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Mental disorders are common in people living with HIV (PLWH) but often remain untreated. This study aimed to explore the treatment gap for mental disorders in adults followed-up in antiretroviral therapy (ART) programmes in South Africa and disparities between ART programmes regarding the provision of mental health services.
We conducted a cohort study using ART programme data and linked pharmacy and hospitalisation data to examine the 12-month prevalence of treatment for mental disorders and factors associated with the rate of treatment for mental disorders among adults, aged 15–49 years, followed-up from 1 January 2012 to 31 December 2017 at one private care, one public tertiary care and two pubic primary care ART programmes in South Africa. We calculated the treatment gap for mental disorders as the discrepancy between the 12-month prevalence of mental disorders in PLWH (aged 15–49 years) in South Africa (estimated based on data from the Global Burden of Disease study) and the 12-month prevalence of treatment for mental disorders in ART programmes. We calculated adjusted rate ratios (aRRs) for factors associated with the treatment rate of mental disorders using Poisson regression.
In total, 182 285 ART patients were followed-up over 405 153 person-years. In 2017, the estimated treatment gap for mental disorders was 40.5% (95% confidence interval [CI] 19.5–52.9) for patients followed-up in private care, 96.5% (95% CI 95.0–97.5) for patients followed-up in public primary care and 65.0% (95% CI 36.5–85.1) for patients followed-up in public tertiary care ART programmes. Rates of treatment with antidepressants, anxiolytics and antipsychotics were 17 (aRR 0.06, 95% CI 0.06–0.07), 50 (aRR 0.02, 95% CI 0.01–0.03) and 2.6 (aRR 0.39, 95% CI 0.35–0.43) times lower in public primary care programmes than in the private sector programmes.
There is a large treatment gap for mental disorders in PLWH in South Africa and substantial disparities in access to mental health services between patients receiving ART in the public vs the private sector. In the public sector and especially in public primary care, PLWH with common mental disorders remain mostly untreated.
The common recommendation that adults with onset of mental illness after the age of 65 should receive specialised psychogeriatric treatment is based on limited evidence.
To compare factors related to psychiatric acute admission in older adults who have no previous psychiatric history (NPH) with that of those who have a previous psychiatric history (PPH).
Cross-sectional cohort study of 918 patients aged ≥65 years consecutively admitted to a general adult psychiatric acute unit from 2005 to 2014.
Patients in the NPH group (n = 526) were significantly older than those in the PPH group (n = 391) (77.6 v. 70.9 years P < 0.001), more likely to be men, married or widowed and admitted involuntarily. Diagnostic prevalence in the NPH and PPH groups were 49.0% v. 8.4% (P < 0.001) for organic mental disorders, 14.6% v. 30.4% (P < 0.001) for psychotic disorders, 30.2% v. 55.5% (P < 0.001) for affective disorders and 20.7% v. 13.3% (P = 0.003) for somatic disorders. The NPH group scored significantly higher on the Health of the Nation Outcome Scale (HoNOS) items agitated behaviour; cognitive problems; physical illness or disability and problems with activities of daily living, whereas those in the PPH group scored significantly higher on depressed mood. Although the PPH group were more likely to report suicidal ideation, those in the NPH group were more likely to have made a suicide attempt before the admission.
Among psychiatric patients >65 years, the subgroup with NPH were characterised by more physical frailty, somatic comorbidity and functional and cognitive impairment as well as higher rates of preadmission suicide attempts. Admitting facilities should be appropriately suited to manage their needs.
Introduction: Emergency patients with decreased level of consciousness often undergo intubation purely for airway protection from aspiration. However, the true risk of aspiration is unclear and intubation poses risks. Anecdotally, experienced emergency physicians often defer intubation in these patients while others intubate to decrease the perceived clinical and medico-legal consequences. No literature exists on the intubation practices of emergency physicians in these cases. Methods: An online questionnaire was circulated to members of the Canadian Association of Emergency Physicians. Participants were asked questions regarding two common clinical cases with decreased level of consciousness : (1) acute, uncomplicated alcohol intoxication and (2) acute, uncomplicated seizure. For each case, providers’ perceptions of aspiration risk, the standard of care, and the need for intubation were assessed. Results: 128 of the 1546 Canadian physicians contacted (8.3%) provided responses. Respondents had a median of 15 years of experience, 88% had CCFP-EM or FRCPC certification, and most worked in urban centers. When intubating, 98% agreed they were competent and 90% agreed they were well supported. A minority (17.4%) considered GCS < 8 an independent indication for intubation. For the alcohol intoxication case, 88% agreed that aspiration risk was present but only 11% agreed they commonly intubate. Only 17% agreed intubation was standard care, and only 0.8% felt their colleagues always intubate such patients. For the seizure case, 65% agreed aspiration risk existed but only 3% agreed they commonly intubate, 1% felt colleagues always intubated, and 5% agreed intubation was standard of care. Additional factors felt to compel intubation (394 total) and support non-intubation (366 total) were compiled and categorized; the most common themes emerging were objective evidence of emesis or aspiration, other standard indications for intubation, head trauma, co-ingestions, co-morbidities and clinical instability. Conclusion: It is acceptable and standard practice to avoid intubating a select subset of intoxicated and post-seizure emergency department patients despite aspiration risk. Most physicians do not view the dogma of “GCS 8, intubate” as an absolute indication for intubation in these patients. Future research is aimed at identifying key factors and evidence supporting intubation for the prevention of aspiration, as well as the development of a validated clinical decision rule for common emergency presentations.
Diagnosis, treatment, and prevention of vector-borne disease (VBD) in pets is one cornerstone of companion animal practices. Veterinarians are facing new challenges associated with the emergence, reemergence, and rising incidence of VBD, including heartworm disease, Lyme disease, anaplasmosis, and ehrlichiosis. Increases in the observed prevalence of these diseases have been attributed to a multitude of factors, including diagnostic tests with improved sensitivity, expanded annual testing practices, climatologic and ecological changes enhancing vector survival and expansion, emergence or recognition of novel pathogens, and increased movement of pets as travel companions. Veterinarians have the additional responsibility of providing information about zoonotic pathogen transmission from pets, especially to vulnerable human populations: the immunocompromised, children, and the elderly. Hindering efforts to protect pets and people is the dynamic and ever-changing nature of VBD prevalence and distribution. To address this deficit in understanding, the Companion Animal Parasite Council (CAPC) began efforts to annually forecast VBD prevalence in 2011. These forecasts provide veterinarians and pet owners with expected disease prevalence in advance of potential changes. This review summarizes the fidelity of VBD forecasts and illustrates the practical use of CAPC pathogen prevalence maps and forecast data in the practice of veterinary medicine and client education.
Introduction: September 2017 saw the launch of the British Columbia (BC) Emergency Medicine Network (EM Network), an innovative clinical network established to improve emergency care across the province. The intent of the EM Network is to support the delivery of evidence-informed, patient-centered care in all 108 Emergency Departments and Diagnostic & Treatment Centres in BC. After one year, the Network undertook a formative evaluation to guide its growth. Our objective is to describe the evaluation approach and early findings. Methods: The EM Network was evaluated on three levels: member demographics, online engagement and member perceptions of value and progress. For member demographics and online engagement, data were captured from member registration information on the Network's website, Google Analytics and Twitter Analytics. Membership feedback was sought through an online survey using a social network analysis tool, PARTNER (Program to Analyze, Record, and Track Networks to Enhance Relationships), and semi-structured individual interviews. This framework was developed based on literature recommendations in collaboration with Network members, including patient representatives. Results: There are currently 622 EM Network members from an eligible denominator of approximately 1400 physicians (44%). Seventy-three percent of the Emergency Departments and Diagnostic and Treatment Centres in BC currently have Network members, and since launch, the EM Network website has been accessed by 11,154 unique IP addresses. Online discussion forum use is low but growing, and Twitter following is high. There are currently 550 Twitter followers and an average of 27 ‘mentions’ of the Network by Twitter users per month. Member feedback through the survey and individual interviews indicates that the Network is respected and credible, but many remain unaware of its purpose and offerings. Conclusion: Our findings underscore that early evaluation is useful to identify development needs, and for the Network this includes increasing awareness and online dialogue. However, our results must be interpreted cautiously in such a young Network, and thus, we intend to re-evaluate regularly. Specific action recommendations from this baseline evaluation include: increasing face-to-face visits of targeted communities; maintaining or accelerating communication strategies to increase engagement; and providing new techniques that encourage member contributions in order to grow and improve content.
Direct measurement of individual animal dry matter intake (DMI) remains a fundamental challenge to assessing dairy feed efficiency (FE). Digesta marker, is currently the most used indirect technique for estimating DMI in production animals. In this meta-analysis we evaluated the performance of marker-based estimates against direct or observed measurements and developed equations for the prediction of FE (g energy-corrected milk (ECM)/kg DMI). Data were taken from 29 change-over studies consisting of 416 cow-within period observations. Most studies used more than one digesta marker. So, for each observed measurement of DMI, faecal dry matter output (FDMO) and apparent total tract dry matter digestibility (DMD), there was one or more corresponding marker estimate. There were 924, 409 and 846 observations for estimated FDMO (eFDMO), estimated apparent total tract DMD (eDMD) and estimated DMI (eDMI), respectively. The experimental diets were based mainly on grass silage, with soya bean or rapeseed meal as protein supplements and cereal grains or by-products as energy supplements. Across all diets, average forage to concentrate ratio on a dry matter (DM) basis was 59 : 41. Variance component and repeatability estimates of observed and marker estimations were determined using random factors in mixed procedures of SAS. Between-cow CV in observed FDMO, DMD and DMI was, 10.3, 1.69 and 8.04, respectively. Overall, the repeatability estimates of observed variables were greater than their corresponding marker-based estimates of repeatability. Regression of observed measurements on marker-based estimates gave good relationships (R2=0.87, 0.68, 0.74 and 0.74, relative prediction error =10.9%, 6.5%, 15.4% and 18.7%for FDMO, DMD, DMI and FE predictions, respectively). Despite this, the mean and slope biases were statistically significant (P<0.001) for all regressions. More than half of the errors in all regressions were due to mean and slope biases (52.4% 87.4%, 82.9% and 85.8% for FDMO, DMD, DMI and FE, respectively), whereas the contributions of random errors were small. Based on residual variance, the best model for predicting FE developed from the dataset was FE (g ECM/kg DMI)=1179(±54.1) +38.2(±2.05)×ECM(kg/day)−0.64(±0.051)×BW (kg)−75.6(±4.39)×eFDMO (kg/day). Although eDMD was positively related to FE, it only showed a tendency to reduce the residual variance. Despite inaccuracy in marker procedures, eFDMO from external markers provided a reliable determination for FE measurement. However, DMD estimated by internal markers did not improve prediction of FE, probably reflecting small variability.
Depression is a common disorder characterized by delayed help-seeking, often remaining undetected and untreated.
We sought to estimate the proportion of adults in Kamuli District with depressive symptoms and to assess their help-seeking behaviour.
This was a population-based cross-sectional study conducted in a rural district in Uganda. Sampling of study participants was done using the probability proportional to size method. Screening for depression was done using Patient Health Questionnaire (PHQ-9). The participants who screened positive also reported on whether and where they had sought treatment. Data collected using PHQ-9 was used both as a symptom-based description of depression and algorithm diagnosis of major depression. All data analysis was done using STATA version 13.
With a cut-off score of ⩾10, 6.4% screened positive for current depressive symptoms and 23.6% reported experiencing depressive symptoms in the past 12 months. The majority of individuals who screened positive for current depression (75.6%) were females. In a crude analysis, people with lower education, middle age and low socio-economic status were more likely to have depressive symptoms. Help-seeking was low, with only 18.9% of the individuals who screened positive for current depression having sought treatment from a health worker.
Depressive symptoms are common in the study district with low levels of help-seeking practices. People with lower levels of education, low socio-economic status and those in middle age are more likely to be affected by these symptoms. Most persons with current depression had past history of depressive symptoms.
Dietary phosphoglycerides and n-3 long-chain PUFA (LC-PUFA) play important functions in the development of pikeperch (Sander lucioperca) larvae. This study aimed to determine optimal dietary levels of soyabean lecithin (SBL)-derived phospholipids (PL) in starter feeds for pikeperch larvae 10–30 d post-hatch (DPH) and examine performance and ontogeny by additional supplementation of n-3 LC-PUFA in the form of Algatrium DHA 70 (glyceride product; 660–700 mg/g DHA; EPA 60–75 mg/g). In total, six isoproteic and isoenergetic extruded diets were formulated with increasing levels of PL (3·7, 8·3 or 14·5 % wet weight (w.w.), respectively); however, three of the diets were supplemented with three levels of Algatrium DHA 70 (0·6, 2·0 or 3·4 %, respectively). Liver proteomic analyses of larvae at 30 DPH were included for effects of PL and primarily DHA on performance, physiological expression and interactions in larval proteins. In addition, bone anomalies, digestive enzymatic activity, candidate gene expression and skeleton morphogenesis were examined. Results confirmed the importance of dietary PL levels of at least 8·2 % w.w., and an additional beneficiary effect of supplementation with DHA plus EPA. Thus, combined supplementation of SBL (up to 14·51 % w.w. PL) and n-3 LC-PUFA (1·004 % DM DHA and 0·169 % DM EPA) in the form of TAG resulted in highest growth and lowest incidence of anomalies, improved digestive enzyme activity and had differential effect on liver proteomics. The results denote that essential fatty acids can be supplemented as TAG to have beneficial effects in pikeperch larvae development.
The properties of the acoustic modes are sensitive to magnetic activity. The unprecedented long-term Kepler photometry, thus, allows stellar magnetic cycles to be studied through asteroseismology. We search for signatures of magnetic cycles in the seismic data of Kepler solar-type stars. We find evidence for periodic variations in the acoustic properties of about half of the 87 analysed stars. In these proceedings, we highlight the results obtained for two such stars, namely KIC 8006161 and KIC 5184732.
The treatment gap between the number of people with mental disorders and the number treated represents a major public health challenge. We examine this gap by socio-economic status (SES; indicated by family income and respondent education) and service sector in a cross-national analysis of community epidemiological survey data.
Data come from 16 753 respondents with 12-month DSM-IV disorders from community surveys in 25 countries in the WHO World Mental Health Survey Initiative. DSM-IV anxiety, mood, or substance disorders and treatment of these disorders were assessed with the WHO Composite International Diagnostic Interview (CIDI).
Only 13.7% of 12-month DSM-IV/CIDI cases in lower-middle-income countries, 22.0% in upper-middle-income countries, and 36.8% in high-income countries received treatment. Highest-SES respondents were somewhat more likely to receive treatment, but this was true mostly for specialty mental health treatment, where the association was positive with education (highest treatment among respondents with the highest education and a weak association of education with treatment among other respondents) but non-monotonic with income (somewhat lower treatment rates among middle-income respondents and equivalent among those with high and low incomes).
The modest, but nonetheless stronger, an association of education than income with treatment raises questions about a financial barriers interpretation of the inverse association of SES with treatment, although future within-country analyses that consider contextual factors might document other important specifications. While beyond the scope of this report, such an expanded analysis could have important implications for designing interventions aimed at increasing mental disorder treatment among socio-economically disadvantaged people.
There is increasing international recognition of the need to build capacity to strengthen mental health systems. This is a fundamental goal of the ‘Emerging mental health systems in low- and middle-income countries’ (Emerald) programme, which is being implemented in six low- and middle-income countries (LMICs) (Ethiopia, India, Nepal, Nigeria, South Africa, Uganda). This paper discusses Emerald's capacity-building approaches and outputs for three target groups in mental health system strengthening: (1) mental health service users and caregivers, (2) service planners and policy-makers, and (3) mental health researchers. When planning the capacity-building activities, the approach taken included a capabilities/skills matrix, needs assessments, a situational analysis, systematic reviews, qualitative interviews and stakeholder meetings, as well as the application of previous theory, evidence and experience. Each of the Emerald LMIC partners was found to have strengths in aspects of mental health system strengthening, which were complementary across the consortium. Furthermore, despite similarities across the countries, capacity-building interventions needed to be tailored to suit the specific needs of individual countries. The capacity-building outputs include three publicly and freely available short courses/workshops in mental health system strengthening for each of the target groups, 27 Masters-level modules (also open access), nine Emerald-linked PhD students, two MSc studentships, mentoring of post-doctoral/mid-level researchers, and ongoing collaboration and dialogue with the three groups. The approach taken by Emerald can provide a potential model for the development of capacity-building activities across the three target groups in LMICs.
Suicidal behaviour is an under-reported and hidden cause of death in most low- and middle-income countries (LMIC) due to lack of national systematic reporting for cause-specific mortality, high levels of stigma and religious or cultural sanctions. The lack of information on non-fatal suicidal behaviour (ideation, plans and attempts) in LMIC is a major barrier to design and implementation of prevention strategies. This study aims to determine the prevalence of non-fatal suicidal behaviour within community- and health facility-based populations in LMIC.
Twelve-month prevalence of suicidal ideation, plans and attempts were established through community samples (n = 6689) and primary care attendees (n = 6470) from districts in Ethiopia, Uganda, South Africa, India and Nepal using the Composite International Diagnostic Interview suicidality module. Participants were also screened for depression and alcohol use disorder.
We found that one out of ten persons (10.3%) presenting at primary care facilities reported suicidal ideation within the past year, and 1 out of 45 (2.2%) reported attempting suicide in the same period. The range of suicidal ideation was 3.5–11.1% in community samples and 5.0–14.8% in health facility samples. A higher proportion of facility attendees reported suicidal ideation than community residents (10.3 and 8.1%, respectively). Adults in the South African facilities were most likely to endorse suicidal ideation (14.8%), planning (9.5%) and attempts (7.4%). Risk profiles associated with suicidal behaviour (i.e. being female, younger age, current mental disorders and lower educational and economic status) were highly consistent across countries.
The high prevalence of suicidal ideation in primary care points towards important opportunities to implement suicide risk reduction initiatives. Evidence-supported strategies including screening and treatment of depression in primary care can be implemented through the World Health Organization's mental health Global Action Programme suicide prevention and depression treatment guidelines. Suicidal ideation and behaviours in the community sample will require detection strategies to identify at risks persons not presenting to health facilities.
We are a group of researchers and clinicians with collective experience in child survival, nutrition, cognitive and social development, and treatment of common mental conditions. We join together to welcome an expanded definition of child development to guide global approaches to child health and overall social development. We call for resolve to integrate maternal and child mental health with child health, nutrition, and development services and policies, and see this as fundamental to the health and sustainable development of societies. We suggest specific steps toward achieving this objective, with associated global organizational and resource commitments. In particular, we call for a Global Planning Summit to establish a much needed Global Alliance for Child Development and Mental Health in all Policies.
Preterm birth and exposure to childhood sexual abuse (CSA) are early physiological and psychological adversities that have been linked to reduced social functioning across the lifespan. However, the joint effects of being born preterm and being exposed to CSA on adult social outcomes remains unclear. We sought to determine the impact of exposure to both preterm birth and CSA on adult social functioning in a group of 179 extremely low birth weight (ELBW; <1000 g) survivors and 145 matched normal birth weight (>2500 g) participants in the fourth decade of life. Social outcome data from a prospective, longitudinal, population-based Canadian birth cohort initiated between the years of 1977 and 1982 were examined. At age 29–36 years, ELBW survivors who experienced CSA reported poorer relationships with their partner, worse family functioning, greater loneliness, lower self-esteem and had higher rates of avoidant personality problems than those who had not experienced CSA. Birth weight status was also found to moderate associations between CSA and self-esteem (P=0.032), loneliness (P=0.021) and family functioning (P=0.060), such that the adverse effects of CSA were amplified in ELBW survivors. Exposure to CSA appears to augment the adult social risks associated with perinatal adversity. Individuals born preterm and exposed to CSA appear to be a group at particularly high risk for adverse social outcomes in adulthood.
Although financing represents a critical component of health system strengthening and also a defining concern of efforts to move towards universal health coverage, many countries lack the tools and capacity to plan effectively for service scale-up. As part of a multi-country collaborative study (the Emerald project), we set out to develop, test and apply a fully integrated health systems resource planning and health impact tool for mental, neurological and substance use (MNS) disorders.
A new module of the existing UN strategic planning OneHealth Tool was developed, which identifies health system resources required to scale-up a range of specified interventions for MNS disorders and also projects expected health gains at the population level. We conducted local capacity-building in its use, as well as stakeholder consultations, then tested and calibrated all model parameters, and applied the tool to three priority mental and neurological disorders (psychosis, depression and epilepsy) in six low- and middle-income countries.
Resource needs for scaling-up mental health services to reach desired coverage goals are substantial compared with the current allocation of resources in the six represented countries but are not large in absolute terms. In four of the Emerald study countries (Ethiopia, India, Nepal and Uganda), the cost of delivering key interventions for psychosis, depression and epilepsy at existing treatment coverage is estimated at US$ 0.06–0.33 per capita of total population per year (in Nigeria and South Africa it is US$ 1.36–1.92). By comparison, the projected cost per capita at target levels of coverage approaches US$ 5 per capita in Nigeria and South Africa, and ranges from US$ 0.14–1.27 in the other four countries. Implementation of such a package of care at target levels of coverage is expected to yield between 291 and 947 healthy life years per one million populations, which represents a substantial health gain for the currently neglected and underserved sub-populations suffering from psychosis, depression and epilepsy.
This newly developed and validated module of OneHealth tool can be used, especially within the context of integrated health planning at the national level, to generate contextualised estimates of the resource needs, costs and health impacts of scaled-up mental health service delivery.
An investigation of stillbirth and early neonatal lamb mortality was conducted in sheep flocks in Norway. Knowledge of actual causes of death are important to aid the interpretation of results obtained during studies assessing the risk factors for lamb mortality, and when tailoring preventive measures at the flock, ewe and individual lamb level. This paper reports on the postmortem findings in 270 liveborn lambs that died during the first 5 days after birth. The lambs were from 17 flocks in six counties. A total of 27% died within 3 h after birth, 41% within 24 h and 80% within 2 days. Most lambs (62%) were from triplet or higher order litters. In 81% of twin and larger litters, only one lamb died. The most frequently identified cause of neonatal death was infectious disease (n=97, 36%); 48% (n=47) of these died from septicaemia, 25% (n=24) from pneumonia, 22% (n=21) from gastrointestinal infections and 5% (n=5) from other infections. Escherichia coli accounted for 65% of the septicaemic cases, and were the most common causal agent obtained from all cases of infection (41%). In total, 14% of neonatal deaths resulted from infection by this bacterium. Traumatic lesions were the primary cause of death in 20% (n=53) of the lambs. A total of 46% of these died within 3 h after birth and 66% within 24 h. Severe congenital malformations were found in 10% (n=27) of the lambs, whereas starvation with no concurrent lesions was the cause of death in 6% (n=17). In 16% (n=43) of the lambs, no specific cause of death was identified, lambs from triplet and higher order litters being overrepresented among these cases. In this study, the main causes of neonatal lamb mortality were infection and traumatic lesions. Most neonatal deaths occurred shortly after birth, suggesting that events related to lambing and the immediate post-lambing period are critical for lamb survival.
In low-income countries, care for people with severe mental disorders (SMDs) who manage to access treatment is usually emergency-based, intermittent or narrowly biomedical. The aim of this study was to inform development of a scalable district-level mental health care plan to meet the long-term care needs of people with SMD in rural Ethiopia.
The present study was carried out as formative work for the Programme for Improving Mental health CarE which seeks to develop, implement and evaluate a district level model of integrating mental health care into primary care. Six focus group discussions and 25 in-depth interviews were conducted with service planners, primary care providers, traditional and religious healers, mental health service users, caregivers and community representatives. Framework analysis was used, with findings mapped onto the domains of the Innovative Care for Chronic Conditions (ICCC) framework.
Three main themes were identified. (1) Focused on ‘Restoring the person's life’, including the need for interventions to address basic needs for food, shelter and livelihoods, as well as spiritual recovery and reintegration into society. All respondents considered this to be important, but service users gave particular emphasis to this aspect of care. (2) Engaging with families, addressed the essential role of families, their need for practical and emotional support, and the importance of equipping families to provide a therapeutic environment. (3) Delivering collaborative, long-term care, focused on enhancing accessibility to biomedical mental health care, utilising community-based health workers and volunteers as an untapped resource to support adherence and engagement with services, learning from experience of service models for chronic communicable diseases (HIV and tuberculosis) and integrating the role of traditional and religious healers alongside biomedical care. Biomedical approaches were more strongly endorsed by health workers, with traditional healers, religious leaders and service users more inclined to see medication as but one component of care. The salience of poverty to service planning was cross-cutting.
Stakeholders prioritised interventions to meet basic needs for survival and endorsed a multi-faceted approach to promoting recovery from SMD, including social recovery. However, sole reliance on this over-stretched community to mobilise the necessary resources may not be feasible. An adapted form of the ICCC framework appeared highly applicable to planning an acceptable, feasible and sustainable model of care.
This paper reviews strategies and methods to improve accuracies of genomic predictions from the perspective of a numerically small population. Improvements are realized by influencing one or both of the main factors: (1) improve or increase genomic connections to phenotypic records in training data. (2) Models and strategies to focus genomic predictions on markers closer to the causative variants. Combining populations into a joint reference population results in high improvements when combining populations of the same breed and diminishes as the genetic distance between populations increases. For distantly related breeds sophisticated Bayesian variable selection models in combination with denser markers sets or functional subsets of markers is needed. This is expected to be further improved by the efficient use of sequence information. In addition predictions can be improved by the use of phenotypes of genotyped and non-genotyped cows directly. For a small population the optimal approach will combine the above components.
There remains a large disparity in the quantity, quality and impact of mental health research carried out in sub-Saharan Africa, relative to both the burden and the amount of research carried out in other regions. We lack evidence on the capacity-building activities that are effective in achieving desired aims and appropriate methodologies for evaluating success.
AFFIRM was an NIMH-funded hub project including a capacity-building program with three components open to participants across six countries: (a) fellowships for an M.Phil. program; (b) funding for Ph.D. students conducting research nested within AFFIRM trials; (c) short courses in specialist research skills. We present findings on progression and outputs from the M.Phil. and Ph.D. programs, self-perceived impact of short courses, qualitative data on student experience, and reflections on experiences and lessons learnt from AFFIRM consortium members.
AFFIRM delivered funded research training opportunities to 25 mental health professionals, 90 researchers and five Ph.D. students across 6 countries over a period of 5 years. A number of challenges were identified and suggestions for improving the capacity-building activities explored.
Having protected time for research is a barrier to carrying out research activities for busy clinicians. Funders could support sustainability of capacity-building initiatives through funds for travel and study leave. Adoption of a train-the-trainers model for specialist skills training and strategies for improving the rigor of evaluation of capacity-building activities should be considered.
There is a dearth of information on how to scale-up evidence-based psychological interventions, particularly within the context of existing HIV programs. This paper describes a strategy for the scale-up of an intervention delivered by lay health workers (LHWs) to 60 primary health care facilities in Zimbabwe.
A mixed methods approach was utilized as follows: (1) needs assessment using a semi-structured questionnaire to obtain information from nurses (n = 48) and focus group discussions with District Health Promoters (n = 12) to identify key priority areas; (2) skills assessment to identify core competencies and current gaps of LHWs (n = 300) employed in the 60 clinics; (3) consultation workshops (n = 2) with key stakeholders to determine referral pathways; and (4) in-depth interviews and consultations to determine funding mechanisms for the scale-up.
Five cross-cutting issues were identified as critical and needing to be addressed for a successful scale-up. These included: the lack of training in mental health, unavailability of psychiatric drugs, depleted clinical staff levels, unavailability of time for counseling, and poor and unreliable referral systems for people suffering with depression. Consensus was reached by stakeholders on supervision and support structure to address the cross-cutting issues described above and funding was successfully secured for the scale-up.
Key requirements for success included early buy-in from key stakeholders, extensive consultation at each point of the scale-up journey, financial support both locally and externally, and a coherent sustainability plan endorsed by both government and private sectors.