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In this Perspective, Mark Tomlinson and Marguerite Marlow argue that equitable improvements in mental health outcomes cannot be achieved without first dismantling colonial and paternalistic approaches to global mental health. [ABSTRACT FROM AUTHOR]

Initial screening can be followed by a diagnostic interview to determine diagnosis and/or the severity of the depression in order to inform treatment [[13]]. Using a screening tool in routine primary health care settings in resource-constrained health systems may overwhelm fragile health systems and direct already limited resources away from people with an actual diagnosis [[6]]. Screening vs. diagnosis The extent to which screening actually improves detection or management of depression remains contested [[4]]. It has been estimated that while screening tools may miss less than 3% of people with a potential diagnosis of depression, fewer than 50% of those screening positive, in fact, have depression [[5]]. [Extracted from the article]

Background: Violence against women by intimate partners remains unacceptably common worldwide. The evidence base for the assumed psychological impacts of intimate partner violence (IPV) is derived primarily from studies conducted in high-income countries. A recently published systematic review identified 13 studies linking IPV to incident depression, none of which were conducted in sub-Saharan Africa. To address this gap in the literature, we analyzed longitudinal data collected during the course of a 3-y cluster-randomized trial with the aim of estimating the association between IPV and depression symptom severity.Methods and Findings: We conducted a secondary analysis of population-based, longitudinal data collected from 1,238 pregnant women during a 3-y cluster-randomized trial of a home visiting intervention in Cape Town, South Africa. Surveys were conducted at baseline, 6 mo, 18 mo, and 36 mo (85% retention). The primary explanatory variable of interest was exposure to four types of physical IPV in the past year. Depression symptom severity was measured using the Xhosa version of the ten-item Edinburgh Postnatal Depression Scale. In a pooled cross-sectional multivariable regression model adjusting for potentially confounding time-fixed and time-varying covariates, lagged IPV intensity had a statistically significant association with depression symptom severity (regression coefficient b = 1.04; 95% CI, 0.61-1.47), with estimates from a quantile regression model showing greater adverse impacts at the upper end of the conditional depression distribution. Fitting a fixed effects regression model accounting for all time-invariant confounding (e.g., history of childhood sexual abuse) yielded similar findings (b = 1.54; 95% CI, 1.13-1.96). The magnitudes of the coefficients indicated that a one-standard-deviation increase in IPV intensity was associated with a 12.3% relative increase in depression symptom severity over the same time period. The most important limitations of our study include exposure assessment that lacked measurement of sexual violence, which could have caused us to underestimate the severity of exposure; the extended latency period in the lagged analysis, which could have caused us to underestimate the strength of the association; and outcome assessment that was limited to the use of a screening instrument for depression symptom severity.Conclusions: In this secondary analysis of data from a population-based, 3-y cluster-randomized controlled trial, IPV had a statistically significant association with depression symptom severity. The estimated associations were relatively large in magnitude, consistent with findings from high-income countries, and robust to potential confounding by time-invariant factors. Intensive health sector responses to reduce IPV and improve women's mental health should be explored. [ABSTRACT FROM AUTHOR]

In a Perspective, Mark Tomlinson discusses research on early interventions to support child development in developing countries. [ABSTRACT FROM AUTHOR]

Alex Tsai and Mark Tomlinson argue for a place for mental health on the post-2015 development agenda. [ABSTRACT FROM AUTHOR]

Background: Interventions are needed to reduce poor perinatal health. We trained community health workers (CHWs) as home visitors to address maternal/infant risks. Methods: In a cluster randomised controlled trial in Cape Town townships, neighbourhoods were randomised within matched pairs to 1) the control, healthcare at clinics (n = 12 neighbourhoods; n = 594 women), or 2) a home visiting intervention by CBW trained in cognitive-behavioural strategies to address health risks (by the Philani Maternal, Child Health and Nutrition Programme), in addition to clinic care (n = 12 neighbourhoods; n = 644 women). Participants were assessed during pregnancy (2% refusal) and 92% were reassessed at two weeks post-birth, 88% at six months and 84% at 18 months later. We analysed 32 measures of maternal/infant well-being over the 18 month follow-up period using longitudinal random effects regressions. A binomial test for correlated outcomes evaluated overall effectiveness over time. The 18 month post-birth assessment outcomes also were examined alone and as a function of the number of home visits received. Results: Benefits were found on 7 of 32 measures of outcomes, resulting in significant overall benefits for the intervention compared to the control when using the binomial test (p = 0.008); nevertheless, no effects were observed when only the 18 month outcomes were analyzed. Benefits on individual outcomes were related to the number of home visits received. Among women living with HIV, intervention mothers were more likely to implement the PMTCT regimens, use condoms during all sexual episodes (OR = 1.25; p = 0.014), have infants with healthy weight-for-age measurements (OR = 1.42; p = 0.045), height-for-age measurements (OR = 1.13, p<0.001), breastfeed exclusively for six months (OR = 3.59; p<0.001), and breastfeed longer (OR = 3.08; p<0.001). Number of visits was positively associated with infant birth weight ≥2500 grams (OR = 1.07; p = 0.012), healthy head-circumference-for-age measurements at 6 months (OR = 1.09, p = 0.017), and improved cognitive development at 18 months (OR = 1.02, p = 0.048). Conclusions: Home visits to neighbourhood mothers by CHWs may be a feasible strategy for enhancing maternal/child outcomes. However, visits likely must extend over several years for persistent benefits. Trial Registration: ClinicalTrials.gov [ABSTRACT FROM AUTHOR]

The article focuses on the evidences for further application and scaling up of mobile health system. The World Bank reports that there were 500 mobile health studies and donor agencies which support the scaling of mobile health. It mentions that despite of various pilot studies, there were insufficient evidences to implement and scale up the mobile health. It suggests that innovative research designs such as randomized controlled trials and data farming may provide additional evidence.

Crick Lund and colleagues describe their plans for the PRogramme for Improving Mental health carE (PRIME), which aims to generate evidence on implementing and scaling up integrated packages of care for priority mental disorders in primary and maternal health care contexts in Ethiopia, India, Nepal, South Africa, and Uganda. [ABSTRACT FROM AUTHOR]

Recent evidence has shown support for the United Nations Development Programme (UNDP) accelerator concept, which highlights the need to identify interventions or programmatic areas that can affect multiple sustainable development goals (SDGs) at once to boost their achievement. These data have also clearly shown enhanced effects when interventions are used in combination, above and beyond the effect of single interventions. However, detailed knowledge is now required on optimum combinations and relative gain in order to derive policy guidance. Which accelerators work for which outcomes, what combinations are optimum, and how many combinations are needed to maximise effect? The current study utilised pooled data from the Young Carers (n = 1402) and Child Community Care (n = 446) studies. Data were collected at baseline (n = 1848) and at a 1 to 1.5- year follow-up (n = 1740) from children and young adolescents aged 9–13 years, living in South Africa. Measures in common between the two databases were used to generate five accelerators (caregiver praise, caregiver monitoring, food security, living in a safe community, and access to community-based organizations) and to investigate their additive effects on 14 SDG-related outcomes. Predicted probabilities and predicted probability differences were calculated for each SDG outcome under the presence of none to five accelerators to determine optimal combinations. Results show that various accelerator combinations are effective, though different combinations are needed for different outcomes. Some accelerators ramified across multiple outcomes. Overall, the presence of up to three accelerators was associated with marked improvements over multiple outcomes. The benefit of targeting access to additional accelerators, with additional costs, needs to be weighed against the relative gains to be achieved with high quality but focused interventions. In conclusion, the current data show the detailed impact of various protective factors and provides implementation guidance for policy makers in targeting and distributing interventions to maximise effect and expenditure. Future work should investigate multiplicative effects and synergistic interactions between accelerators. [ABSTRACT FROM AUTHOR]

An essay concerning less attention received by mental health issues through a framework of analysis developed by J. Shiffman and S. Smith is presented. It states that Shiffman and Smith have argued that a mental health disorder gains political priority only when three conditions including politicians expressing support for the issue, policies enacted to address the problem, and resources are allocated, however in the case of mental health none of these conditions is currently being met.

Nearly 100,000 children under 5 years die annually in South Africa. This paper defines health research priorities to address this unacceptably high mortality rate. [ABSTRACT FROM AUTHOR]

Prenatal alcohol-drinking is often measured with self-report, but it is unclear whether mothers give more accurate answers when asked while pregnant or some time after their pregnancy. There is also the question of whether to measure drinking in a dichotomous or continuous fashion. We sought to examine how the timing and scale of self-reports affected the content of reports. From a sample of 576 black mothers around Cape Town, South Africa, we compared prenatal reports of prenatal drinking with 5-year retrospective reports, and dichotomous metrics (drinking or abstinent) with continuous metrics (fluid ounces of absolute alcohol drunk per day). Amounts increased over the 5-year period, whereas dichotomous measures found mothers less likely to report drinking later. All four measures were weakly associated with birth weight, birth height, child head circumference soon after birth, and child intelligence at age 5. Furthermore, neither reporting time nor the scale of measurement were consistently related to the strengths of these associations. Our results point to problems with self-report, particularly with this population, but we recommend post-birth continuous measures as the best of the group for their flexibility and their consistency with previous research. [ABSTRACT FROM AUTHOR]

Background: Antenatal depression and anxiety disorders are highly prevalent in low and middle-income countries. Screening of pregnant women in primary care antenatal settings provides an opportunity for entry to care, but data are needed on the performance of different screening tools. We compared five widely-used questionnaires in a sample of pregnant women in urban South Africa. Method: Pregnant women attending a primary care antenatal clinic were administered five tools by trained research assistants: the Edinburgh Postnatal Depression Scale (EPDS), the Patient Health Questionnaire (PHQ-9), the Kessler Psychological Distress scale (K10) and a shortened 6-item version (K6), the Whooley questions and the two-item Generalised Anxiety Disorder scale (GAD-2). Following this, a registered mental health counsellor administered the MINI Plus, a structured clinical diagnostic interview. The Area Under the Curve (AUC) from Receiver Operator Characteristic curve analysis was used to summarise screening test performance and Cronbach’s α used to assess internal consistency. Results: Of 376 participants, 32% were diagnosed with either MDE and/or anxiety disorders. All five questionnaires demonstrated moderate to high performance (AUC = 0.78–0.85). The EPDS was the best performing instrument for detecting MDE and the K10 and K6 for anxiety disorder. For MDE and/or anxiety disorders, the EPDS had the highest AUC (0.83). Of the short instruments, the K10 (AUC = 0.85) and the K6 (AUC = 0.85) performed the best, with the K6 showing good balance between sensitivity (74%) and specificity (85%) and a good positive predictive value (70%). The Whooley questions (AUC = 0.81) were the best performing ultra-short instrument. Internal consistency ranged from good to acceptable (α = 0.89–0.71). However, the PPV of the questionnaires compared with the diagnostic interview, ranged from 54% to 71% at the optimal cut-off scores. Conclusions: Universal screening for case identification of antenatal depression and anxiety disorders in low-resource settings can be conducted with a number of commonly used screening instruments. Short and ultra-short screening instruments such as the K6 and the Whooley questions may be feasible and acceptable for use in these settings. [ABSTRACT FROM AUTHOR]

Background: Community health workers (CHWs) can supplement professional medical providers, especially in rural settings where resources are particularly scarce. Yet, outcomes of studies evaluating CHWs effectiveness have been highly variable and lack impact when scaled nationally. This study examines if child and maternal outcomes are better when existing government CHWs, who are perinatal home visitors, receive ongoing enhanced supervision and monitoring, compared to standard care. Methods and findings: A cluster randomized controlled effectiveness trial was conducted comparing outcomes over 2 years when different supervision and support are provided. Primary health clinics were randomized by clinic to receive monitoring and supervision from either (1) existing supervisors (Standard Care (SC); n = 4 clinics, 23 CHWs, 392 mothers); or (2) supervisors from a nongovernmental organization that provided enhanced monitoring and supervision (Accountable Care [AC]; n = 4 clinic areas, 20 CHWs, 423 mothers). Assessments were conducted during pregnancy and at 3, 6, 15, and 24 months post-birth with high retention rates (76% to 86%). The primary outcome was the number of statistically significant intervention effects among 13 outcomes of interest; this approach allowed us to evaluate the intervention holistically while accounting for correlation among the 13 outcomes and considering multiple comparisons. The observed benefits were not statistically significant and did not show the AC's efficacy over the SC. Only the antiretroviral (ARV) adherence effect met the significance threshold established a priori (SC mean 2.3, AC mean 2.9, p < 0.025; 95% CI = [0.157, 1.576]). However, for 11 of the 13 outcomes, we observed an improvement in the AC compared to the SC. While the observed outcomes were not statistically significant, benefits were observed for 4 outcomes: increasing breastfeeding for 6 months, reducing malnutrition, increasing ARV adherence, and improving developmental milestones. The major study limitation was utilizing existing CHWs and being limited to a sample of 8 clinics. There were no major study-related adverse events. Conclusions: Supervision and monitoring were insufficient to improve CHWs' impact on maternal and child outcomes. Alternative strategies for staff recruitment and narrowing the intervention outcomes to the specific local community problems are needed for consistently high impact. Trial registration: Clinicaltrials.gov, NCT02957799. In a randomised controlled trial, Dr. Mary Jane Rotheram-Borus and colleagues investigate the effect of supervision on community health workers' effectiveness in households of rural South Africa. Author summary: Why was this study done?: There are too few health professionals in low- and middle-income countries, and there will be too few until about 2050. Healthcare tasks are being shifted to 2 million community health workers (CHWs). Yet, the efficacy of these CHWs often disappears when randomized controlled trials (RCTs) are ended and national programs are implemented. What did the researchers do and find?: Existing government-employed CHWs serving 8 deeply rural health clinics were randomized by clinic in a cluster effectiveness RCT to either standard supervision or enhanced accountable monitoring and supervision by a nongovernment organization. The CHWs and perinatal mothers/children were monitored at 5 points over the first 2 years of life. Supervision did not lead to significantly better outcomes for mothers and children. Yet, it is noteworthy that 11 of 13 outcomes were better when CHWs received enhanced, accountable supervision, compared to standard care. What do these findings mean?: A key component of implementation at scale in the real world is the ability to hold CHWs accountable and to release CHWs not meeting expectations. To successfully deploy CHWs in a manner that has significant and sustained improvements, the procedures for selecting and recruiting CHWs may be critical. [ABSTRACT FROM AUTHOR]

The article discusses the challenges facing mental health research in poor countries and offers suggestions on how it should be governed. These challenges include the lack of an organizational structure, financial limitations, and research capacity constraints. It stresses the importance of institutionalizing the general orientation of mental health research to address the challenges. It notes that expensive research must be balanced with assessment services and resources using cheap methods.

The article discusses the study which aims to set priorities in research towards humanitarian psychosocial support and mental health. The researchers have emphasized the establishment of practical knowledge with tangible benefits for programming in humanitarian settings. However an effective research agenda requires a better sociocultural alignment between researchers and practitioners affected by the humanitarian crises.

An essay is presented on the prioritization tools which can be used for African maternal, neonatal, and child health care policy. It explores health care prioritization tools including Marginal Budgeting for Bottlenecks (MBB), Choosing Interventions that are Cost-Effective (WHO-CHOICE), and Lives Saved Tool (LiST). It tackles research prioritization tools including Council on Health Research for Development (COHRED), Essential National Health Research (ENHR), and Combined Approach Matrix (CAM).

Background: In South Africa, breastfeeding promotion is a national health priority. Regular perinatal home visits by community health workers (CHWs) have helped promote exclusive breastfeeding (EBF) in underresourced settings. Innovative, digital approaches including mobile video content have also shown promise, especially as access to mobile technology increases among CHWs. We measured the effects of an animated, mobile video series, the Philani MObile Video Intervention for Exclusive breastfeeding (MOVIE), delivered by a cadre of CHWs ("mentor mothers").Methods and Findings: We conducted a stratified, cluster-randomized controlled trial from November 2018 to March 2020 in Khayelitsha, South Africa. The trial was conducted in collaboration with the Philani Maternal Child Health and Nutrition Trust, a nongovernmental community health organization. We quantified the effect of the MOVIE intervention on EBF at 1 and 5 months (primary outcomes), and on other infant feeding practices and maternal knowledge (secondary outcomes). We randomized 1,502 pregnant women in 84 clusters 1:1 to 2 study arms. Participants' median age was 26 years, 36.9% had completed secondary school, and 18.3% were employed. Mentor mothers in the video intervention arm provided standard-of-care counseling plus the MOVIE intervention; mentor mothers in the control arm provided standard of care only. Within the causal impact evaluation, we nested a mixed-methods performance evaluation measuring mentor mothers' time use and eliciting their subjective experiences through in-depth interviews. At both points of follow-up, we observed no statistically significant differences between the video intervention and the control arm with regard to EBF rates and other infant feeding practices [EBF in the last 24 hours at 1 month: RR 0.93 (95% CI 0.86 to 1.01, P = 0.091); EBF in the last 24 hours at 5 months: RR 0.90 (95% CI 0.77 to 1.04, P = 0.152)]. We observed a small, but significant improvement in maternal knowledge at the 1-month follow-up, but not at the 5-month follow-up. The interpretation of the results from this causal impact evaluation changes when we consider the results of the nested mixed-methods performance evaluation. The mean time spent per home visit was similar across study arms, but the intervention group spent approximately 40% of their visit time viewing videos. The absence of difference in effects on primary and secondary endpoints implies that, for the same time investment, the video intervention was as effective as face-to-face counseling with a mentor mother. The videos were also highly valued by mentor mothers and participants. Study limitations include a high loss to follow-up at 5 months after premature termination of the trial due to the COVID-19 pandemic and changes in mentor mother service demarcations.Conclusions: This trial measured the effect of a video-based, mobile health (mHealth) intervention, delivered by CHWs during home visits in an underresourced setting. The videos replaced about two-fifths of CHWs' direct engagement time with participants in the intervention arm. The similar outcomes in the 2 study arms thus suggest that the videos were as effective as face-to-face counselling, when CHWs used them to replace a portion of that counselling. Where CHWs are scarce, mHealth video interventions could be a feasible and practical solution, supporting the delivery and scaling of community health promotion services.Trial Registration: The study and its outcomes were registered at clinicaltrials.gov (#NCT03688217) on September 27, 2018. [ABSTRACT FROM AUTHOR]

Children and adolescents with delayed or disordered language development are at increased risk of a number of negative outcomes, including social and emotional problems and mental health difficulties. Yet, in low- and middle- income countries, where risk factors for compromised language development are known to be prevalent, there is a lack of research on the association between child and adolescent language ability and mental health outcomes. This study evaluates data from a cross-sectional study in Khayelitsha, a semi-urban impoverished community near Cape Town, South Africa. To measure language ability, behaviour and mental health, adolescents aged 13 (n = 200) were assessed using the Riddles subtest of the Kaufman Assessment Battery for Children Version 2, the parent report Child Behaviour Checklist, and the self-report Moods and Feelings Questionnaire and the Self-Esteem Questionnaire. We conducted univariate and multivariate analyses to determine associations between language skills, self-esteem and mental health in this group of adolescents. Poor language ability was related to a range of concurrent adverse difficulties, such as attention deficits, self-esteem problems, social withdrawal, and depressive symptoms. Increased levels of language ability were related to better psychosocial profiles. In some cases, only individuals with a low level of language (bottom 10% of sample) were at increased risk of maladaptive outcomes. This study replicates the well-established relationship between language ability and poorer mental health found within high income countries in an upper middle-income country setting. Locally accessible support for children with reduced language ability is required, given the longer-term consequences of poorer mental health. [ABSTRACT FROM AUTHOR]

Background: In high-income countries, individual- and community-level factors are associated with increased contact with the criminal justice system. However, little is known about how these factors contribute to the risk of arrest in South Africa, which has one of the highest rates of arrests globally. We examine both individual- and community-level factors associated with arrests among young men living in the townships of Cape Town. Methods: Data were collected from a stratified community sample of 906 young men aged 18–29 years old living in 18 township neighborhoods. Communities with high and low rates of arrest were identified. Logistic regression models were used to assess which individual-level (such as substance use and mental health status) and community-level (such as infrastructure and presence of bars and gangs) factors predict arrests. Results: Significant predictors of arrests were substance use, gang activity, being older, more stressed, and less educated. Living in communities with better infrastructure and in more recently established communities populated by recent immigrants was associated with having a history of arrests. Conclusions: When considering both individual- and community-level factors, substance use and gang violence are the strongest predictors of arrests among young men in South Africa. Unexpectedly, communities with better infrastructure have higher arrest rates. Community programs are needed to combat substance use and gang activity as a pathway out of risk among South African young men. Trial registration: ClinicalTrials.gov registration , registered Nov 24, 2014 [ABSTRACT FROM AUTHOR]

Intimate partner violence (IPV) experienced by pregnant and post-partum women has negative health effects for women, as well as the foetus, and the new-born child. In this study we sought to assess the prevalence and factors associated with recent IPV amongst post-partum women in one clinic in eThekwini Municipality, South Africa, and explore the relationship between IPV, depression and functional limitations/disabilities. Past 12 month IPV-victimisation was 10.55%. Logistic regression modelled relationships between IPV, functional limitations, depressive symptoms, socio-economic measures, and sexual relationship power. In logistic regression models, overall severity of functional limitations were not associated with IPV-victimisation when treated as a continuous overall score. In this model relationship power (aOR0.22, p = 0.001) and depressive symptoms (aOR1.26, p = 0.001) were significant. When the different functional limitations were separated out in a second model, significant factors were relationship power (aOR0.20, p = 0.001), depressive symptoms (aOR1.20, p = 0.011) and mobility limitations (aOR2.96, p = 0.024). The study emphasises that not all functional limitations are associated with IPV-experience, that depression and disability while overlapping can also be considered different drivers of vulnerability, and that women’s experience of IPV is not dependent on pregnancy specific factors, but rather wider social factors that all women experience. [ABSTRACT FROM AUTHOR]

Background: Clear recognition of the damaging effects of poverty on early childhood development has fueled an interest in interventions aimed at mitigating these harmful consequences. Psychosocial interventions aimed at alleviating the negative impacts of poverty on children are frequently shown to be of benefit, but effect sizes are typically small to moderate. However, averaging outcomes over an entire sample, as is typically done, could underestimate efficacy because weaker effects on less susceptible individuals would dilute estimation of effects on those more disposed to respond. This study investigates whether a genetic polymorphism of the serotonin transporter gene moderates susceptibility to a psychosocial intervention.Methods and Findings: We reanalyzed data from a randomized controlled trial of a home-visiting program delivered by community health workers in a black, isiXhosa-speaking population in Khayelitsha, South Africa. The intervention, designed to enhance maternal-infant attachment, began in the third trimester and continued until 6 mo postpartum. Implemented between April 1999 and February 2003, the intervention comprised 16 home visits delivered to 220 mother-infant dyads by specially trained community health workers. A control group of 229 mother-infant dyads did not receive the intervention. Security of maternal-infant attachment was the main outcome measured at infant age 18 mo. Compared to controls, infants in the intervention group were significantly more likely to be securely attached to their primary caregiver (odds ratio [OR] = 1.7, p = 0.029, 95% CI [1.06, 2.76], d = 0.29). After the trial, 162 intervention and 172 control group children were reenrolled in a follow-up study at 13 y of age (December 2012-June 2014). At this time, DNA collected from 279 children (134 intervention and 145 control) was genotyped for a common serotonin transporter polymorphism. There were both genetic data and attachment security data for 220 children (110 intervention and 110 control), of whom 40% (44 intervention and 45 control) carried at least one short allele of the serotonin transporter gene. For these 220 individuals, carrying at least one short allele of the serotonin transporter gene was associated with a 26% higher rate of attachment security relative to controls (OR = 3.86, p = 0.008, 95% CI [1.42, 10.51], d = 0.75), whereas there was a negligible (1%) difference in security between intervention and control group individuals carrying only the long allele (OR = 0.95, p = 0.89, 95% CI [0.45, 2.01], d = 0.03). Expressed in terms of absolute risk, for those with the short allele, the probability of secure attachment being observed in the intervention group was 84% (95% CI [73%, 95%]), compared to 58% (95% CI [43%, 72%]) in the control group. For those with two copies of the long allele, 70% (95% CI [59%, 81%]) were secure in the intervention group, compared to 71% (95% CI [60%, 82%]) of infants in the control group. Controlling for sex, maternal genotype, and indices of socioeconomic adversity (housing, employment, education, electricity, water) did not change these results. A limitation of this study is that we were only able to reenroll 49% of the original sample randomized to the intervention and control conditions. Attribution of the primary outcome to causal effects of intervention in the present subsample should therefore be treated with caution.Conclusions: When infant genotype for serotonin transporter polymorphism was taken into account, the effect size of a maternal-infant attachment intervention targeting impoverished pregnant women increased more than 2.5-fold when only short allele carriers were considered (from d = 0.29 for all individuals irrespective of genotype to d = 0.75) and decreased 10-fold when only those carrying two copies of the long allele were considered (from d = 0.29 for all individuals to d = 0.03). Genetic differential susceptibility means that averaging across all participants is a misleading index of efficacy. The study raises questions about how policy-makers deal with the challenge of balancing equity (equal treatment for all) and efficacy (treating only those whose genes render them likely to benefit) when implementing psychosocial interventions.Trial Registration: Current Controlled Trials ISRCTN25664149. [ABSTRACT FROM AUTHOR]

Context: A robust evidence base is now emerging that indicates that treatment for depression and alcohol use disorders (AUD) delivered in low and middle-income countries (LMIC) can be effective. However, the coverage of services for these conditions in most LMIC settings remains unknown. Objective: To describe the methods of a repeat cross-sectional survey to determine changes in treatment contact coverage for probable depression and for probable AUD in four LMIC districts, and to present the baseline findings regarding treatment contact coverage. Methods: Population-based cross-sectional surveys with structured questionnaires, which included validated screening tools to identify probable cases. We defined contact coverage as being the proportion of cases who sought professional help in the past 12 months. Setting: Sodo District, Ethiopia; Sehore District, India; Chitwan District, Nepal; and Kamuli District, Uganda Participants: 8036 adults residing in these districts between May 2013 and May 2014 Main Outcome Measures: Treatment contact coverage was defined as having sought care from a specialist, generalist, or other health care provider for symptoms related to depression or AUD. Results: The proportion of adults who screened positive for depression over the past 12 months ranged from 11.2% in Nepal to 29.7% in India and treatment contact coverage over the past 12 months ranged between 8.1% in Nepal to 23.5% in India. In Ethiopia, lifetime contact coverage for probable depression was 23.7%. The proportion of adults who screened positive for AUD over the past 12 months ranged from 1.7% in Uganda to 13.9% in Ethiopia and treatment contact coverage over the past 12 months ranged from 2.8% in India to 5.1% in Nepal. In Ethiopia, lifetime contact coverage for probable AUD was 13.1%. Conclusions: Our findings are consistent with and contribute to the limited evidence base which indicates low treatment contact coverage for depression and for AUD in LMIC. The planned follow up surveys will be used to estimate the change in contact coverage coinciding with the implementation of district-level mental health care plans. [ABSTRACT FROM AUTHOR]

Community-based responses have a lengthy history. The ravages of HIV on family functioning has included a widespread community response. Although much funding has been invested in front line community-based organisations (CBO), there was no equal investment in evaluations. This study was set up to compare children aged 9–13 years old, randomly sampled from two South African provinces, who had not received CBO support over time (YC) with a group of similarly aged children who were CBO attenders (CCC). YC baseline refusal rate was 2.5% and retention rate was 97%. CCC baseline refusal rate was 0.7% and retention rate was 86.5%. 1848 children were included—446 CBO attenders compared to 1402 9–13 year olds drawn from a random sample of high-HIV prevalence areas. Data were gathered at baseline and 12–15 months follow-up. Standardised measures recorded demographics, violence and abuse, mental health, social and educational factors. Multivariate regression analyses revealed that children attending CBOs had lower odds of experiencing weekly domestic conflict between adults in their home (OR 0.17; 95% CI 0.09, 0.32), domestic violence (OR 0.22; 95% CI 0.08, 0.62), or abuse (OR 0.11; 95% CI 0.05, 0.25) at follow-up compared to participants without CBO contact. CBO attenders had lower odds of suicidal ideation (OR 0.41; 95% CI 0.18, 0.91), fewer depressive symptoms (B = -0.40; 95% CI -0.62, -0.17), less perceived stigma (B = -0.37; 95% CI -0.57, -0.18), fewer peer problems (B = -1.08; 95% CI -1.29, -0.86) and fewer conduct problems (B = -0.77; 95% CI -0.95, -0.60) at follow-up. In addition, CBO contact was associated with more prosocial behaviours at follow-up (B = 1.40; 95% CI 1.13, 1.67). No associations were observed between CBO contact and parental praise or post-traumatic symptoms. These results suggest that CBO exposure is associated with behavioural and mental health benefits for children over time. More severe psychopathology was not affected by attendance and may need more specialised input. [ABSTRACT FROM AUTHOR]

Background: Little is known about how to tailor implementation of mental health services in low- and middle-income countries (LMICs) to the diverse settings encountered within and between countries. In this paper we compare the baseline context, challenges and opportunities in districts in five LMICs (Ethiopia, India, Nepal, South Africa and Uganda) participating in the PRogramme for Improving Mental health carE (PRIME). The purpose was to inform development and implementation of a comprehensive district plan to integrate mental health into primary care. Methods: A situation analysis tool was developed for the study, drawing on existing tools and expert consensus. Cross-sectional information obtained was largely in the public domain in all five districts. Results: The PRIME study districts face substantial contextual and health system challenges many of which are common across sites. Reliable information on existing treatment coverage for mental disorders was unavailable. Particularly in the low-income countries, many health service organisational requirements for mental health care were absent, including specialist mental health professionals to support the service and reliable supplies of medication. Across all sites, community mental health literacy was low and there were no models of multi-sectoral working or collaborations with traditional or religious healers. Nonetheless health system opportunities were apparent. In each district there was potential to apply existing models of care for tuberculosis and HIV or non-communicable disorders, which have established mechanisms for detection of drop-out from care, outreach and adherence support. The extensive networks of community-based health workers and volunteers in most districts provide further opportunities to expand mental health care. Conclusions: The low level of baseline health system preparedness across sites underlines that interventions at the levels of health care organisation, health facility and community will all be essential for sustainable delivery of quality mental health care integrated into primary care. [ABSTRACT FROM AUTHOR]

Objective: We evaluate the effect of clinic-based support by HIV-positive Peer Mentors, in addition to standard clinic care, on maternal and infant well-being among Women Living with HIV (WLH) from pregnancy through the infant's first year of life. Methods: In a cluster randomized controlled trial in KwaZulu-Natal, South Africa, eight clinics were randomized for pregnant WLH to receive either: a Standard Care condition (SC; 4 clinics; n = 656 WLH); or an Enhanced Intervention (EI; 4 clinics; n = 544 WLH). WLH in the EI were invited to attend four antenatal and four postnatal meetings led by HIV-positive Peer Mentors, in addition to SC. WLH were recruited during pregnancy, and at least two post-birth assessment interviews were completed by 57% of WLH at 1.5, 6 or 12 months. EI's effect was ascertained on 19 measures of maternal and infant well-being using random effects regressions to control for clinic clustering. A binomial test for correlated outcomes evaluated EI's overall efficacy. Findings: WLH attended an average of 4.1 sessions (SD = 2.0); 13% did not attend any sessions. Significant overall benefits were found in EI compared to SC using the binomial test. Secondarily, over time, WLH in the EI reported significantly fewer depressive symptoms and fewer underweight infants than WLH in the SC condition. EI WLH were significantly more likely to use one feeding method for six months and exclusively breastfeed their infants for at least 6 months. Conclusions: WLH benefit by support from HIV-positive Peer Mentors, even though EI participation was partial, with incomplete follow-up rates from 6–12 months. Trial Registration: ClinicalTrials.gov NCT00972699 [ABSTRACT FROM AUTHOR]

The article presents a case study which describes a step-wise primary care model for pregnant women under the Perinatal Mental Health Project (PMHP) in South Africa. It is inferred that 90 percent of women receiving antenatal care were offered with mental health screening. It highlights the feasibility of the stepped care approach in the delivery of mental health services at the primary care level.

Background:A major barrier to improving perinatal mental health in Africa is the lack of locally validated tools for identifying probable cases of perinatal depression or for measuring changes in depression symptom severity. We systematically reviewed the evidence on the reliability and validity of instruments to assess perinatal depression in African settings. Methods and Findings:Of 1,027 records identified through searching 7 electronic databases, we reviewed 126 full-text reports. We included 25 unique studies, which were disseminated in 26 journal articles and 1 doctoral dissertation. These enrolled 12,544 women living in nine different North and sub-Saharan African countries. Only three studies (12%) used instruments developed specifically for use in a given cultural setting. Most studies provided evidence of criterion-related validity (20 [80%]) or reliability (15 [60%]), while fewer studies provided evidence of construct validity, content validity, or internal structure. The Edinburgh postnatal depression scale (EPDS), assessed in 16 studies (64%), was the most frequently used instrument in our sample. Ten studies estimated the internal consistency of the EPDS (median estimated coefficient alpha, 0.84; interquartile range, 0.71-0.87). For the 14 studies that estimated sensitivity and specificity for the EPDS, we constructed 2 x 2 tables for each cut-off score. Using a bivariate random-effects model, we estimated a pooled sensitivity of 0.94 (95% confidence interval [CI], 0.68-0.99) and a pooled specificity of 0.77 (95% CI, 0.59-0.88) at a cut-off score of ≥9, with higher cut-off scores yielding greater specificity at the cost of lower sensitivity. Conclusions:The EPDS can reliably and validly measure perinatal depression symptom severity or screen for probable postnatal depression in African countries, but more validation studies on other instruments are needed. In addition, more qualitative research is needed to adequately characterize local understandings of perinatal depression-like syndromes in different African contexts. [ABSTRACT FROM AUTHOR]