Search

Background: Peer support workers provide support for people experiencing mental health conditions based on their own lived experience of mental health problems. Assessing fidelity to core ingredients of peer support is vital for successful implementation and intervention delivery. Modifications to its implementation are needed when scaling up to different socio-economic settings, raising further uncertainty about fidelity. As part of a large multi-centre study on peer support called Using Peer Support In Developing Empowering Mental Health Services (UPSIDES), we developed and evaluated the psychometric properties of the UPSIDES Fidelity Scale., Methods: We constructed the fidelity scale based on an initial item pool developed through international expert consultation and iterative feedback. Scale refinement involved site-level expert consultation and translation, resulting in a service user-rated 28-item version and a peer support worker-rated 21-item version assessing receipt, engagement, enactment, competence, communication and peer support-specific components. Both versions are available in six languages: English, German, Luganda, Kiswahili, Hebrew and Gujarati. The scale was then evaluated at six study sites across five countries, with peer support workers and their clients completing their respective ratings four and eight months after initial peer support worker contact. Psychometric evaluation included analysis of internal consistency, construct validity and criterion validity., Results: For the 315 participants, item statistics showed a skewed distribution of fidelity values but no restriction of range. Internal consistency was adequate (range α = 0.675 to 0.969) for total scores and all subscales in both versions. Confirmatory factor analysis indicated acceptable fit of the proposed factor structure for the service user version (χ2/df = 2.746; RMSEA = 0.084) and moderate fit for the peer support worker version (χ2/df = 3.087; RMSEA = 0.093). Both versions showed significant correlations with external criteria: number of peer support sessions; perceived recovery orientation of the intervention; and severity of illness., Conclusions: The scale demonstrates good reliability, construct and criterion validity, making it a pragmatic and psychometrically acceptable measure for assessing fidelity to a manualised peer support worker intervention. Recommendations for use, along with research and practical implications, are addressed. As validated, multi-lingual tool that adapts to diverse settings this scale is uniquely positioned for global application., Trial Registration: ISRCTN, ISRCTN26008944. Registered on 30 October 2019., (© 2024. The Author(s).)

Recovery Colleges (RCs) are learning-based mental health recovery communities, located globally. However, evidence on RC effectiveness outside Western, educated, industrialised, rich, and democratic (WEIRD) countries is limited. This study aimed to evaluate associations between cultural characteristics and RC fidelity, to understand how culture impacts RC operation. Service managers from 169 RCs spanning 28 WEIRD and non-WEIRD countries assessed the fidelity using the RECOLLECT Fidelity Measure, developed based upon key RC operation components. Hofstede's cultural dimension scores were entered as predictors in linear mixed-effects regression models, controlling for GDP spent on healthcare and Gini coefficient. Higher Individualism and Indulgence, and lower Uncertainty Avoidance were associated with higher fidelity, while Long-Term Orientation was a borderline negative predictor. RC operations were predominantly aligned with WEIRD cultures, highlighting the need to incorporate non-WEIRD cultural perspectives to enhance RCs' global impact. Findings can inform the refinement and evaluation of mental health recovery interventions worldwide., (© 2024. The Author(s).)

Background: Stakeholder engagement is essential to the design, implementation and evaluation of complex mental health interventions like peer support. Theory of Change (ToC) is commonly used in global health research to help structure and promote stakeholder engagement throughout the project cycle. Stakeholder insights are especially important in the context of a multi-site trial, in which an intervention may need to be adapted for implementation across very different settings while maintaining fidelity to a core model. This paper describes the development of a ToC for a peer support intervention to be delivered to people with severe mental health conditions in five countries as part of the UPSIDES trial., Methods: One hundred thirty-four stakeholders from diverse backgrounds participated in a total of 17 workshops carried out at six UPSIDES implementing sites across high-, middle- and low-income settings (one site each in India, Israel, Uganda and Tanzania; two sites in Germany). The initial ToC maps created by stakeholders at each site were integrated into a cross-site ToC map, which was then revised to incorporate additional insights from the academic literature and updated iteratively through multiple rounds of feedback provided by the implementers., Results: The final ToC map divides the implementation of the UPSIDES peer support intervention into three main stages: preparation, implementation, and sustainability. The map also identifies three levels of actors involved in peer support: individuals (service users and peer support workers), organisations (and their staff members), and the public. In the UPSIDES trial, the ToC map proved especially helpful in characterising and distinguishing between (a) common features of peer support, (b) shared approaches to implementation and (c) informing adaptations to peer support or implementation to account for contextual differences., Conclusions: UPSIDES is the first project to develop a multi-national ToC for a mental health peer support intervention. Stakeholder engagement in the ToC process helped to improve the cultural and contextual appropriateness of a complex intervention and ensure equivalence across sites for the purposes of a multi-site trial. It may serve as a blueprint for implementing similar interventions with a focus on recovery and social inclusion among people with mental ill-health across diverse settings., Trial Registration: ISRCTN26008944 (Registration Date: 30/10/2019)., (© 2024. The Author(s).)

Background: Peer support in mental health is a low-threshold intervention with increasing evidence for enhancing personal recovery and empowerment of persons living with severe mental health conditions. As peer support spreads globally, there is a growing need for peer support training programmes that work well in different contexts and cultures. This study evaluates the applicability and transferability of implementing a manualised multi-national training programme for mental health peer support workers called UPSIDES from the perspective of different local stakeholders in high-, middle-, and low-income countries., Method: Data from seven focus groups across six study sites in Africa (Tanzania, Uganda), Asia (India, Israel), and Europe (Germany 2 sites) with 44 participants (3 service users, 7 peer support workers, 25 mental health staff members, 6 clinical directors and 3 local community stakeholders) were thematically analysed., Results: 397 codes were identified, which were thematically analysed. Five implementation enablers were identified: (i) Enhancing applicability through better guidance and clarity of training programme management, (ii) provision of sufficient time for training, (iii) addressing negative attitudes towards peer support workers by additional training of organisations and staff, (iv) inclusion of core components in the training manual such as communication skills, and (v) addressing cultural differences of society, mental health services and discrimination of mental health conditions., Discussion: Participants in all focus groups discussed the implementation of the training and peer support intervention to a greater extent than the content of the training. This is in line with growing literature of difficulties in the implementation of peer support including difficulties in hiring peer support workers, lack of funding, and lack of role clarity. The results of this qualitative study with stakeholders from different mental health settings worldwide emphasises the need to further investigate the successful implementation of peer support training. All results have been incorporated into the manualisation of the UPSIDES peer support training., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Nixdorf et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objectives: Despite the established evidence base for mental health peer support work, widespread implementation remains a challenge. This study aimed to explore societal and organisational influences on the implementation of peer support work in low-income and high-income settings., Design: Study sites conducted two focus groups in local languages at each site, using a topic guide based on a conceptual framework describing eight peer support worker (PSW) principles and five implementation issues. Transcripts were translated into English and an inductive thematic analysis was conducted to characterise implementation influences., Setting: The study took place in two tertiary and three secondary mental healthcare sites as part of the Using Peer Support in Developing Empowering Mental Health Services (UPSIDES) study, comprising three high-income sites (Hamburg and Ulm, Germany; Be'er Sheva, Israel) and two low-income sites (Dar es Salaam, Tanzania; Kampala, Uganda) chosen for diversity both in region and in experience of peer support work., Participants: 12 focus groups were conducted (including a total of 86 participants), across sites in Ulm (n=2), Hamburg (n=2), Dar es Salaam (n=2), Be'er Sheva (n=2) and Kampala (n=4). Three individual interviews were also done in Kampala. All participants met the inclusion criteria: aged over 18 years; actual or potential PSW or mental health clinician or hospital/community manager or regional/national policy-maker; and able to give informed consent., Results: Six themes relating to implementation influences were identified: community and staff attitudes, resource availability, organisational culture, role definition, training and support and peer support network., Conclusions: This is the first multicountry study to explore societal attitudes and organisational culture influences on the implementation of peer support. Addressing community-level discrimination and developing a recovery orientation in mental health systems can contribute to effective implementation of peer support work. The relationship between societal stigma about mental health and resource allocation decisions warrants future investigation., Trial Registration Number: ISRCTN26008944., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Background: There is limited data on the burden of mental disorders among children in the general population in Africa. We examined the prevalence and correlates of neurocognitive and psychiatric disorders among schoolchildren in Uganda. Methods: This cross-sectional study enrolled 322 schoolchildren aged 5-17years in Wakiso, Uganda. We assessed for neurocognitive impairment using the Kaufmann-Assessment-Battery, and psychiatric disorders (major-depressive-disorder (MDD), attention-deficit-hyperactivity-disorder (ADHD), generalised-anxiety-disorder (GAD), and substance-use-disorder (SUD)) using the parent version of the Child and Adolescent Symptom Inventory-5, and Youth Inventory-4R Self Report. Prevalence and risk factors were determined using respectively descriptive statistics, and univariable and multivariable logistic regression. Results: Twenty-five participants (8%) had neurocognitive impairment. Nineteen (5.9%) participants had MDD, nine (2.8%) had ADHD, seven (2.2%) had GAD, 14 (8.6%) had SUD; and 30 (9.3%) had any psychiatric disorder. Among the exposure variables examined in this study, including asthma, age, sex, grade of schooling, type of school and maternal and father's education and family socio-economic status, only asthma was associated with the disorders (MDD). Conclusions: The relatively high burden of mental disorders in this general population of children warrants targeted screening of those at risk, and treatment of those affected. Further, future studies should extensively investigate the factors that underlie the identified psychiatric disorders in this and similar general populations., Competing Interests: No competing interests were disclosed., (Copyright: © 2022 Nampijja M et al.)

There is growing recognition of the burden of depression in people living with HIV/AIDS (PLWHA), associated with negative behavioural and clinical outcomes. Unfortunately, most HIV care providers in sub-Saharan Africa do not routinely provide mental health services to address this problem. This article describes the process of developing a model for integrating the management of depression in HIV care in Uganda. Theory of Change (ToC) methodology was used to guide the process of developing the model. Three successive ToC workshops were held with a multi-disciplinary group of 38 stakeholders within Wakiso district, in the Central region of Uganda. The first 2 workshops were for generating practical ideas for a feasible and acceptable model of integrating the management of depression in HIV care at all levels of care within the district healthcare system; while the third and final workshop was for consensus building. Following meaningful brainstorming and discussions, the stakeholders suggested improved mental wellbeing among PLWHA as the ultimate outcome of the program. This would be preceded by short-term and intermediate outcomes including reduced morbidity among persons with HIV attributable to depression, allocation of more resources towards management of depression, increased help-seeking among depressed PLWHA and more health workers detecting and managing depression. These would be achieved following several interventions undertaken at all levels of care. The participants further identified some indicators of successful implementation such as emphasis of depression management in the district healthcare plans, increased demand for anti-depressants etc; as well as various assumptions underlying the intervention. All these were graphically aligned in a causal pathway, leading to a ToC map, contextualizing and summarizing the intervention model. The ToC was a valuable methodology that brought together stakeholders to identify key strategies for development of a comprehensible contextualized intervention model for managing depression within HIV care in Uganda; allowing greater stakeholder engagement and buy-in., Competing Interests: The authors have declared that no competing interests exist.

Background: There is limited data on the burden of mental disorders among 'healthy' children in Africa. We examined the prevalence and correlates of neurocognitive and psychiatric disorders among schoolchildren in Uganda. Methods : This cross-sectional study enrolled 322 schoolchildren aged 5-17years in Wakiso, Uganda. We assessed for neurocognitive impairment using the Kaufmann-Assessment-Battery, and psychiatric disorders (major-depressive-disorder (MDD), attention-deficit-hyperactivity-disorder (ADHD), generalised-anxiety-disorder (GAD), and substance-use-disorder (SUD)) using the parent version of the Child and Adolescent Symptom Inventory-5, and Youth Inventory-4R Self Report. Prevalence and risk factors were determined using percentages and logistic regression. Results: Twenty-five participants (8%) had neurocognitive impairment. Nineteen (5.9%) participants had MDD, nine (2.8%) had ADHD, seven (2.2%) had GAD, 14 (8.6%) had SUD; and 30 (9.3%) had any psychiatric disorder. None of the factors examined were associated with the disorders. Conclusions: The unexpectedly high burden of mental disorders in this general population of children warrants targeted screening of those at risk, and treatment of those affected. Further, future studies should extensively investigate the factors that underlie the identified psychiatric disorders in this and similar general populations., Competing Interests: No competing interests were disclosed., (Copyright: © 2021 Nampijja M et al.)

Background: A recent editorial urged those working in global mental health to "change the conversation" on coronavirus disease (Covid-19) by putting more focus on the needs of people with severe mental health conditions. UPSIDES (Using Peer Support In Developing Empowering mental health Services) is a six-country consortium carrying out implementation research on peer support for people with severe mental health conditions in high- (Germany, Israel), lower middle- (India) and low-income (Tanzania, Uganda) settings. This commentary briefly outlines some of the key challenges faced by UPSIDES sites in low- and middle-income countries as a result of Covid-19, sharing early lessons that may also apply to other services seeking to address the needs of people with severe mental health conditions in similar contexts., Challenges and Lessons Learned: The key take-away from experiences in India, Tanzania and Uganda is that inequalities in terms of access to mobile technologies, as well as to secure employment and benefits, put peer support workers in particularly vulnerable situations precisely when they and their peers are also at their most isolated. Establishing more resilient peer support services requires attention to the already precarious situation of people with severe mental health conditions in low-resource settings, even before a crisis like Covid-19 occurs. While it is essential to maintain contact with peer support workers and peers to whatever extent is possible remotely, alternatives to face-to-face delivery of psychosocial interventions are not always straightforward to implement and can make it more difficult to observe individuals' reactions, talk about emotional issues and offer appropriate support., Conclusions: In environments where mental health care was already heavily medicalized and mostly limited to medications issued by psychiatric institutions, Covid-19 threatens burgeoning efforts to pursue a more holistic and person-centered model of care for people with severe mental health conditions. As countries emerge from lockdown, those working in global mental health will need to redouble their efforts not only to make up for lost time and help individuals cope with the added stressors of Covid-19 in their communities, but also to regain lost ground in mental health care reform and in broader conversations about mental health in low-resource settings.

Background: Peer support work roles are being implemented internationally, and increasingly in lower-resource settings. However, there is no framework to inform what types of modifications are needed to address local contextual and cultural aspects., Aims: To conduct a systematic review identifying a typology of modifications to peer support work for adults with mental health problems., Method: We systematically reviewed the peer support literature following PRISMA guidelines for systematic reviews (registered on PROSPERO (International Prospective Register of Systematic Reviews) on 24 July 2018: CRD42018094832). All study designs were eligible and studies were selected according to the stated eligibility criteria and analysed with standardised critical appraisal tools. A narrative synthesis was conducted to identify types of, and rationales for modifications., Results: A total of 15 300 unique studies were identified, from which 39 studies were included with only one from a low-resource setting. Six types of modifications were identified: role expectations; initial training; type of contact; role extension; workplace support for peer support workers; and recruitment. Five rationales for modifications were identified: to provide best possible peer support; to best meet service user needs; to meet organisational needs, to maximise role clarity; and to address socioeconomic issues., Conclusions: Peer support work is modified in both pre-planned and unplanned ways when implemented. Considering each identified modification as a candidate change will lead to a more systematic consideration of whether and how to modify peer support in different settings. Future evaluative research of modifiable versus non-modifiable components of peer support work is needed to understand the modifications needed for implementation among different mental health systems and cultural settings.

Background: Peer support is an established intervention involving a person recovering from mental illness supporting others with mental illness. Peer support is an under-used resource in global mental health. Building upon comprehensive formative research, this study will rigorously evaluate the impact of peer support at multiple levels, including service user outcomes (psychosocial and clinical), peer support worker outcomes (work role and empowerment), service outcomes (cost-effectiveness and return on investment), and implementation outcomes (adoption, sustainability and organisational change)., Methods: UPSIDES-RCT is a pragmatic, parallel-group, multicentre, randomised controlled trial assessing the effectiveness of using peer support in developing empowering mental health services (UPSIDES) at four measurement points over 1 year (baseline, 4-, 8- and 12-month follow-up), with embedded process evaluation and cost-effectiveness analysis. Research will take place in a range of high-, middle- and low-income countries (Germany, UK, Israel, India, Uganda and Tanzania). The primary outcome is social inclusion of service users with severe mental illness (N = 558; N = 93 per site) at 8-month follow-up, measured with the Social Inclusion Scale. Secondary outcomes include empowerment (using the Empowerment Scale), hope (using the HOPE scale), recovery (using Stages of Recovery) and health and social functioning (using the Health of the Nations Outcome Scales). Mixed-methods process evaluation will investigate mediators and moderators of effect and the implementation experiences of four UPSIDES stakeholder groups (service users, peer support workers, mental health workers and policy makers). A cost-effectiveness analysis examining cost-utility and health budget impact will estimate the value for money of UPSIDES peer support., Discussion: The UPSIDES-RCT will explore the essential components necessary to create a peer support model in mental health care, while providing the evidence required to sustain and eventually scale-up the intervention in different cultural, organisational and resource settings. By actively involving and empowering service users, UPSIDES will move mental health systems toward a recovery orientation, emphasising user-centredness, community participation and the realisation of mental health as a human right., Trial Registration: ISRCTN, ISRCTN26008944. Registered on 30 October 2019.

Background: Reducing readmissions among frequent users of psychiatric inpatient care could result in substantial cost savings to under-resourced mental health systems. Studies from high-income countries indicate that formal peer support can be an effective intervention for the reduction of readmissions among frequent users. Although in recent years formal peer support programmes have been established in mental health services in a few low- and middle-income countries (LMICs), they have not been rigorously evaluated., Methods: This protocol describes a quasi-experimental difference-in-differences study conducted as part of a broader evaluation of the Brain Gain II peer support programme based at Butabika National Referral Hospital in Kampala, Uganda. The primary objective is to investigate whether frequent users of psychiatric inpatient care who have access to a peer support worker (PSW+) experience a greater reduction in rehospitalisation rates and number of days spent in hospital compared to those who do not have access to a peer support worker (PSW-). Frequent users, defined as adults diagnosed with either a mental disorder or epilepsy who have had three or more inpatient stays at Butabika over the previous 24 months, are referred to Brain Gain II by hospital staff on five inpatient wards. Frequent users who normally reside in a district where peer support workers currently operate (Kampala, Jinja, Wakiso and Mukono) are eligible for formal peer support and enter the PSW+ group. Participants in the PSW+ group are expected to receive at least one inpatient visit by a trained peer support worker before hospital discharge and three to six additional visits after discharge. Frequent users from other districts enter the PSW- group and receive standard care. Participants' admissions data are extracted from hospital records at point of referral and six months following referral., Discussion: To the best of our knowledge, this will be the first quasi-experimental study of formal peer support in a LMIC and the first to assess change in readmissions, an outcome of particular relevance to policy-makers seeking cost-effective alternatives to institutionalised mental health care.

Background: There is still wide variability in HIV disease course and other HIV-related outcomes, attributable in part to psychosocial factors such as major depressive disorder (MDD), a subject that has received little attention in sub-Saharan Africa., Methods: Using a longitudinal cohort of 1099 HIV-positive antiretroviral therapy-naive persons, we investigated the impact of MDD on 4 HIV-related negative outcome domains in Uganda. MDD was assessed using a Diagnostic Statistical Manual IV-based tool. Also collected were data on surrogate measures of the HIV-related outcome domains. Data were collected at the 3 time points of baseline, 6, and 12 months. Multiple regression and discrete time survival models were used to investigate the relationship between MDD and indices of the HIV outcomes., Results: MDD was a significant predictor of "missed antiretroviral therapy doses" [adjusted odds ratio (aOR) = 4.75, 95% confidence interval (CI): 1.87 to 12.04, P = 0.001], "time to first visit to healthy facility" (aOR = 1.71; 95% CI: 1.07 to 2.73; P = 0.024), "time to first self-reported risky sexual activity" (aOR = 2.11, 95% CI: 1.27 to 3.49; P = 0.004) but not of "CD4 counts at months 6 and 12" (estimated effect 29.0; 95% CI: -7.8 to 65.7; P = 0.12), and "time to new WHO stage 3 or 4 clinical event" (aOR = 0.52, 95% CI: 0.12 to 2.20, P = 0.37)., Conclusions: MDD significantly impacted 3 of the 4 investigated outcome domains. These results by demonstrating the adverse consequences of an untreated mental health disorder (MDD) on HIV-related outcomes further strengthen the need to urgently act on WHO's call to integrate mental health care in general HIV care.

The International Health Partnership ('the Link') between the East London NHS Foundation Trust and Butabika Hospital in Uganda was set up in 2005. It has facilitated staff exchanges and set up many workstreams (e.g. in child and adolescent psychiatry, nursing and psychology) and projects (e.g. a peer support worker project and a violence reduction programme). The Link has been collaborative and mutually beneficial. The authors describe benefits and challenges at individual and organisational levels. Notably, the Link has achieved a commitment to service user involvement and an increasingly central involvement of the Ugandan diaspora working in mental health in the UK.