect sizes than found previously. This underpins further robust evaluation. [ABSTRACT FROM AUTHOR]

SUMMARY: Eye movement desensitisation and reprocessing (EMDR), a therapy initially developed by Dr Francine Shapiro for treating post-traumatic stress disorder, has broadened its scope to include other forms of stress and trauma, even showing promise for physical health conditions. This commentary on a series of three articles on EMDR in this journal outlines the therapy's underlying theoretical model, adaptive information processing (AIP), which involves trauma-focused case conceptualisation. It also introduces the work of the EMDR Council of Scholars, which identified three categories of treatment: EMDR psychotherapy, EMDR treatment protocols and EMDR-derived techniques. Finally, it considers EMDR training and credentialing and the aim of current leaders in the EMDR community to solidify EMDR's standing as a scientifically validated, front-line trauma therapy, while honouring Shapiro's legacy of striving to end the cycle of violence, especially in low- and middle-income countries. [ABSTRACT FROM AUTHOR]

Abstract Background Low- and middle-income countries often lack access to mental health services, leading to calls for integration within other primary care systems. In sub-Saharan Africa, integration of depression treatment in non-communicable disease (NCD) settings is feasible, acceptable, and effective. However, leadership and implementation climate challenges often hinder effective integration and quality of services. The aim of this study was to identify discrete leadership strategies that facilitate overcoming barriers to the integration of depression care in NCD clinics in Malawi and to understand how clinic leadership shapes the implementation climate. Methods We conducted 39 in-depth interviews with the District Medical Officer, the NCD coordinator, one NCD provider, and the research assistant from each of the ten Malawian NCD clinics (note one District Medical Officer served two clinics). Based on semi-structured interview guides, participants were asked their perspectives on the impact of leadership and implementation climate on overcoming barriers to integrating depression care into existing NCD services. Thematic analysis used both inductive and deductive approaches to identify emerging themes and compare among participant type. Results The results revealed how engaged leadership can fuel a positive implementation climate where clinics had heightened capacity to overcome implementation barriers. Effective leaders were approachable and engaged in daily operations of the clinic and problem-solving. They held direct involvement with and mentorship during the intervention, providing assistance in patient screening and consultation with treatment plans. Different levels of leadership utilized their respective standings and power dynamics to influence provider attitudes and perceptions surrounding the intervention. Leaders acted by informing providers about the intervention source and educating them on the importance of mental healthcare, as it was often undervalued. Lastly, they prioritized teamwork and collective ownership for the intervention, increasing provider responsibility. Conclusion Training that prioritizes leadership visibility and open communication will facilitate ongoing Malawi Ministry of Health efforts to scale up evidence-based depression treatment within NCD clinics. This proves useful where extensive and external monitoring may be limited. Ultimately, these results can inform successful strategies to close implementation gaps to achieve integration of mental health services in low-resource settings through improved leadership and implementation climate. Trial registration These findings are reported from ClinicalTrials.gov, NCT03711786. Registered on 18/10/2018. https://clinicaltrials.gov/ct2/show/NCT03711786 .

Abstract Background A 15 million health workforce shortage is still experienced globally leading to a sub-optimal healthcare worker-to-population ratio in most countries. The use of low-skilled care assistants has been suggested as a cost-saving human resource for health strategy that can significantly reduce the risks of rationed, delayed, or missed care. However, the characterisation, role assignment, regulation, and clinical governance mechanisms for unlicensed assistive workforce remain unclear or inconsistent. The purpose of this study was to map and collate evidence of how care assistants are labelled, utilised, regulated, and managed in formal hospital settings as well as their impact on patient care. Methods We conducted a scoping review of literature from PUBMED, CINAHL, PsychINFO, EMBASE, Web of Science, Scopus, and Google Scholar. Searches and eligibility screening were conducted using the Participants–Context–Concepts framework. Thematic content analysis guided the synthesis of the findings. Results 73 records from a total of 15 countries were included in the final full-text review and synthesis. A majority (78%) of these sources were from high-income countries. Many titles are used to describe care assistants, and these vary within and across countries. On ascribed roles, care assistants perform direct patient care, housekeeping, clerical and documentation, portering, patient flow management, ordering of laboratory tests, emergency response and first aid duties. Additional extended roles that require higher competency levels exist in the United States, Australia, and Canada. There is a mixture of both positive and negative sentiments on their impact on patient care or nurses’ perception and experiences. Clinical and organisational governance mechanisms vary substantially across the 15 countries. Licensure, regulatory mechanisms, and task-shifting policies are largely absent or not reported in these countries. Conclusions The nomenclature used to describe care assistants and the tasks they perform vary substantially within countries and across healthcare systems. There is, therefore, a need to review and update the international and national classification of occupations for clarity and more meaningful nomenclature for care assistants. In addition, the association between care assistants and care outcomes or nurses’ experience remains unclear. Furthermore, there is a dearth of empirical evidence on this topic from low- and middle-income countries.

People with HIV (PHW) are at greater risk of depression than the general population. Insight into the time-to-treatment-response and predictors of response to psychotherapy may improve implementation in primary care. We assessed depression treatment response among 80 participants in a trial of cognitive-behavioral therapy for adherence and depression (CBT-AD) for PWH with MDD and suboptimal antiretroviral therapy (ART) adherence. Participants self-reported depressive symptoms (CES D) at each therapy session. Clinicians assessed participants' depression (HAM D), along with potential predictors of response, every four months for one year. Latent class analyses examined classes of responders for the active and the post-treatment phases. Regression analyses identified predictors of class membership for each phase. During the active treatment phase (CES D) we identified an early response (at session 2 and with continued trajectory of improvement) and a non-response group. There were also two classes during post-treatment (HAM-D): early responders (4-month) and late responders (12-month). Distress aversion was associated with lower likelihood of early response to CBT-AD (aOR = 0.74, 95%CI[0.56–0.90], p =.009), and social support was associated with increased likelihood of early response (aOR = 2.24, 95%CI[1.07–5.46], p =.045). Self-reported depression during the treatment phase may have resulted from social desirability bias. Most participants responded to CBT-AD early during treatment (89 %) and had sustained improvements in depression by 4 months (80 %). Distress aversion was a risk factor for late response, and social support was protective. Future research is needed to assess the optimal dose of CBT-AD in resource limited settings. • Cognitive Behavioural Therapy effectively treats depression and adherence in Persons with HIV. It therefore improves rates of viral suppression, more than treatment as usual. • Early self-reported improvements in depression most likely are the result of being in a trial. Improvement continued to occur throughout the acute treatment phase. • Clinician-rated depression over 4, 8 and 12 months also occurred, with steep improvement seen at 4 months. • Whether or not shorter durations of therapy, delivered by nurses, is effective remains to be explored. [ABSTRACT FROM AUTHOR]

Background: Low- and middle-income countries often lack access to mental health services, leading to calls for integration within other primary care systems. In sub-Saharan Africa, integration of depression treatment in non-communicable disease (NCD) settings is feasible, acceptable, and effective. However, leadership and implementation climate challenges often hinder effective integration and quality of services. The aim of this study was to identify discrete leadership strategies that facilitate overcoming barriers to the integration of depression care in NCD clinics in Malawi and to understand how clinic leadership shapes the implementation climate. Methods: We conducted 39 in-depth interviews with the District Medical Officer, the NCD coordinator, one NCD provider, and the research assistant from each of the ten Malawian NCD clinics (note one District Medical Officer served two clinics). Based on semi-structured interview guides, participants were asked their perspectives on the impact of leadership and implementation climate on overcoming barriers to integrating depression care into existing NCD services. Thematic analysis used both inductive and deductive approaches to identify emerging themes and compare among participant type. Results: The results revealed how engaged leadership can fuel a positive implementation climate where clinics had heightened capacity to overcome implementation barriers. Effective leaders were approachable and engaged in daily operations of the clinic and problem-solving. They held direct involvement with and mentorship during the intervention, providing assistance in patient screening and consultation with treatment plans. Different levels of leadership utilized their respective standings and power dynamics to influence provider attitudes and perceptions surrounding the intervention. Leaders acted by informing providers about the intervention source and educating them on the importance of mental healthcare, as it was often undervalued. Lastly, they prioritized teamwork and collective ownership for the intervention, increasing provider responsibility. Conclusion: Training that prioritizes leadership visibility and open communication will facilitate ongoing Malawi Ministry of Health efforts to scale up evidence-based depression treatment within NCD clinics. This proves useful where extensive and external monitoring may be limited. Ultimately, these results can inform successful strategies to close implementation gaps to achieve integration of mental health services in low-resource settings through improved leadership and implementation climate. Trial registration: These findings are reported from ClinicalTrials.gov, NCT03711786. Registered on 18/10/2018. https://clinicaltrials.gov/ct2/show/NCT03711786. [ABSTRACT FROM AUTHOR]

Background: A 15 million health workforce shortage is still experienced globally leading to a sub-optimal healthcare worker-to-population ratio in most countries. The use of low-skilled care assistants has been suggested as a cost-saving human resource for health strategy that can significantly reduce the risks of rationed, delayed, or missed care. However, the characterisation, role assignment, regulation, and clinical governance mechanisms for unlicensed assistive workforce remain unclear or inconsistent. The purpose of this study was to map and collate evidence of how care assistants are labelled, utilised, regulated, and managed in formal hospital settings as well as their impact on patient care. Methods: We conducted a scoping review of literature from PUBMED, CINAHL, PsychINFO, EMBASE, Web of Science, Scopus, and Google Scholar. Searches and eligibility screening were conducted using the Participants–Context–Concepts framework. Thematic content analysis guided the synthesis of the findings. Results: 73 records from a total of 15 countries were included in the final full-text review and synthesis. A majority (78%) of these sources were from high-income countries. Many titles are used to describe care assistants, and these vary within and across countries. On ascribed roles, care assistants perform direct patient care, housekeeping, clerical and documentation, portering, patient flow management, ordering of laboratory tests, emergency response and first aid duties. Additional extended roles that require higher competency levels exist in the United States, Australia, and Canada. There is a mixture of both positive and negative sentiments on their impact on patient care or nurses' perception and experiences. Clinical and organisational governance mechanisms vary substantially across the 15 countries. Licensure, regulatory mechanisms, and task-shifting policies are largely absent or not reported in these countries. Conclusions: The nomenclature used to describe care assistants and the tasks they perform vary substantially within countries and across healthcare systems. There is, therefore, a need to review and update the international and national classification of occupations for clarity and more meaningful nomenclature for care assistants. In addition, the association between care assistants and care outcomes or nurses' experience remains unclear. Furthermore, there is a dearth of empirical evidence on this topic from low- and middle-income countries. [ABSTRACT FROM AUTHOR]

Background: The mental health impacts of climate change-related disasters are significant. However, access to mental health services is often limited by the availability of trained clinicians. Although building local community capability for the mental health response is often prioritised in policy settings, the lack of evidence-based programs is problematic. The aim of this study was to test the efficacy of the Skills for Life Adjustment and Resilience programme (SOLAR) delivered by trained local community members following compound disasters (drought, wildfires, pandemic-related lockdowns) in Australia. Method: Thirty-six community members were trained to deliver the SOLAR programme, a skills-based, trauma informed, psychosocial programme. Sixty-six people with anxiety, depression and/or posttraumatic stress symptoms, and impairment were randomised into the SOLAR programme or a Self-Help condition. They were assessed pre, post and two months following the interventions. The SOLAR programme was delivered across five 1-hourly sessions (either face to face or virtually). Those in the Self-Help condition received weekly emails with self-help information including links to online educational videos. Results: Multigroup analyses indicated that participants in the SOLAR condition experienced significantly lower levels of anxiety and depression, and PTSD symptom severity between pre – and post-intervention (T1 to T2), relative to the Self-Help condition, while controlling for scores at intake. These differences were not statistically different at follow-up. The SOLAR programme was associated with large effect size improvements in posttraumatic stress symptoms over time. Conclusion: The SOLAR programme was effective in improving anxiety, depression and posttraumatic stress symptoms over time. However, by follow-up the size of the effect was similar to an active self-help condition. Given the ongoing stressors in the community associated with compounding disasters it may be that booster sessions would have been useful to sustain programme impact. Trial registration: Australian New Zealand Clinical Trials Registry identifier: ACTRN12621000283875.. We tested the efficacy of a brief, skills-based psychosocial programme under randomised controlled conditions following compound disasters. The SOLAR programme was associated with improvements in anxiety, depression and posttraumatic stress symptoms across time. The SOLAR programme may benefit from booster sessions especially where there are ongoing impacts of disaster. [ABSTRACT FROM AUTHOR]

Abstract Background A key question in implementation science is how to balance adaptation and fidelity in translating interventions to new settings. There is growing consensus regarding the importance of planned adaptations to deliver interventions in contextually sensitive ways. However, less research has examined ad-hoc adaptations, or those that occur spontaneously in the course of intervention delivery. A key question is whether ad-hoc adaptations ultimately contribute to or detract from intervention goals. This study aimed to (a) identify ad-hoc adaptations made during delivery of a family therapy intervention and (b) assess whether they promoted or interrupted intervention goals. Methods Tuko Pamoja (Swahili: “We are Together”) is an evidence-informed family therapy intervention aiming to improve family dynamics and mental health in Kenya. Tuko Pamoja employs a task-shifting model, delivered by lay counselors who are afforded a degree of flexibility in presenting content and in practices they use in sessions. We used transcripts of therapy sessions with 14 families to examine ad-hoc adaptations used by counselors. We first identified and characterized ad-hoc adaptations through a team-based code development, coding, and code description process. Then, we evaluated to what extent ad-hoc adaptations promoted the principles and strategies of the intervention (“TP-promoting”), disrupted them (“TP-interrupting”), or neither (“TP-neutral”). To do this, we first established inter-coder agreement on application of these categories with verification by the intervention developer. Then, coders categorized ad-hoc adaptation text segments as TP-promoting, TP-interrupting, or TP-neutral. Results Ad-hoc adaptations were frequent and included (in decreasing order): incorporation of religious content, exemplars/role models, community dynamics and resources, self-disclosure, and metaphors/proverbs. Ad-hoc adaptations were largely TP-promoting (49%) or neutral (39%), but practices were TP-interrupting 12% of the time. TP-interrupting practices most often occurred within religious content and exemplars/role models, which were also the most common practices overall. Conclusion Extra attention is needed during planned adaptation, training, and supervision to promote intervention-aligned use of common ad-hoc adaptation practices. Discussing them in trainings can provide guidance for lay providers on how best to incorporate ad-hoc adaptations during delivery. Future research should evaluate whether well-aligned ad-hoc adaptations improve therapeutic outcomes. Trial registration Pilot trial registered at clinicaltrials.gov (C0058)

Abstract Background Children and adolescents who live in resource-limited communities in sub-Saharan Africa (SSA) experience significant mental health problems, including behavioral problems. In SSA, one of the most significant impediments to expanding services is a scarcity of mental health specialists. Task-shifting can effectively solve the mental health care gap in low-resource settings, yet it is underutilized in child and adolescent mental health. Moreover, the experiences of lay providers are understudied in global mental health, despite their potential impact on intervention effectiveness. In this study, we examined the experiences of community health workers and parent peers with the task-shifting of an evidence-based family strengthening intervention in Uganda. Methods As part of a larger randomized clinical trial, semi-structured in-depth interviews were conducted with 24 facilitators selected using stratified purposive sampling. Interviews explored their decision to participate in the program; experiences with the training; and experiences with intervention delivery. All interviews were conducted in Luganda (local language) and audio recorded. They were transcribed verbatim and translated into English. Thematic analysis was used to analyze the data. Results Despite concerns around lack of previous experience and time commitment, facilitators reported high relevance of the intervention to the families in their communities as well as their own as a motivation to participate. They also identified financial incentives as a motivating factor. These two factors also ensured their attendance at the training. They were satisfied with the content and skills provided during the training and felt prepared to deliver the intervention. During intervention delivery, they enjoyed seeing the families engaged and participating actively in the sessions as well as observing positive changes in the families. Some challenges with family attendance and engagement were noted. The facilitators reported an increased sense of self-efficacy and competence over time; and expressed high satisfaction with supervision. Conclusion Facilitators’ positive experiences point to the high acceptability and appropriateness of task-shifting this intervention in low-resource settings. As the global mental health field continues to be interested in task-shifting interventions to lay providers, successful examples should be studied so that evidence-based models can be put in place to support them through the process.

BackgroundThere are increasing initiatives to reduce mental illness stigma among primary care providers (PCPs) being trained in mental health services. However, there is a gap in understanding how stigma reduction initiatives for PCPs produce changes in attitudes and clinical practices. We conducted a pilot randomized controlled trial of a stigma reduction intervention in Nepal: REducing Stigma among HealthcAre Providers (RESHAPE). In a previous analysis of this pilot, we described differences in stigmatizing attitudes and clinical behaviors between PCPs receiving a standard mental health training (mental health Gap Action Program, mhGAP) vs. those receiving an mhGAP plus RESHAPE training. The goal of this analysis is to use qualitative interview data to explain the quantitative differences in stigma outcomes identified between the trial arms.MethodsPCPs were randomized to either standard mental health training using mhGAP led by mental health specialists or the experimental condition (RESHAPE) in which service users living with mental illness shared photographic recovery narratives and participated in facilitated social contact. Qualitative interviews were conducted with PCPs five months post-training (n = 8, standard mhGAP training; n = 20, RESHAPE). Stigmatizing attitudes and clinical practices before and after training were qualitatively explored to identify mechanisms of change.ResultsPCPs in both training arms described changes in knowledge, skills, and confidence in providing mental healthcare. PCPs in both arms described a positive feedback loop, in which discussing mental health with patients encouraged more patients to seek treatment and open up about their illness, which demonstrated for PCPs that mental illness can be treated and boosted their clinical confidence. Importantly, PCPs in the RESHAPE arm were more likely to describe a willingness to treat mental health patients and attributed this in part to social contact with service users during the training.ConclusionsOur qualitative research identified testable mechanisms of action for stigma reduction and improving clinical behavior: specifically, recovery stories from service users and social engagement led to greater willingness to engage with patients about mental illness, triggering a feedback loop of more positive experiences with patients who benefit from mental healthcare, which further reinforces willingness to deliver mental healthcare. Trial registration ClinicalTrials.gov identifier, NCT02793271.

Abstract Background Global chronic health worker shortages and stagnating routine immunization rates require new strategies to increase vaccination coverage and equity. As trained, trusted members of their local communities, community health workers (CHWs) are in a prime position to expand the immunization workforce and increase vaccination coverage in under-reached communities. Malawi is one of only a few countries that relies on CHWs—called Health Surveillance Assistants (HSAs) in Malawi—to administer routine immunizations, and as such offers a unique example of how this can be done. Case presentation We sought to describe the operational and programmatic characteristics of a functional CHW-led routine immunization program by conducting interviews with HSAs, HSA supervisors, ministry of health officials, and community members in Malawi. This case study describes how and where HSAs provide vaccinations, their vaccination-related responsibilities, training and supervision processes, vaccine safety considerations, and the community-level vaccine supply chain. Interview participants consistently described HSAs as a high-functioning vaccination cadre, skilled and dedicated to increasing vaccine access for children. They also noted a need to strengthen some aspects of professional support for HSAs, particularly related to training, supervision, and supply chain processes. Interviewees agreed that other countries should consider following Malawi’s example and use CHWs to administer vaccines, provided they can be sufficiently trained and supported. Conclusions This account from Malawi provides an example of how a CHW-led vaccination program operates. Leveraging CHWs as vaccinators is a promising yet under-explored task-shifting approach that shows potential to help countries maximize their health workforce, increase vaccination coverage and reach more zero-dose children. However, more research is needed to produce evidence on the impact of leveraging CHWs as vaccinators on patient safety, immunization coverage/vaccine equity, and cost-effectiveness as compared to use of other cadres for routine immunization.

This study describes an alternative to face-to-face training method for community health volunteers (CHVs) as used by a collaborative group from the University of Nairobi, University of Washington and the Nairobi Metropolitan Mental Health Team during the COVID-19 lockdown in Kenya. This qualitative study describes the experiences of 17 CHVs enrolled in a training study, required to utilize different digital platforms (Google Meet or Jitsi) as a training forum for the first time. Verbatim extracts of the participants’ daily experiences are extracted from a series of write-ups in the group WhatsApp just before the training. Daily failures and success experiences in joining a Google meet or Jitsi are recorded. Then, 17 participants, 10 women and 7 men, aged between 21 and 51 years (mean = 33), owning a smartphone, were enrolled in the study. None had used Jitsi or Google meet before. Different challenges were reported in login to either and a final decision to use Jitsi, which became the training platform. Training CHVs to deliver a psychosocial intervention using smartphones is possible. However, the trainer must establish appropriate and affordable methods when resources are constrained.

BackgroundWith a neonatal mortality rate of 33 per 1,000 live births in 2019, Ethiopia is striving to attain the Sustainable Development Goal target of 12 deaths per 1,000 live births by 2030. A better understanding of the major causes of neonatal mortality is needed to effectively design and implement interventions to achieve this goal. Minimally Invasive Tissue Sampling (MITS), an alternative to conventional autopsy, requires fewer resources and through task-shifting of sample collection from pathologists to nurses, has the potential to support the expansion of pathology-based post-mortem examination and improve mortality data. This paper evaluates the accuracy and adequacy of MITS performed by nurses at a tertiary and general hospital and in the home of the deceased.MethodsNurses in a tertiary and general hospital in Ethiopia were trained in MITS sample collection on neonatal deaths and stillbirths using standardized protocols. MITS sample collection was performed by both pathologists and nurses in the tertiary hospital and by nurses in the general hospital and home-setting. Agreement in the performance of MITS between pathologists and nurses was calculated for samples collected at the tertiary hospital. Samples collected by nurses in the general hospital and home-setting were evaluated for technical adequacy using preestablished criteria.ResultsOne hundred thirty-nine MITS were done: 125 in hospitals and 14 inside homes. There was a perfect or almost perfect agreement between the pathologists and the nurses in the tertiary hospital using Gwet's agreement interpretation criteria. The adequacy of MITS samples collected by nurses in the general hospital was more than 72% when compared to the preset criteria. The adequacy of the MITS sampling yield ranged from 87% to 91% on liveborn neonatal deaths and 76% for the liver, right and left lungs and 55% for brain tissues in stillbirths.ConclusionsThis study demonstrated that task-shifting MITS sample collection to nurses can be achieved with comparable accuracy and adequacy as pathologists. Our study showed that with standardized training and supportive supervision MITS sample collection can be conducted by nurses in a tertiary, general hospital and, at the home of the deceased. Future studies should validate and expand on this work by evaluating task-shifting of MITS sample collection to nurses within community settings and with larger sample sizes.

ABSTRACTBackground: The mental health impacts of climate change-related disasters are significant. However, access to mental health services is often limited by the availability of trained clinicians. Although building local community capability for the mental health response is often prioritised in policy settings, the lack of evidence-based programs is problematic. The aim of this study was to test the efficacy of the Skills for Life Adjustment and Resilience programme (SOLAR) delivered by trained local community members following compound disasters (drought, wildfires, pandemic-related lockdowns) in Australia.Method: Thirty-six community members were trained to deliver the SOLAR programme, a skills-based, trauma informed, psychosocial programme. Sixty-six people with anxiety, depression and/or posttraumatic stress symptoms, and impairment were randomised into the SOLAR programme or a Self-Help condition. They were assessed pre, post and two months following the interventions. The SOLAR programme was delivered across five 1-hourly sessions (either face to face or virtually). Those in the Self-Help condition received weekly emails with self-help information including links to online educational videos.Results: Multigroup analyses indicated that participants in the SOLAR condition experienced significantly lower levels of anxiety and depression, and PTSD symptom severity between pre – and post-intervention (T1 to T2), relative to the Self-Help condition, while controlling for scores at intake. These differences were not statistically different at follow-up. The SOLAR programme was associated with large effect size improvements in posttraumatic stress symptoms over time.Conclusion: The SOLAR programme was effective in improving anxiety, depression and posttraumatic stress symptoms over time. However, by follow-up the size of the effect was similar to an active self-help condition. Given the ongoing stressors in the community associated with compounding disasters it may be that booster sessions would have been useful to sustain programme impact.Trial registration: Australian New Zealand Clinical Trials Registry identifier: ACTRN12621000283875..

Background: Ensuring access to quality family planning (FP) services is fundamental to achieving the Sustainable Development Goals (SDG) targets 3.1, 3.7, and 5.6, including universal access to reproductive health services. However, barriers such as health workforce shortages and restrictive policies on the role of mid and lower-level health workforce cadres limit access to contraceptives and FP in many settings. Workforce reorganization makes more efficient use of human resources. Consequently, the World Health Organization (WHO) recommends task-sharing for FP by different cadres. Evidence on the implementation strategies, facilitators, and barriers to scaling up and sustaining task-sharing could inform financing, implementation approaches, and technical assistance of national and global FP task-sharing programs. Therefore, this study aims to describe and assess the quality of the evidence on implementation strategies, facilitators, and barriers to scaling up and sustaining task-sharing in FP and the outcome of the scale-up/sustainability interventions. Methods: This systematic review protocol was developed using relevant guidelines, including the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Protocols (PRISMA-P). A search of five databases, namely CINAHL (EBSCOhost), EMBASE (OvidSP), Global Health (OvidSP), MEDLINE (OvidSP), and Scopus (www.scopus.com), and gray literature resources will be conducted. Two independent reviewers will screen and select studies, assess their quality using the "Mixed Methods Appraisal Tool," and extract data from eligible studies. Publications or articles are eligible if they report implementation strategies, facilitators, or barriers to scaling up/sustainability of task-sharing in FP/contraception or the outcomes of the scale-up/sustainability interventions. A convergent synthesis that integrates qualitative, quantitative, descriptive, and mixed-methods data into one dataset will be used for analysis based on an a priori framework—the Cochrane Effective Practice and Organization of Care (EPOC) taxonomy of the health system framework. Two independent reviewers will assess the quality of evidence using the GRADE-CERQual guideline. Discussion: To our knowledge, this systematic review of implementation strategies, facilitators, and barriers to scaling up and sustaining task-sharing in family planning is the first in this area. Our rigorous methodology based on up-to-date guidelines can help generate relevant recommendations to support interventions to scale up and sustain task-sharing in family planning. Systematic review registration: PROSPERO CRD42022339885. [ABSTRACT FROM AUTHOR]

The global shortage of skilled anaesthesiologists, surgeons and obstetricians is a leading cause of high unmet surgical need. Although anaesthetic and surgical task-shifting are widely practised to mitigate this barrier, little is known about their safety and efficacy. This systematic review seeks to highlight the existing evidence on the clinical outcomes of patients operated on by non-physicians or non-specialist physicians globally. Relevant articles were identified by searching four databases (MEDLINE, EMBASE, CINAHL and Global Health) in all languages between January 2008 and February 2022. Retrieved documents were screened against pre-specified inclusion and exclusion criteria, and their qualities were appraised critically. Data were extracted by two independent reviewers and findings were synthesized narratively. In total, 40 studies have been included. Thirty-five focus on task-shifting for surgical and obstetric procedures, whereas four studies address anaesthetic task-shifting; one study covers both interventions. The majority are located in sub-Saharan Africa and the USA. Seventy-five per cent present perioperative mortality outcomes and 85% analyse morbidity measures. Evidence from low- and middle-income countries, which primarily concentrates on caesarean sections, hernia repairs and surgical male circumcisions, points to the overall safety of non-surgeons. On the other hand, the literature on surgical task-shifting in high-income countries (HICs) is limited to nine studies analysing tube thoracostomies, neurosurgical procedures, caesarean sections, male circumcisions and basal cell carcinoma excisions. Finally, only five studies pertaining to anaesthetic task-shifting across all country settings answer the research question with conflicting results, making it difficult to draw conclusions on the quality of non-physician anaesthetic care. Overall, it appears that non-specialists can safely perform high-volume, low-complexity operations. Further research is needed to understand the implications of surgical task-shifting in HICs and to better assess the performance of non-specialist anaesthesia providers. Future studies must adopt randomized study designs and include long-term outcome measures to generate high-quality evidence. [ABSTRACT FROM AUTHOR]

This pilot study integrated quantitative and qualitative data to examine the feasibility of implementing a modified version of a multiple family group behavioral parent training intervention (The 4Rs and 2Ss for Strengthening Families Program [4Rs and 2Ss]) in child welfare (CW) placement prevention services from the perspectives of participating caregivers (n = 12) and CW staff (n = 12; i.e., 6 caseworkers, 4 supervisors, and 2 administrators). Quantitative surveys were administered to caregivers and CW staff followed by semi-structured interviews to examine the feasibility of implementing the modified 4Rs and 2Ss program as well as factors impacting feasibility. Results indicated that quantitative benchmarks for high feasibility were met in all assessed areas (e.g., family recruitment, caseworker fidelity ratings, CW staff feasibility ratings) except for family attendance, which was markedly lower than desired. Factors facilitating feasibility included agency and research support, intervention ease-of-use, perceived benefits to existing CW practice, and logistical support (e.g., food, transportation, child care) promoting attendance. Factors hindering feasibility included conflicts between research-based eligibility criteria and existing client population demographics, research-related processes resulting in delays, CW staff role conflicts, added workload burden, complex family issues, and power differentials inherent to CW services which complicated families' voluntary participation. [ABSTRACT FROM AUTHOR]

Youth suicide is increasing in the United States, with deaths among younger people of color driving this upward trend. For more than four decades, American Indian and Alaska Native (AIAN) communities have suffered disproportionate rates of youth suicide and years of productive life lost compared to other U.S. Races. The National Institute of Mental Health (NIMH) recently funded three regional Collaborative Hubs to carry out suicide prevention research, practice, and policy development with AIAN communities in Alaska and rural and urban areas of the Southwestern United States. The Hub partnerships are supporting a diverse array of tribally-driven studies, approaches, and policies with immediate value for increasing empirically driven public health strategies to address youth suicide. We discuss unique features of the cross-Hub work, including: (a) long-standing Community-Based Participatory Research processes that led to the Hubs' innovative designs and novel approaches to suicide prevention and evaluation, (b) comprehensive ecological theoretical approaches that contextualize individual risk and protective factors in multilevel social contexts; (c) unique task-shifting and systems of care approaches to increase reach and impact on youth suicide in low-resource settings; and (d) prioritization of strengths-based approaches. The work of the Collaborative Hubs for AIAN youth suicide prevention is generating specific and substantive implications for practice, policy, and research presented in this article at a time when youth suicide prevention is a dire national priority. Approaches also have relevance for historically marginalized communities worldwide. [ABSTRACT FROM AUTHOR]

The supply of school mental health (SMH) providers and services cannot meet the demand of students in-need, and this gap is expected to widen in coming years. One way to increase the reach of helpful services for youth is to grow the SMH workforce through task-shifting to paraprofessionals. Task-shifting could be especially promising in expanding Motivational Interviewing (MI) interventions, as MI can be molded to target a number of academic and behavioral outcomes important to schools. However, no review of training exclusively paraprofessional samples in MI has yet been conducted. The current paper provides a scoping review of 19 studies of training paraprofessional providers to use MI to evaluate trainee characteristics, training content and format, and outcomes. Of these 19 studies, 15 reported that paraprofessionals improved in using MI following training. Nine studies reported that task-shifting MI was positively received by clients and/or providers. Six studies examined task-shifting MI in youth-serving contexts, and four examined the practice in traditional school contexts, suggesting its potential for use in SMH. Other findings and implications, such as client behavior change and provider fidelity, are shared, along with ideas for advancing research, practice, and policy in this subfield. [ABSTRACT FROM AUTHOR]

Background: Children and adolescents who live in resource-limited communities in sub-Saharan Africa (SSA) experience significant mental health problems, including behavioral problems. In SSA, one of the most significant impediments to expanding services is a scarcity of mental health specialists. Task-shifting can effectively solve the mental health care gap in low-resource settings, yet it is underutilized in child and adolescent mental health. Moreover, the experiences of lay providers are understudied in global mental health, despite their potential impact on intervention effectiveness. In this study, we examined the experiences of community health workers and parent peers with the task-shifting of an evidence-based family strengthening intervention in Uganda. Methods: As part of a larger randomized clinical trial, semi-structured in-depth interviews were conducted with 24 facilitators selected using stratified purposive sampling. Interviews explored their decision to participate in the program; experiences with the training; and experiences with intervention delivery. All interviews were conducted in Luganda (local language) and audio recorded. They were transcribed verbatim and translated into English. Thematic analysis was used to analyze the data. Results: Despite concerns around lack of previous experience and time commitment, facilitators reported high relevance of the intervention to the families in their communities as well as their own as a motivation to participate. They also identified financial incentives as a motivating factor. These two factors also ensured their attendance at the training. They were satisfied with the content and skills provided during the training and felt prepared to deliver the intervention. During intervention delivery, they enjoyed seeing the families engaged and participating actively in the sessions as well as observing positive changes in the families. Some challenges with family attendance and engagement were noted. The facilitators reported an increased sense of self-efficacy and competence over time; and expressed high satisfaction with supervision. Conclusion: Facilitators' positive experiences point to the high acceptability and appropriateness of task-shifting this intervention in low-resource settings. As the global mental health field continues to be interested in task-shifting interventions to lay providers, successful examples should be studied so that evidence-based models can be put in place to support them through the process. [ABSTRACT FROM AUTHOR]

Background: Suicide is a leading cause of death among people living with HIV (PLWH) worldwide, with suicide deaths occurring twice as frequently among PLWH than among the general public. In Tanzania, resources for mental health care are sorely lacking, with 55 psychiatrists and psychologists providing treatment for 60 million people. In light of this shortage, nonspecialists play a crucial role. The objective of this study was to assess feasibility of implementing task-shifted screening, assessment, and safety planning for suicide risk among PLWH. Setting: Two adult HIV clinics in Kilimanjaro, Tanzania. Methods: Registered professional nurses in the HIV clinics were trained to administer brief screening of suicidal ideation in the past month. Patients experiencing suicidal ideation were referred to bachelor's-level counselors for further assessment and safety planning, supervised by specialist providers who reviewed audio recordings for quality assurance. Results: During 180 days of implementation, nurses screened patients attending 2745 HIV appointments. Sixty-one (2.2%) endorsed suicidal ideation and were linked to further assessment and safety planning. We cross-checked screening with clinic attendance logs on 7 random days and found high fidelity to screening (206 of 228 screened, 90%). Quality assurance ratings demonstrated key assessment pieces were consistently completed (mean = 9.3/10 possible), with "Good" to "Excellent" counseling skills (mean = 23.7/28) and "Good" to "Excellent" quality (mean = 17.1/20), including appropriate referral for higher levels of care. Conclusions: Brief screening can be implemented and paired with task-shifted counseling to facilitate high-quality assessment of suicide risk. This model shows excellent potential to extend mental health services for PLWH in low-resource settings. [ABSTRACT FROM AUTHOR]

Abstract Background Anti-vascular endothelial growth factor is a medicine administered intravitreally by an injection to maintain visual acuity in patients with a variety of retinal diseases. The demand for this treatment has grown considerably in the westernized world the last two decades and will continue to increase due to an aging population. Because of the high volume, injections seize enormous resources and represent high costs for both hospitals and society. Task-shifting of injections from physicians to nurses may be a means to reduce such costs, however the magnitude of possible savings has been poorly investigated. To this end we investigated changes in the hospital costs per injection, six-year cost projections of physician- versus nurse-administered injections for a Norwegian tertiary hospital and we compared the societal costs per patient per year. Methods Patients (n = 318) were randomized to either physician- or nurse administered injections, and data were prospectively collected. Hospital costs per injection were calculated as the sum of training costs, personnel time and running expenses. The number of injections for the years 2014 – 21 from a Norwegian tertiary hospital was combined with age group specific injection prevalence and population projections to calculate cost projections for 2022 – 27. Societal costs per patient were calculated as the sum of hospital costs, transport costs for patients, caregivers’ use of time, costs of ophthalmology consultations and community-based homecare. Results The hospital costs per injection were 5.5 € higher for physicians compared to nurses (281.6 € versus 276.1 €). Cost projections estimated an annual hospital saving of task-shifting of 48 921 € for 2022 – 27. Societal costs per patient did not differ significantly between the two groups (mean 4988 € vs 5418 €, p = 0.398). Conclusion Task-shifting of injections from physicians to nurses can reduce hospital costs and increase the flexibility of physician resources. The annual savings are modest, but increased demand for injections might increase future cost savings. To achieve future savings for society, organizing ophthalmology consultations and injections on the same day to reduce the number of visits might be a solution. Trial registration ClinicalTrials.gov NCT02359149 (09/02/2015).

Hypertension is a leading cause of mortality globally and one of the most common risk factors for cardiovascular disease. Diagnosis, awareness, and optimal treatment rates are suboptimal, especially in low- and middle-income countries, with attendant high health consequences and grave socioeconomic impact. There is an enormous gap between disease burden and physician-patient ratios that needs to be bridged. Task sharing and task shifting (TSTS) provide a viable temporary solution. However, sociocultural, demographic, and economic factors influence the effective uptake of such interventions. This review discusses the dynamics of TSTS in the African context looking at challenges, feasibility, and approach to adopt it in the management of hypertension in Africa.

Background: A key question in implementation science is how to balance adaptation and fidelity in translating interventions to new settings. There is growing consensus regarding the importance of planned adaptations to deliver interventions in contextually sensitive ways. However, less research has examined ad-hoc adaptations, or those that occur spontaneously in the course of intervention delivery. A key question is whether ad-hoc adaptations ultimately contribute to or detract from intervention goals. This study aimed to (a) identify ad-hoc adaptations made during delivery of a family therapy intervention and (b) assess whether they promoted or interrupted intervention goals. Methods: Tuko Pamoja (Swahili: "We are Together") is an evidence-informed family therapy intervention aiming to improve family dynamics and mental health in Kenya. Tuko Pamoja employs a task-shifting model, delivered by lay counselors who are afforded a degree of flexibility in presenting content and in practices they use in sessions. We used transcripts of therapy sessions with 14 families to examine ad-hoc adaptations used by counselors. We first identified and characterized ad-hoc adaptations through a team-based code development, coding, and code description process. Then, we evaluated to what extent ad-hoc adaptations promoted the principles and strategies of the intervention ("TP-promoting"), disrupted them ("TP-interrupting"), or neither ("TP-neutral"). To do this, we first established inter-coder agreement on application of these categories with verification by the intervention developer. Then, coders categorized ad-hoc adaptation text segments as TP-promoting, TP-interrupting, or TP-neutral. Results: Ad-hoc adaptations were frequent and included (in decreasing order): incorporation of religious content, exemplars/role models, community dynamics and resources, self-disclosure, and metaphors/proverbs. Ad-hoc adaptations were largely TP-promoting (49%) or neutral (39%), but practices were TP-interrupting 12% of the time. TP-interrupting practices most often occurred within religious content and exemplars/role models, which were also the most common practices overall. Conclusion: Extra attention is needed during planned adaptation, training, and supervision to promote intervention-aligned use of common ad-hoc adaptation practices. Discussing them in trainings can provide guidance for lay providers on how best to incorporate ad-hoc adaptations during delivery. Future research should evaluate whether well-aligned ad-hoc adaptations improve therapeutic outcomes. Trial registration: Pilot trial registered at clinicaltrials.gov (C0058) [ABSTRACT FROM AUTHOR]

Task-shifting is a valuable approach for redistributing clinical tasks to nonprofessional health workers and relieving human resource shortages. The Community-Based HIV Services (CBHS) program is a national cohort of volunteer community health workers (CHWs) who support HIV care engagement at clinics in Tanzania. We recruited 23 patients initiating HIV care at two clinics to understand their experiences with the CBHS program. Participants completed qualitative interviews by telephone discussing the perceived helpfulness of the program, their level of connection with CHWs, and suggestions for improvement. Data were analyzed through an inductive, team-based qualitative approach. Most participants found the program to be helpful and described close, positive connections. CHWs offered education, emotional support to accept one's diagnosis and cope with stigma, and encouragement to remain engaged in HIV care. However, several participants described minimal, shallow contact with CHWs, and felt the program did not benefit their HIV care. Participants recommended increasing CHW efforts to engage people living with HIV (PLWH) in the broader community, and addressing socioeconomic barriers to care engagement. When contacts are consistent, the CBHS program is a strong resource for PLWH. To maximize the potential of the program, administrators should enhance oversight and extend new training opportunities for CHWs. [ABSTRACT FROM AUTHOR]

Background: The greatest mortality and disability from stroke occurs in low- and middle-income countries. A significant barrier to implementation of best stroke care practices in these settings is limited availability of specialized healthcare training. We conducted a systematic review to determine the most effective methods for the provision of speciality stroke care education for hospital-based healthcare professionals in low-resource settings. Methods: We followed the PRISMA guidelines for systematic reviews and searched PubMed, Web of Science and Scopus for original clinical research articles that described or evaluated stroke care education for hospital-based healthcare professionals in low-resource settings. Two reviewers screened titles/abstracts and then full text articles. Three reviewers critically appraised the articles selected for inclusion. Results: A total of 1,182 articles were identified and eight were eligible for inclusion in this review; three were randomized controlled trials, four were non-randomized studies, and one was a descriptive study. Most studies used several approaches to education. A "train-the-trainer" approach to education was found to have the most positive clinical outcomes (lower overall complications, lengths of stay in hospital, and clinical vascular events). When used for quality improvement, the "train-the-trainer" approach increased patient reception of eligible performance measures. When technology was used to provide stroke education there was an increased frequency in diagnosis of stroke and use of antithrombotic treatment, reduced door-to-needle times, and increased support for decision making in medication prescription was reported. Task-shifting workshops for non-neurologists improved knowledge of stroke and patient care. Multidimensional education demonstrated an overall care quality improvement and increased prescriptions for evidence-based therapies, although, there were no significant differences in secondary prevention efforts, stroke reoccurrence or mortality rates. Conclusions: The "train the trainer" approach is likely the most effective strategy for specialist stroke education, while technology is also useful if resources are available to support its development and use. If resources are limited, basic knowledge education should be considered at a minimum and multidimensional training may not be as beneficial. Research into communities of practice, led by those in similar settings, may be helpful to develop educational initiatives with relevance to local contexts. [ABSTRACT FROM AUTHOR]

In response to the global call to upscale mental health services in low--income countries, mental health non-governmental organisations (MHNGOs) have sprung up in Kerala to address mental health needs by partnering with pre-existing locally grown, bottom-up, community-led pain and palliative clinics (PPCs) to increase access to mental health care through task-shifting. The MHNGOs mandate filtering only patients with 'severe mental disorders' from low socioeconomic backgrounds for their free services. This eligibility criterion mandated by the MHNGO is ruffling feathers within the palliative clinics that oppose such -classifications. They believe that suffering cuts across all divisions and should not be discriminated against based on economic background and severity of illnesses. When chronicity and suffering are held universal by the MHNGO and palliative care, respectively, it brings to the fore the enactment of two perspectives of care. Drawing on observations of clinical interactions between patients, MHNGO staff and mental health professionals and interviews with community volunteers of palliative care clinics in Kerala, this paper demonstrates how chronicity narrative promoted by MHNGOs based on biopsychiatric model gains hegemony, whereas the community care model loses traction progressively. The state, caught between these two narratives, frontstages development by submitting its health machinery to the MHNGOs flouting basic medical safety laws in its services to marginalised people like the tribal population. This paper argues that the rising dominance of chronicity narrative in community mental health clinics as well as in popular media discourses evolves out of power relations between the MHNGOs and the palliative clinics. [ABSTRACT FROM AUTHOR]

We examined whether patients' satisfaction improved when patients' preoperative consultations were conducted with perianesthesia nurses (PANs) in collaboration with anesthesiologists, as compared with preoperative consultations conducted by anesthesiologists only. We conducted a study using questionnaires regarding outpatient satisfaction among patients who visited the perioperative management department of Yokohama City University Medical Center between July and December 2018. There were 1,595 outpatients during the survey period. After exclusion criteria were applied, we analyzed 590 valid responses. Regarding the level of understanding, 96.9% of the patients in the nurse-and-anesthesiologist group and 95.6% of the patients in the anesthesiologist-only group answered, "easy to understand," indicating no significant difference. A reduction in concerns, worries, and anxiety was reported by 86.3% of the patients in the nurse-and-anesthesiologist group and 70.4% in the anesthesiologist-only group, indicating a significant difference. Furthermore, 94.1% of the patients in the nurse-and-anesthesiologist group and 87.9% in the anesthesiologist-only group indicated patients' satisfaction with the overall evaluation, indicating another significant difference. A multiple logistic regression analysis was conducted to analyze the anxiety reduction and overall evaluation. We uncovered significant differences in PANs' examinations regarding anxiety reduction and overall evaluation. Collaboration between anesthesiologists and PANs might be associated with satisfaction and reduced anxiety in preoperative patients without adversely affecting patients' comprehension of anesthesia. Further research is necessary to verify the impacts of PANs' involvement in anesthesia patient care on intra and postoperative patient outcomes and on the cost and efficiency of anesthetic care. [ABSTRACT FROM AUTHOR]

Background: Global chronic health worker shortages and stagnating routine immunization rates require new strategies to increase vaccination coverage and equity. As trained, trusted members of their local communities, community health workers (CHWs) are in a prime position to expand the immunization workforce and increase vaccination coverage in under-reached communities. Malawi is one of only a few countries that relies on CHWs—called Health Surveillance Assistants (HSAs) in Malawi—to administer routine immunizations, and as such offers a unique example of how this can be done. Case presentation: We sought to describe the operational and programmatic characteristics of a functional CHW-led routine immunization program by conducting interviews with HSAs, HSA supervisors, ministry of health officials, and community members in Malawi. This case study describes how and where HSAs provide vaccinations, their vaccination-related responsibilities, training and supervision processes, vaccine safety considerations, and the community-level vaccine supply chain. Interview participants consistently described HSAs as a high-functioning vaccination cadre, skilled and dedicated to increasing vaccine access for children. They also noted a need to strengthen some aspects of professional support for HSAs, particularly related to training, supervision, and supply chain processes. Interviewees agreed that other countries should consider following Malawi's example and use CHWs to administer vaccines, provided they can be sufficiently trained and supported. Conclusions: This account from Malawi provides an example of how a CHW-led vaccination program operates. Leveraging CHWs as vaccinators is a promising yet under-explored task-shifting approach that shows potential to help countries maximize their health workforce, increase vaccination coverage and reach more zero-dose children. However, more research is needed to produce evidence on the impact of leveraging CHWs as vaccinators on patient safety, immunization coverage/vaccine equity, and cost-effectiveness as compared to use of other cadres for routine immunization. [ABSTRACT FROM AUTHOR]

Background: Refugees are at an increased risk of developing symptoms of mental disorders but face various structural and socio-cultural barriers to accessing mental health care. The SPIRIT project (Scaling-up Psychological Interventions in Refugees In SwiTzerland) seeks to promote the resilience of refugees and improve their access to mental health care. For this purpose, Problem Management Plus (PM+), an evidence-based low-intensity psychological intervention delivered by trained non-specialist "helpers", is being scaled-up in Switzerland. Objective: To identify factors influencing the process of the large-scale implementation of PM + for refugees in Switzerland and to develop recommendations to guide the implementation process. Methods: 22 semi-structured interviews were conducted with key informants (Syrian refugees who previously participated in PM+, PM + helpers, health professionals working with refugees and decision-makers from the migration, integration, social, and health sectors). The data were analyzed using thematic analysis, combining an inductive and deductive approach. Results: The data revealed three major themes, which might have an impact for the longer-term implementation of PM + in Switzerland. First, preconditions for successful integration in the health system prior to scaling-up such as sustainable funding or the introduction of a stepped care approach. Second, the requirements for the PM + intervention supporting scale-up such as quality control during PM + delivery, PM + modality, time and setting when PM + is offered or the views on task sharing. Third, the perceived benefits of scaling-up PM + in Switzerland. Conclusions: Our results have shown that PM + must be scaled-up within a stepped care approach, including a functioning triage system and sustainable funding. Rather than selecting one modality or setting, it seemed preferable to offer a variety of formats and settings to achieve maximum reach and benefits. A successful scale-up of PM + in Switzerland might have various benefits. Communicating them to policy-makers and health providers, might enhance their acceptability of the intervention and their willingness to adopt PM + in regulatory structure and promote it. [ABSTRACT FROM AUTHOR]

Mental healthcare is largely unavailable throughout Haiti, particularly in rural areas. The aim of the current study is to explore perceived feasibility, acceptability, and effectiveness of potential culturally adapted interventions to improve mental health among Haitian women. The study used focus group discussions (n = 12) to explore five potential interventions to promote mental health: individual counseling, income-generating skills training, peer support groups, reproductive health education, and couples' communication training. Findings indicate that individual counseling, support group, and skills training components were generally anticipated to be effective, acceptable, and feasible by both male and female participants. That being said, participants expressed doubts regarding the acceptability of the couples' communication training and reproductive health education due to: a perceived lack of male interest, traditional male and female gender roles, lack of female autonomy, and misconceptions about family planning. Additionally, the feasibility, effectiveness, and acceptability of the components were described as dependent on cost, proximity to participants, and inclusion of a female health promoter that is known in the community. Given the lack of research on intervention approaches in Haiti, particularly those targeting mental health, this study provides a foundation for developing prevention and treatment approaches for mental distress among Haitian women.

Abstract Background Perinatal depression (PND) is prevalent and negatively impacts HIV care among women living with HIV (WLHIV), yet PND remains under-identified in Malawian WLHIV. Accordingly, this formative study explored perceptions of the feasibility and acceptability of an integrated, task-shifted approach to PND screening and treatment in maternity clinics. Methods We completed consecutive PND screenings of HIV+ women attending pre- or post-natal appointments at 5 clinics in Lilongwe district, Malawi. We conducted in-depth interviews with the first 4-5 women presenting with PND per site (n = 24 total) from July to August 2018. PND classification was based on a score ≥ 10 on the Edinburgh Postnatal Depression Scale (EPDS). We conducted 10 additional in-depth interviews with HIV and mental health providers at the 5 clinics. Results Most participants endorsed the feasibility of integrated PND screening, as they believed that PND had potential for significant morbidity. Among providers, identified barriers to screening were negative staff attitudes toward additional work, inadequate staffing numbers and time constraints. Suggested solutions to barriers were health worker training, supervision, and a brief screening tool. Patient-centered counselling strategies were favored over medication by WLHIV as the acceptable treatment of choice, with providers supporting the role of medication to be restricted to severe depression. Providers identified nurses as the most suitable health workers to deliver task-shifted interventions and emphasized further training as a requirement to ensure successful task shifting. Conclusion Improving PND in a simple, task-shifted intervention is essential for supporting mental health among women with PND and HIV. Our results suggest that an effective PND intervention for this population should include a brief, streamlined PND screening questionnaire and individualized counselling for those who have PND, with supplemental support groups and depression medication readily available. These study results support the development of a PND intervention to address the gap in treatment of PND and HIV among WLHIV in Malawi.

Abstract Background The acceptability of teachers delivering task-shifted mental health care to their school-aged students is understudied. Here, we evaluate teachers’, students’, and caregivers’ acceptability of Tealeaf (Teachers Leading the Frontlines), an alternative system of care in which teachers are trained and supervised to deliver transdiagnostic, non-manualized task-shifted care to their students. Methods In a 2019 single-arm, mixed methods, pragmatic acceptability pilot study in Darjeeling, India, 13 teachers delivered task-shifted child mental health care to 26 students in need. Teachers delivered care through using a transdiagnostic, non-manualized therapy modality, “education as mental health therapy” (Ed-MH). Measured with validated scales, teachers’ and students’ acceptability were compared after teacher training (PRE) and at the end of intervention (POST) using paired t tests. Teachers (n = 7), students (n = 7), and caregivers (n = 7) completed semi-structured interviews POST. Results Teachers’ quantitative measures indicated moderate acceptability PRE and POST and did not change PRE to POST. Children’s measures showed acceptability PRE and POST but decreased PRE to POST. Teachers and caregivers universally expressed acceptability in interviews. Facilitators of acceptability included impact, trust of teachers, and teachers’ ability to make adaptations. Conditions required for acceptability included supervision and teachers emphasizing academics benefits over mental health benefits to caregivers. Barriers to acceptability included a lack of teacher time and stigma. Interviewed students universally were unaware of receiving care; teachers intentionally avoided singling them out. Conclusion Teachers, caregivers, and children found teacher delivering task-shifted care acceptable, a key factor in care adoption and sustainability, though interviewed children were unaware of receiving care. Trial registration The trial was registered on January 01, 2018 with Clinical Trials Registry—India (CTRI), Reg. No. CTRI/2018/01/011471, Ref. No. REF/2017/11/015895. http://ctri.nic.in/Clinicaltrials/pdf_generate.php?trialid=21129&EncHid=&modid=&compid=%27,%2721129det%27

Abstract Background Hypertension is the most common cardiovascular disease in Nigeria and contributes to a large non-communicable disease burden. Our aim was to implement and evaluate a large-scale hypertension treatment and control program, adapted from the Kaiser Permanent Northern California and World Health Organization HEARTS models, within public primary healthcare centers in the Federal Capital Territory, Nigeria. Methods A type 2 hybrid, interrupted time series design was used to generate novel information on large-scale implementation and effectiveness of a multi-level hypertension control program within 60 primary healthcare centers in the Federal Capital Territory, Nigeria. During the formative phase, baseline qualitative assessments were held with patients, health workers, and administrators to inform implementation package adaptation. The package includes a hypertension patient registry with empanelment, performance and quality reporting, simplified treatment guideline emphasizing fixed-dose combination therapy, reliable access to quality essential medicines and technology, team-based care, and health coaching and home blood pressure monitoring. Strategies to implement and adapt the package were identified based on barriers and facilitators mapped in the formative phase, previous implementation experience, mid-term qualitative evaluation, and ongoing stakeholder and site feedback. The control phase included 11 months of sequential registration of hypertensive patients at participating primary healthcare centers, followed by implementation of the remainder of the package components and evaluation over 37 subsequent, consecutive months of the intervention phase. The formative phase was completed between April 2019 and August 2019, followed by initiation of the control phase in January 2020. The control phase included 11 months (January 2020 to November 2020) of sequential registration and empanelment of hypertensive patients at participating primary healthcare centers. After completion of the control phase in November 2020, the intervention phase commenced in December 2020 and will be completed in December 2023. Discussion This trial will provide robust evidence for implementation and effectiveness of a multi-level implementation package more broadly throughout the Federal Capital Territory, which may inform hypertension systems of care throughout Nigeria and in other low- and middle-income countries. Implementation outcome results will be important to understand what system-, site-, personnel-, and patient-level factors are necessary for successful implementation of this intervention. Trial registration ClinicalTrials.gov NCT04158154 . The trial was prospectively registered on November 8, 2019.

Abstract Background There are increasing initiatives to reduce mental illness stigma among primary care providers (PCPs) being trained in mental health services. However, there is a gap in understanding how stigma reduction initiatives for PCPs produce changes in attitudes and clinical practices. We conducted a pilot randomized controlled trial of a stigma reduction intervention in Nepal: REducing Stigma among HealthcAre Providers (RESHAPE). In a previous analysis of this pilot, we described differences in stigmatizing attitudes and clinical behaviors between PCPs receiving a standard mental health training (mental health Gap Action Program, mhGAP) vs. those receiving an mhGAP plus RESHAPE training. The goal of this analysis is to use qualitative interview data to explain the quantitative differences in stigma outcomes identified between the trial arms. Methods PCPs were randomized to either standard mental health training using mhGAP led by mental health specialists or the experimental condition (RESHAPE) in which service users living with mental illness shared photographic recovery narratives and participated in facilitated social contact. Qualitative interviews were conducted with PCPs five months post-training (n = 8, standard mhGAP training; n = 20, RESHAPE). Stigmatizing attitudes and clinical practices before and after training were qualitatively explored to identify mechanisms of change. Results PCPs in both training arms described changes in knowledge, skills, and confidence in providing mental healthcare. PCPs in both arms described a positive feedback loop, in which discussing mental health with patients encouraged more patients to seek treatment and open up about their illness, which demonstrated for PCPs that mental illness can be treated and boosted their clinical confidence. Importantly, PCPs in the RESHAPE arm were more likely to describe a willingness to treat mental health patients and attributed this in part to social contact with service users during the training. Conclusions Our qualitative research identified testable mechanisms of action for stigma reduction and improving clinical behavior: specifically, recovery stories from service users and social engagement led to greater willingness to engage with patients about mental illness, triggering a feedback loop of more positive experiences with patients who benefit from mental healthcare, which further reinforces willingness to deliver mental healthcare. Trial registration ClinicalTrials.gov identifier, NCT02793271

At present, the mental healthcare system cannot meet the demand for services, and the need‐to‐access gap is widest among children and adolescents. Single session interventions (SSIs) are brief, intentional, and mechanism‐targeted programs that have shown promise in increasing the reach of effective, evidence‐based services; yet, a wide gap still remains due to structural barriers (e.g., lack of awareness, workforce shortages). The present paper posits the integration of SSIs and mentor‐delivered programs as a promising future step to further overcome the inaccessibility of youth mental health services. Capitalizing on the advantages of mentoring relationships (e.g., the associated interpersonal benefits and mentors' pre‐existence in most community settings) has the potential to complement and enhance the value of SSIs, and to expand the acceptability and reach of evidence‐based mental health services. In this paper, we discuss the anticipated benefits of mentor‐delivered SSIs, as well as cautionary considerations related to the proposed model. To conclude, we highlight the necessary implementation and research implications. [ABSTRACT FROM AUTHOR]

Background: Mental illnesses comprise the single largest source of health-related economic burden globally, and low- and middle-income countries are disproportionately affected. The majority of people with schizophrenia who need treatment do not receive it and are often wholly reliant on family caregivers for daily care and support. Family interventions have an exceptionally robust evidence base for their efficacy in high-resource settings, but it is unknown whether they can produce equivalent effects in some low-resource settings where cultural beliefs, explanatory models of illness and contextual socio-economic issues differ. Methods: This protocol describes the methods for a randomised controlled trial to determine the feasibility of testing culturally adapt and refine an evidence-based, family intervention for relatives and caregivers of people with schizophrenia in Indonesia. The feasibility and acceptability of implementing our adapted, co-produced intervention via task shifting in primary care settings will be evaluated using the Medical Research Council framework for complex interventions. We will recruit 60 carer-service-user dyads and randomise them in a 1:1 ratio either to receive our manualised intervention or continue to receive treatment as usual. Healthcare workers in primary care settings will be trained to deliver family interventions using our manualised intervention by a family intervention specialist. Participants will complete the ECI, IEQ, KAST and GHQ. Service-user symptom level and relapse status will be measured using the PANSS at baseline, post-intervention and 3 months later by trained researchers. Fidelity to the intervention model will be measured using the FIPAS. Qualitative evaluation will further assist with refining the intervention, evaluating trial processes and evaluating acceptability. Discussion: National healthcare policy in Indonesia supports the delivery of mental health services in a complex network of primary care centres. This study will provide important information on the feasibility of delivering family interventions for people with schizophrenia via task shifting in primary care settings in Indonesia and allow further refinement of the intervention and trial processes. [ABSTRACT FROM AUTHOR]

Background: Anti-vascular endothelial growth factor is a medicine administered intravitreally by an injection to maintain visual acuity in patients with a variety of retinal diseases. The demand for this treatment has grown considerably in the westernized world the last two decades and will continue to increase due to an aging population. Because of the high volume, injections seize enormous resources and represent high costs for both hospitals and society. Task-shifting of injections from physicians to nurses may be a means to reduce such costs, however the magnitude of possible savings has been poorly investigated. To this end we investigated changes in the hospital costs per injection, six-year cost projections of physician- versus nurse-administered injections for a Norwegian tertiary hospital and we compared the societal costs per patient per year. Methods: Patients (n = 318) were randomized to either physician- or nurse administered injections, and data were prospectively collected. Hospital costs per injection were calculated as the sum of training costs, personnel time and running expenses. The number of injections for the years 2014 – 21 from a Norwegian tertiary hospital was combined with age group specific injection prevalence and population projections to calculate cost projections for 2022 – 27. Societal costs per patient were calculated as the sum of hospital costs, transport costs for patients, caregivers' use of time, costs of ophthalmology consultations and community-based homecare. Results: The hospital costs per injection were 5.5 € higher for physicians compared to nurses (281.6 € versus 276.1 €). Cost projections estimated an annual hospital saving of task-shifting of 48 921 € for 2022 – 27. Societal costs per patient did not differ significantly between the two groups (mean 4988 € vs 5418 €, p = 0.398). Conclusion: Task-shifting of injections from physicians to nurses can reduce hospital costs and increase the flexibility of physician resources. The annual savings are modest, but increased demand for injections might increase future cost savings. To achieve future savings for society, organizing ophthalmology consultations and injections on the same day to reduce the number of visits might be a solution. Trial registration: ClinicalTrials.gov NCT02359149 (09/02/2015). [ABSTRACT FROM AUTHOR]

Background: Safe and timely access to cesarean section (CS) in low‐ and middle‐income countries (LMIC) remains a significant challenge. Objectives: To compare maternal and perinatal outcomes of CS by non‐physician clinicians (NPCs) versus physicians in LMIC. Search strategy and Selection criteria: A systematic search of Ovid MEDLINE, EMBASE, Cochrane Library (including CENTRAL), Web of Science, and LILACS was performed from inception to January 2022. Data collection and analysis: Data were extracted by two independent reviewers and meta‐analysis was performed when possible. Main results: Ten studies from seven African countries were included. There was no significant difference in maternal mortality for CS performed by NPCs versus physicians (odds ratio [OR] 1.09, 95% confidence interval [CI] 0.56–2.14, P = 0.8, I2 = 70%, P < 0.05, eight studies, n = 20 711) or in perinatal mortality (OR 1.18, 95% CI 0.86–1.61, P = 0.3, I2 = 88%, n = 19 716). Despite heterogeneous clinical settings between providers, there was no difference in the rates of wound infection or re‐operation, although there was a higher rate of wound complications (such as dehiscence) in the NPC group (OR 1.89, 95% CI 1.21–2.95, P = 0.005, n = 6507). Conclusions: NPCs have comparable maternal and neonatal outcomes for CS compared with standard providers, albeit with increased odds of wound complication. PROSPERO Registration: CRD42020217966. Synopsis: Task‐shifting cesarean sections are frequently performed in some sub‐Saharan countries with comparable maternal/perinatal outcomes to standard providers. [ABSTRACT FROM AUTHOR]