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Implementing Psychological Interventions Through Nonspecialist Providers and Telemedicine in High-Income Countries: Qualitative Study from a Multistakeholder Perspective.

ABSTRACT: BACKGROUND:Task sharing has been used worldwide to improve access to mental health care, where nonspecialist providers-individuals with no formal training in mental health-have been trained to effectively treat perinatal depressive and anxiety symptoms. Little formative research has been conducted to examine relevant barriers and facilitators of nonspecialist providers and the use of telemedicine in treatment service delivery. OBJECTIVE:The primary objective of this study was to examine the main barriers and facilitators of nonspecialist provider-delivered psychological treatments for perinatal populations with common mental health disorders, such as depression and anxiety, from a multistakeholder perspective. METHODS:This study took place in Toronto, Canada. In total, 33 in-depth interviews were conducted with multiple stakeholder groups (women with lived experience and their significant others, as well as health and mental health professionals). Qualitative data were quantified to estimate commonly endorsed themes within and across stakeholder groups. RESULTS:Psychological treatments delivered by nonspecialist providers were considered acceptable by the vast majority of participants (30/33, 90%). Across all stakeholder groups, nurses (20/33, 61%) and midwives (14/33, 42%) were the most commonly endorsed cadre of nonspecialist providers. The majority of stakeholders (32/33, 97%) were amenable to nonspecialist providers delivering psychological treatment via telemedicine (27/33, 82%), although concerns were raised about the ability to establish a therapeutic alliance via telemedicine (16/33, 48%). Empathy was the most desired characteristic of a nonspecialist provider (61%). Patient and patient advocate stakeholders were more likely to emphasize stigma as an important barrier to accessing psychological treatments (7/12, 58%), compared to clinicians (2/9, 22%) and spouses (1/5, 20%). Clinician stakeholders were more likely to emphasize the importance of ensuring nonspecialist providers were trained to deliver psychological treatments (3/9, 33%), compared to other stakeholder groups. CONCLUSIONS:These results can inform the design, implementation, and integration of nonspecialist-delivered interventions via telemedicine for women with perinatal depressive and anxiety symptoms in high-income country contexts.

SUBMITTER: Singla DR

PROVIDER: S-EPMC7484770 | biostudies-literature | 2020 Aug

REPOSITORIES: biostudies-literature

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Implementing Psychological Interventions Through Nonspecialist Providers and Telemedicine in High-Income Countries: Qualitative Study from a Multistakeholder Perspective.

Singla Daisy Radha DR Lemberg-Pelly Sasha S Lawson Andrea A Zahedi Nika N Thomas-Jacques Tyla T Dennis Cindy-Lee CL

JMIR mental health 20200827 8

<h4>Background</h4>Task sharing has been used worldwide to improve access to mental health care, where nonspecialist providers-individuals with no formal training in mental health-have been trained to effectively treat perinatal depressive and anxiety symptoms. Little formative research has been conducted to examine relevant barriers and facilitators of nonspecialist providers and the use of telemedicine in treatment service delivery.<h4>Objective</h4>The primary objective of this study was to e ...[more]

PMID: 32852281

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Project description:Hypertension remains the leading cause of cardiovascular disease worldwide and disproportionately impacts patients living in low- and middle-income countries (LMICs). Telemedicine offers a potential solution for improving access to health care for vulnerable patients in LMICs.ObjectivesThe purpose of this scoping review was to summarize the evidence for telemedicine interventions for blood pressure management in LMICs and assess the relationships between the telemedicine intervention characteristics and clinical outcomes.DesignPublished studies were identified from the following databases (from their inception to May 2020): PubMed, Scopus, and Embase. Search terms related to "Low and Middle Income Countries," "Telemedicine," and "Hypertension" were used, and clinical outcomes were extracted from the screened articles.ResultsOur search resulted in 530 unique articles, and 14 studies were included in this review. Five studies assessed telemedicine interventions for patient-provider behavioral counseling, four assessed patient-provider medical management, and five assessed provider-provider consultation technologies. Out of fourteen individual studies, eleven demonstrated a significant improvement in systolic or diastolic blood pressure in the intervention group. Of the eight studies that reported difference-in-differences changes in systolic blood pressure, between-arm differences ranged from 13.2 mmHg to 0.4 mmHg.ConclusionsThe majority of the studies in this review demonstrated a significant reduction in blood pressure with use of the telemedicine intervention, though the magnitude of benefit was not consistently large. Limitations of the studies included small sample sizes, short duration, and intervention heterogeneity. Current evidence suggests that telemedicine may provide a promising approach to increase access to care and improve outcomes for hypertension in LMICs, especially during events that limit access to in-person care, such as the COVID-19 pandemic. However, high-quality clinical trials of sufficient size and duration are needed to establish the impact and role of telemedicine in hypertension care. The protocol for this review was not registered.

Project description:ImportanceTask sharing-or training of nonspecialist providers with no formal training in counseling-is an effective strategy to improve access to evidence-based counseling interventions and has the potential to address the burden of perinatal depression and anxiety.ObjectivesTo identify the relevant implementation processes (who, what, where, and how) and to assess the effectiveness of counseling interventions delivered by nonspecialist providers for perinatal depression and anxiety in high-income countries.Data sourcesCINAHL, Ovid MEDLINE, Ovid MEDLINE In-Process, PsycINFO, Web of Science, Cochrane Central Register of Controlled Trials, and Embase through December 31, 2019. Relevant systematic reviews were also considered.Study selectionRandomized clinical trials of counseling interventions that assessed depression or anxiety after intervention, delivered by a nonspecialist provider for adults, and that targeted perinatal populations in a high-income country were included. Self-help interventions that did not include a provider component were excluded.Data extraction and synthesisFour researchers independently reviewed abstracts and full-text articles, and 2 independently rated the quality of included studies. Random-effects meta-analysis was used to estimate the benefits of the interventions. The Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline was followed.Main outcomes and measuresFor implementation processes, the frequencies represented by a total or percentage were estimated, where the denominator is the total number of eligible trials, unless otherwise indicated. For effectiveness, primary and secondary outcome data of depression, anxiety, or both symptoms were used, with separate analyses for prevention and treatment, stratified by depression or anxiety. Subgroup analyses compared outcome types (anxiety vs depression) and study objectives (treatment vs prevention).ResultsIn total, 46 trials (18 321 participants) were included in the systematic review; 44 trials (18 101 participants) were included in the meta-analysis. Interventions were implemented across 11 countries, with the majority in Australia, UK, and US. Two-thirds (65%) of counseling interventions were provided by nurses and midwives, lasted a mean of 11.2 weeks (95% CI, 6.4-16.0 weeks), and most were delivered face to face (31 [67.4%]). Only 2 interventions were delivered online. A dearth of information related to important implementation processes, such as supervision, fidelity, and participant sociodemographic characteristics, was observed in many articles. Compared with controls, counseling interventions were associated with lower depressive symptoms (standardized mean difference [SMD], 0.24 [95% CI, 0.14-0.34]; 43 trials; I2 = 81%) and anxiety scores (SMD, 0.30 [95% CI, 0.11-0.50]; 11 trials; I2 = 80%). Treatment interventions were reported to be effective for both depressive symptoms (SMD, 0.38 [95% CI, 0.17-0.59]; 15 trials; I2 = 69%) and anxiety symptoms (SMD, 0.34 [95% CI, 0.09-0.58]; 6 trials; I2 = 71%). However, heterogeneity was high among the trials included in this analysis.Conclusions and relevanceThis study found evidence in high-income countries indicating that nonspecialist providers may be effective in delivering counseling interventions. Additional studies are needed to assess digital interventions and ensure the reporting of implementation processes to inform the optimal delivery and scale-up of these services.

Project description:BackgroundAdjunctive psychological interventions for bipolar disorder have demonstrated better efficacy in preventing or delaying relapse and improving outcomes compared with pharmacotherapy alone.AimsTo evaluate the efficacy of psychological interventions for bipolar disorder in low- and middle-income countries.MethodA systematic review was conducted using PubMed, PsycINFO, Medline, EMBASE, Cochrane database for systematic review, Cochrane central register of controlled trials, Latin America and Caribbean Center on Health Science Literature and African Journals Online databases with no restriction of language or year of publication. Methodological heterogeneity of studies precluded meta-analysis.ResultsA total of 18 adjunctive studies were identified: psychoeducation (n = 14), family intervention (n = 1), group cognitive-behavioural therapy (CBT) (n = 2) and group mindfulness-based cognitive therapy (MBCT) (n = 1). In total, 16 of the 18 studies were from upper-middle-income countries and none from low-income countries. All used mental health specialists or experienced therapists to deliver the intervention. Most of the studies have moderately high risk of bias. Psychoeducation improved treatment adherence, knowledge of and attitudes towards bipolar disorder and quality of life, and led to decreased relapse rates and hospital admissions. Family psychoeducation prevented relapse, decreased hospital admissions and improved medication adherence. CBT reduced both depressive and manic symptoms. MBCT reduced emotional dysregulation.ConclusionsAdjunctive psychological interventions alongside pharmacotherapy appear to improve the clinical outcome and quality of life of people with bipolar disorder in middle-income countries. Further studies are required to investigate contextual adaptation and the role of non-specialists in the provision of psychological interventions to ensure scalability and the efficacy of these interventions in low-income country settings.Declaration of interestNone.

Project description:The vast majority of patients with chronic respiratory disease live in low- and middle-income countries (LMICs). Paradoxically, relevant interventions often fail to be effective particularly in these settings, as LMICs lack solid evidence on how to implement interventions successfully. Therefore, we aimed to identify factors critical to the implementation of lung health interventions in LMICs, and weigh their level of evidence.This systematic review followed Cochrane methodology and Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) reporting standards. We searched eight databases without date or language restrictions in July 2019, and included all relevant original, peer-reviewed articles. Two researchers independently selected articles, critically appraised them (using Critical Appraisal Skills Programme (CASP)/Meta Quality Appraisal Tool (MetaQAT)), extracted data, coded factors (following the Consolidated Framework for Implementation Research (CFIR)), and assigned levels of confidence in the factors (via Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual)). We meta-synthesised levels of evidence of the factors based on their frequency and the assigned level of confidence (PROSPERO:CRD42018088687).We included 37 articles out of 9111 screened. Studies were performed across the globe in a broad range of settings. Factors identified with a high level of evidence were: 1) "Understanding needs of local users"; 2) ensuring "Compatibility" of interventions with local contexts (cultures, infrastructures); 3) identifying influential stakeholders and applying "Engagement" strategies; 4) ensuring adequate "Access to knowledge and information"; and 5) addressing "Resource availability". All implementation factors and their level of evidence were synthesised in an implementation tool.To conclude, this study identified implementation factors for lung health interventions in LMICs, weighed their level of evidence, and integrated the results into an implementation tool for practice. Policymakers, non-governmental organisations, practitioners, and researchers may use this FRESH AIR (Free Respiratory Evaluation and Smoke-exposure reduction by primary Health cAre Integrated gRoups) Implementation tool to develop evidence-based implementation strategies for related interventions. This could increase interventions' implementation success, thereby optimising the use of already-scarce resources and improving health outcomes.

Project description:BackgroundThe effectiveness of digital psychological interventions in low-income and middle-income countries (LMICs) remains unclear. We aimed to systematically investigate the available evidence for digital psychological interventions in reducing mental health problems in LMICs.MethodsIn this systematic review and meta-analysis, we searched PubMed, PsycINFO, Embase, and Cochrane databases for articles published in English from database inception to March 9, 2020. We included randomised controlled trials investigating digital psychological interventions in individuals with mental health problems in LMICs. We extracted data on demographics, inclusion and exclusion criteria, details of the intervention, including the setting, digital delivery method, control group conditions, number of sessions, therapeutic orientation (eg, cognitive therapy or behaviour therapy), presence or absence of guidance, and length of follow-up, and statistical information to calculate effect sizes. If a study reported insufficient data to calculate effect sizes, the corresponding authors were contacted to provide data that could be aggregated. We did random-effects meta-analyses, and calculated the standardised mean difference in scores of digital psychological interventions versus control conditions (Hedges'g). Quality of evidence was assessed by use of the Grading of Recommendations Assessment, Development, and Evaluation approach. The primary outcome was post-intervention mental health problems, as measured by self-reporting instruments or clinical interviews. This study is registered with PROSPERO, CRD42019137755.FindingsWe identified 22 eligible studies that were included in the meta-analysis. The included studies involved a total of 4104 participants (2351 who received a digital psychological intervention and 1753 who were in the control group), and mainly focused on young adults (mean age of the study population was 20-35 years) with depression or substance misuse. The results showed that digital psychological interventions are moderately effective when compared with control interventions (Hedges'g 0·60 [95% CI 0·45-0·75]; Hedges'g with treatment as usual subgroup for comparison 0·54 [0·35-0·73]). Heterogeneity between studies was substantial (I2=74% [95% CI 60-83]). There was no evidence of publication bias, and the quality of evidence according to the GRADE criteria was generally high.InterpretationDigital psychological interventions, which have been mostly studied in individuals with depression and substance misuse, are superior to control conditions, including usual care, and are moderately effective in LMICs. However, the considerable heterogeneity observed in our analysis highlights the need for more studies to be done, with standardised implementation of digital psychological intervention programmes to improve their reproducibility and efficiency. Digital psychological interventions should be considered for regions where usual care for mental health problems is minimal or absent.FundingNone.TranslationsFor the Persian, Chinese, Hindi, Portuguese, Bahasa, Turkish, Romanian, Spanish and Thai translations of the abstract see Supplementary Materials section.

Project description:BackgroundHypertension and diabetes are becoming increasingly prevalent worldwide. Telemedicine is an accessible and cost-effective means of supporting hypertension and diabetes management, especially as the COVID-19 pandemic has accelerated the adoption of technological solutions for care. However, to date, no review has examined the contextual factors that influence the implementation of telemedicine interventions for hypertension or diabetes worldwide.ObjectiveWe adopted a comprehensive implementation research perspective to synthesize the barriers to and facilitators of implementing telemedicine interventions for the management of hypertension, diabetes, or both.MethodsWe performed a scoping review involving searches in Ovid MEDLINE, Embase, CINAHL, Cochrane Library, Web of Science, and Google Scholar to identify studies published in English from 2017 to 2022 describing barriers and facilitators related to the implementation of telemedicine interventions for hypertension and diabetes management. The coding and synthesis of barriers and facilitators were guided by the Consolidated Framework for Implementation Research.ResultsOf the 17,687 records identified, 35 (0.2%) studies were included in our scoping review. We found that facilitators of and barriers to implementation were dispersed across the constructs of the Consolidated Framework for Implementation Research. Barriers related to cost, patient needs and resources (eg, lack of consideration of language needs, culture, and rural residency), and personal attributes of patients (eg, demographics and priorities) were the most common. Facilitators related to the design and packaging of the intervention (eg, user-friendliness), patient needs and resources (eg, personalized information that leveraged existing strengths), implementation climate (eg, intervention embedded into existing infrastructure), knowledge of and beliefs about the intervention (eg, convenience of telemedicine), and other personal attributes (eg, technical literacy) were the most common.ConclusionsOur findings suggest that the successful implementation of telemedicine interventions for hypertension and diabetes requires comprehensive efforts at the planning, execution, engagement, and reflection and evaluation stages of intervention implementation to address challenges at the individual, interpersonal, organizational, and environmental levels.

Project description:BackgroundEvidence on the effectiveness of psychological interventions for women with common mental disorders (CMDs) who also experience intimate partner violence is scarce. We aimed to test our hypothesis that exposure to intimate partner violence would reduce intervention effectiveness for CMDs in low-income and middle-income countries (LMICs).MethodsFor this systematic review and meta-analysis, we searched MEDLINE, Embase, PsycINFO, Web of Knowledge, Scopus, CINAHL, LILACS, ScieELO, Cochrane, PubMed databases, trials registries, 3ie, Google Scholar, and forward and backward citations for studies published between database inception and Aug 16, 2019. All randomised controlled trials (RCTs) of psychological interventions for CMDs in LMICs which measured intimate partner violence were included, without language or date restrictions. We approached study authors to obtain unpublished aggregate subgroup data for women who did and did not report intimate partner violence. We did separate random-effects meta-analyses for anxiety, depression, post-traumatic stress disorder (PTSD), and psychological distress outcomes. Evidence from randomised controlled trials was synthesised as differences between standardised mean differences (SMDs) for change in symptoms, comparing women who did and who did not report intimate partner violence via random-effects meta-analyses. The quality of the evidence was assessed with the Cochrane risk of bias tool. This study is registered on PROSPERO, number CRD42017078611.FindingsOf 8122 records identified, 21 were eligible and data were available for 15 RCTs, all of which had a low to moderate risk of overall bias. Anxiety (five interventions, 728 participants) showed a greater response to intervention among women reporting intimate partner violence than among those who did not (difference in standardised mean differences [dSMD] 0·31, 95% CI 0·04 to 0·57, I2=49·4%). No differences in response to intervention were seen in women reporting intimate partner violence for PTSD (eight interventions, n=1436; dSMD 0·14, 95% CI -0·06 to 0·33, I2=42·6%), depression (12 interventions, n=2940; 0·10, -0·04 to 0·25, I2=49·3%), and psychological distress (four interventions, n=1591; 0·07, -0·05 to 0·18, I2=0·0%, p=0·681).InterpretationPsychological interventions treat anxiety effectively in women with current or recent intimate partner violence exposure in LMICs when delivered by appropriately trained and supervised health-care staff, even when not tailored for this population or targeting intimate partner violence directly. Future research should investigate whether adapting evidence-based psychological interventions for CMDs to address intimate partner violence enhances their acceptability, feasibility, and effectiveness in LMICs.FundingUK National Institute for Health Research ASSET and King's IoPPN Clinician Investigator Scholarship.

Dataset Information

Implementing Psychological Interventions Through Nonspecialist Providers and Telemedicine in High-Income Countries: Qualitative Study from a Multistakeholder Perspective.

Publications

Implementing Psychological Interventions Through Nonspecialist Providers and Telemedicine in High-Income Countries: Qualitative Study from a Multistakeholder Perspective.

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