Training school teachers to promote mental and social well-being in low and middle income countries : lessons to facilitate scale-up from a participatory action research trial of youth first in India

Mental and social wellbeing (MSWB) promotion programs could improve mental health and other outcomes for youth in Low and Middle Income Countries (LMICs). Unfortunately, few such programs have progressed to scale-up and few studies have detailed processes and considerations that could facilitate doing so. This study begins to fill these gaps, describing key findings from training and supporting government middle school teachers to deliver the Youth First Resilience Curriculum, a MSWB promotion program, in Bihar, India. We conducted a Participatory Action Research trial of the resilience curriculum among 792 middle school youth and 55 teachers at 15 government schools. Participant-observations, exit interviews, and group discussions were conducted and analyzed via multiple rounds of coding to generate thematic findings. A number of schools showed relatively high levels of interest, session reliability and fidelity, student interaction and teacher facilitative abilities, but there was great variation within the sample. Three leverage points emerged to facilitate future scale-up: factors for successful site assessment and program initiation, supporting teacher success via interest and motivation, and responding to varied teacher skill levels. These points represent critical focus areas for practitioners and policy-makers as more MSWB promotion programs begin to scale in LMICs.peer-reviewe

The acceptability, feasibility and impact of a lay health counsellor delivered health promoting schools programme in India: a case study evaluation.

BACKGROUND: Studies in resource-limited settings have shown that there are constraints to the use of teachers, peers or health professionals to deliver school health promotion interventions. School health programmes delivered by trained lay health counsellors could offer a cost-effective alternative. This paper presents a case study of a multi-component school health promotion intervention in India that was delivered by lay school health counsellors, who possessed neither formal educational nor health provider qualifications. METHODS: The intervention was based on the WHO's Health Promoting Schools framework, and included health screening camps; an anonymous letter box for student questions and complaints; classroom-based life skills training; and, individual psycho-social and academic counselling for students. The intervention was delivered by a lay school health counsellor who had attained a minimum of a high school education. The counsellor was trained over four weeks and received structured supervision from health professionals working for the implementing NGO. The evaluation design was a mixed methods case study. Quantitative process indicators were collected to assess the extent to which the programme was delivered as planned (feasibility), the uptake of services (acceptability), and the number of students who received corrective health treatment (evidence of impact). Semi-structured interviews were conducted over two years with 108 stakeholders, and were analysed to identify barriers and facilitators for the programme (feasibility), evaluate acceptability, and gather evidence of positive or negative effects of the programme. RESULTS: Feasibility was established by the high reported coverage of all the targeted activities by the school health counsellor. Acceptability was indicated by a growing number of submissions to the students' anonymous letter-box; more students self-referring for counselling services over time; and, the perceived need for the programme, as expressed by principals, parents and students. A minority of teachers complained that there was inadequate information sharing about the programme and mentioned reservations about the capacities of the lay health counsellor. Preliminary evidence of the positive effects of the programme included the correction of vision problems detected in health screening camps, and qualitative evidence of changes in health-related knowledge and behaviour of students. CONCLUSION: A task-shifting approach of delegating school health promotion activities to lay school health counsellors rather than education or health professionals shows promise of effectiveness as a scalable model for promoting the health and well being of school based adolescents in resource constrained settings

The integration of the treatment for common mental disorders in primary care: experiences of health care providers in the MANAS trial in Goa, India

BACKGROUND: The MANAS trial reported that a Lay Health Counsellor (LHC) led collaborative stepped care intervention (the "MANAS intervention") for Common Mental Disorders (CMD) was effective in public sector primary care clinics but private sector General Practitioners (GPs) did as well with or without the additional counsellor. This paper aims to describe the experiences of integrating the MANAS intervention in primary care. METHODS: Qualitative semi-structured interviews with key members (n = 119) of the primary health care teams upon completion of the trial and additional interviews with control arm GPs upon completion of the outcome analyses which revealed non-inferiority of this arm. RESULTS: Several components of the MANAS intervention were reported to have been critically important for facilitating integration, notably: screening and the categorization of the severity of CMD; provision of psychosocial treatments and adherence management; and the support of the visiting psychiatrist. Non-adherence was common, often because symptoms had been controlled or because of doubt that health care interventions could address one's 'life difficulties'. Interpersonal therapy was intended to be provided face to face by the LHC; however it could not be delivered for most eligible patients due to the cost implications related to travel to the clinic and the time lost from work. The LHCs had particular difficulty in working with patients with extreme social difficulties or alcohol related problems, and elderly patients, as the intervention seemed unable to address their specific needs. The control arm GPs adopted practices similar to the principles of the MANAS intervention; GPs routinely diagnosed CMD and provided psychoeducation, advice on life style changes and problem solving, prescribed antidepressants, and referred to specialists as appropriate. CONCLUSION: The key factors which enhance the acceptability and integration of a LHC in primary care are training, systematic steps to build trust, the passage of time, the observable impacts on patient outcomes, and supervision by a visiting psychiatrist. Several practices by the control arm GPs approximated those of the LHC which may partly explain our findings that they were as effective as the MANAS intervention arm GPs in enabling recovery

The human homologue of unc-93 maps to chromosome 6q27 – characterisation and analysis in sporadic epithelial ovarian cancer

BACKGROUND: In sporadic ovarian cancer, we have previously reported allele loss at D6S193 (62%) on chromosome 6q27, which suggested the presence of a putative tumour suppressor gene. Based on our data and that from another group, the minimal region of allele loss was between D6S264 and D6S149 (7.4 cM). To identify the putative tumour suppressor gene, we established a physical map initially with YACs and subsequently with PACs/BACs from D6S264 to D6S149. To accelerate the identification of genes, we sequenced the entire contig of approximately 1.1 Mb. Seven genes were identified within the region of allele loss between D6S264 and D6S149. RESULTS: The human homologue of unc-93 (UNC93A) in C. elegans was identified to be within the interval of allele loss centromeric to D6S149. This gene is 24.5 kb and comprises of 8 exons. There are two transcripts with the shorter one due to splicing out of exon 4. It is expressed in testis, small intestine, spleen, prostate, and ovary. In a panel of 8 ovarian cancer cell lines, UNC93A expression was detected by RT-PCR which identified the two transcripts in 2/8 cell lines. The entire coding sequence was examined for mutations in a panel of ovarian tumours and ovarian cancer cell lines. Mutations were identified in exons 1, 3, 4, 5, 6 and 8. Only 3 mutations were identified specifically in the tumour. These included a c.452G>A (W151X) mutation in exon 3, c.676C>T (R226X) in exon 5 and c.1225G>A(V409I) mutation in exon 8. However, the mutations in exon 3 and 5 were also present in 6% and 2% of the normal population respectively. The UNC93A cDNA was shown to express at the cell membrane and encodes for a protein of 60 kDa. CONCLUSIONS: These results suggest that no evidence for UNC93A as a tumour suppressor gene in sporadic ovarian cancer has been identified and further research is required to evaluate its normal function and role in the pathogenesis of ovarian cancer

The psychological and social contexts of complaints of abnormal vaginal discharge: a study of illness narratives in India.

OBJECTIVE: Epidemiological studies have reported strong associations between psychosocial adversity and complaints of abnormal vaginal discharge (AVD) in South Asia. We aimed to explore the mechanism of these associations through qualitative research. METHOD: We carried out serial in-depth interviews with 42 married women with the complaint of AVD who were purposively selected from a sample of 2494 women recruited into a population-based cohort study in Goa, India. The interviews elicited illness narratives of their complaint, focusing on causal attributions and help-seeking behaviors. RESULTS: Women explicitly link their personal experiences of social adversity and stress (such as marital problems and heavy workloads) with their complaints of AVD. The complaint of tiredness, a core feature of depressive and somatoform disorders, and complaint of "tension" were commonly associated with AVD through bidirectional causal interpretations. Reproductive events, particularly related to the menstrual cycle and contraception, comprise another set of causal attributions. Many women hold multiple causal attributions. Most women sought health care, both biomedical and traditional, and their narratives indicate reinforcement of their causal attributions by health care providers. However, treatments were often discontinued or changed due to lack of symptomatic relief, side effects, or costs. CONCLUSIONS: Reproductive health policy and practice must explicitly acknowledge and integrate research findings on psychosocial associations of AVD to promote a holistic and evidence-based approach for this common complaint in women in South Asia

The explanatory models of depression in low income countries: listening to women in India.

INTRODUCTION: Women, and persons facing social and economic disadvantage, are at greater risk for depressive disorders. Our objective was to describe the explanatory models of illness in depressed women, in particular, their idioms of distress, and their views of their social circumstances and how this related to their illness. METHOD: We carried out a qualitative investigation nested in a population based cohort study of women's mental and reproductive health in Goa, India. We purposively sampled women who were ever-married and who had been found to be suffering from a depressive disorder on the basis of a structured diagnostic interview. In-depth interviews were carried out about six months apart exploring stressors in women's lives, a typical day in their recent lives, and their illness narratives (idioms of distress, causal models, impact of illness, help-seeking). RESULTS: 35 women consented to participate in the study, 28 completing both interviews. Women gave expression to their problems primarily through somatic complaints, typically a variety of body aches, autonomic symptoms, gynecological symptoms and sleep problems. There was frequent mention of overall "weakness" and tiredness. Economic difficulties and difficulties with interpersonal relationships (particularly related to marital relationships) were the most common causal models. However, women rarely considered biomedical concepts, for example, the notion that they may suffer from an illness or that their complaints were due to a biochemical disturbance in the brain. Despite the lack of a biomedical concept, most of the participants had sought medical help, typically for reproductive and somatic complaints. CONCLUSIONS: We recommend the use of somatic idioms as the defining clinical features, and a broader, psychosocial model for understanding the aetiology and conceptualization of the clinical syndrome of depression for public health interventions and mental health promotion in the Indian context