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Chatterjee S.,Sangath | Naik S.,Sangath | John S.,Schizophrenia Research Foundation | Dabholkar H.,Parivartan | And 12 more authors.
The Lancet | Year: 2014

Background Observational evidence suggests that community-based services for people with schizophrenia can be successfully provided by community health workers, when supervised by specialists, in low-income and middleincome countries. We did the COmmunity care for People with Schizophrenia in India (COPSI) trial to compare the effectiveness of a collaborative community-based care intervention with standard facility-based care. Methods We did a multicentre, parallel-group, randomised controlled trial at three sites in India between Jan 1, 2009 and Dec 31, 2010. Patients aged 16-60 years with a primary diagnosis of schizophrenia according to the tenth edition of the International Classification of Diseases, Diagnostic Criteria for Research (ICD-10-DCR) were randomly assigned (2:1), via a computer-generated randomisation list with block sizes of three, six, or nine, to receive either collaborative community-based care plus facility-based care or facility-based care alone. Randomisation was stratified by study site. Outcome assessors were masked to group allocation. The primary outcome was a change in symptoms and disabilities over 12 months, as measured by the positive and negative syndrome scale (PANSS) and the Indian disability evaluation and assessment scale (IDEAS). Analysis was by modified intention to treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN 56877013. Findings 187 participants were randomised to the collaborative community-based care plus facility-based care group and 95 were randomised to the facility-based care alone group; 253 (90%) participants completed follow-up to month 12. At 12 months, total PANSS and IDEAS scores were lower in patients in the intervention group than in those in the control group (PANSS adjusted mean difference -3·75, 95% CI -7·92 to 0·42; p=0·08; IDEAS -0·95, -1·68 to -0·23; p=0·01). However, no difference was shown in the proportion of participants who had a reduction of more than 20% in overall symptoms (PANSS 85 [51%] in the intervention group vs 44 [51%] in the control group; p=0·89; IDEAS 75 [48%] vs 28 [35%]). We noted a significant reduction in symptom and disability outcomes at the rural Tamil Nadu site (-9·29, -15·41 to -3·17; p=0·003). Two patients (one in each group) died by suicide during the study, and two patients died because of complications of a road traffic accident and pre-existing cardiac disease. 18 (73%) patients (17 in the intervention group) were admitted to hospital during the course of the trial, of whom seven were admitted because of physical health problems, such as acute gastritis and vomiting, road accident, high fever, or cardiovascular disease. Interpretation The collaborative community-based care plus facility-based care intervention is modestly more effective than facility-based care, especially for reducing disability and symptoms of psychosis. Our results show that the study intervention is best implemented as an initial service in settings where services are scarce, for example in rural areas. Copyright © Chatterjee et al.

Elsabbagh M.,Montreal Childrens Hospital | Elsabbagh M.,Birkbeck, University of London | Divan G.,Sangath | Koh Y.-J.,Seoul Development Institute | And 11 more authors.
Autism Research | Year: 2012

We provide a systematic review of epidemiological surveys of autistic disorder and pervasive developmental disorders (PDDs) worldwide. A secondary aim was to consider the possible impact of geographic, cultural/ethnic, and socioeconomic factors on prevalence estimates and on clinical presentation of PDD. Based on the evidence reviewed, the median of prevalence estimates of autism spectrum disorders was 62/10000. While existing estimates are variable, the evidence reviewed does not support differences in PDD prevalence by geographic region nor of a strong impact of ethnic/cultural or socioeconomic factors. However, power to detect such effects is seriously limited in existing data sets, particularly in low-income countries. While it is clear that prevalence estimates have increased over time and these vary in different neighboring and distant regions, these findings most likely represent broadening of the diagnostic concets, diagnostic switching from other developmental disabilities to PDD, service availability, and awareness of autistic spectrum disorders in both the lay and professional public. The lack of evidence from the majority of the world's population suggests a critical need for further research and capacity building in low- and middle-income countries. © 2012 International Society for Autism Research, Wiley Periodicals, Inc.

Breuer E.,University of Cape Town | De Silva M.J.,London School of Hygiene and Tropical Medicine | Fekadu A.,Addis Ababa Institute of Technology | Fekadu A.,King's College London | And 5 more authors.
International Journal of Mental Health Systems | Year: 2014

Background: The Theory of Change (ToC) approach has been used to develop and evaluate complex health initiatives in a participatory way in high income countries. Little is known about its use to develop mental health care plans in low and middle income countries where mental health services remain inadequate.Aims: ToC workshops were held as part of formative phase of the Programme for Improving Mental Health Care (PRIME) in order 1) to develop a structured logical and evidence-based ToC map as a basis for a mental health care plan in each district; (2) to contextualise the plans; and (3) to obtain stakeholder buy-in in Ethiopia, India, Nepal, South Africa and Uganda. This study describes the structure and facilitator's experiences of ToC workshops.Methods: The facilitators of the ToC workshops were interviewed and the interviews were recorded, transcribed and analysed together with process documentation from the workshops using a framework analysis approach.Results: Thirteen workshops were held in the five PRIME countries at different levels of the health system. The ToC workshops achieved their stated goals with the contributions of different stakeholders. District health planners, mental health specialists, and researchers contributed the most to the development of the ToC while service providers provided detailed contextual information. Buy-in was achieved from all stakeholders but valued more from those in control of resources.Conclusions: ToC workshops are a useful approach for developing ToCs as a basis for mental health care plans because they facilitate logical, evidence based and contextualised plans, while promoting stakeholder buy in. Because of the existing hierarchies within some health systems, strategies such as limiting the types of participants and stratifying the workshops can be used to ensure productive workshops. © 2014 Breuer et al.; licensee BioMed Central Ltd.

Pillai A.,Sangath | Pillai A.,Columbia University | Nayak M.B.,Public Health Institute | Greenfield T.K.,Public Health Institute | And 5 more authors.
Social Psychiatry and Psychiatric Epidemiology | Year: 2013

Purpose: Associations between low socio-economic class and alcohol use disorders are relatively well established in developed countries; however, there is comparably little research in India and other developing countries on the associations between socio-economic class, drinking patterns, and alcohol-related problems. We sought to assess drinking patterns and adverse outcomes among male drinkers and examine whether the association between drinking patterns and adverse outcomes differ by socioeconomic class. Methods: Population survey of 732 male drinkers screened from 1,899 men, aged 18 to 49 years, randomly selected from rural and urban communities in northern Goa, India. Results: Usual quantity of alcohol consumed by 14.8 % (rural 16.8 %; urban 13.6 %) current drinkers is at high-risk level. About 28.6 % (rural 31 %; urban 27.2 %) and 33.7 % (rural 30.5 %; urban 35.5 %) of current drinkers reported monthly or more frequent heavy episodic drinking and drunkenness, respectively. Lower education and lower standard of living (SLI) were associated with higher usual quantity of alcohol consumption. More frequent heavy episodic drinking was associated with older age, being separated, lower education, and lower standard of living; weekly or more frequent drunkenness was associated only with rural residence. All three risky drinking patterns were associated with common mental disorders, sexual risk, intimate partner violence, acute alcohol-related consequences, and alcohol dependence. Significant interactions between SLI and risky alcohol use patterns suggested an increased risk of intimate partner violence among men with risky drinking and lower SLI. Conclusions: Risky drinking patterns are common among male drinkers in Goa and associated with lower socio-economic class. A range of adverse health and social outcomes were associated with risky drinking across all socio-economic classes. Alcohol policy should target risky drinking patterns, particularly among poorer men, to reduce the health and social burden of alcohol use in India. © 2012 Springer-Verlag.

Patel V.,London School of Hygiene and Tropical Medicine | Kieling C.,Federal University of Rio Grande do Sul | Maulik P.K.,George Institute for Global Health | Maulik P.K.,University of Oxford | Divan G.,Sangath
Archives of Disease in Childhood | Year: 2013

Developmental disabilities, emotional disorders and disruptive behaviour disorders are the leading mental health-related causes of the global burden of disease in children aged below 10 years. This article aims to address the treatment gap for child mental disorders through synthesising three bodies of evidence: the global evidence base on the treatment of these priority disorders; the barriers to implementation of this knowledge; and the innovative approaches taken to address these barriers and improve access to care. Our focus is on low-resource settings, which are mostly found in low- and middle-income countries (LMIC). Despite the evidence base on the burden of child mental disorders and their long-term consequences, and the recent mental health Gap Action Programme guidelines which testify to the effectiveness of a range of pharmacological and psychosocial interventions for these disorders, the vast majority of children in LMIC do not have access to these interventions. We identify three major barriers for the implementation of efficacious treatments: the lack of evidence on delivery of the treatments, the low levels of detection of child mental disorders and the shortage of skilled child mental health professionals. The evidence based on implementation, although weak, supports the use of screening measures for detection of probable disorders, coupled with a second-stage diagnostic assessment and the use of nonspecialist workers in community and school settings for the delivery of psychosocial interventions. The most viable strategy to address the treatment gap is through the empowerment of existing human resources who are most intimately concerned with child care, including parents, through innovative technologies, such as mobile health, with the necessary skills for the detection and treatment of child mental disorders.

Balaji M.,Sangath | Andrews T.,Manipal University India | Andrew G.,Sangath | Patel V.,Sangath | Patel V.,London School of Hygiene and Tropical Medicine
Journal of Adolescent Health | Year: 2011

Purpose To evaluate the acceptability, feasibility, and effectiveness of a population-based intervention to promote health of youth (age: 1624 years) in Goa. Methods Two pairs of urban and rural communities were selected; one of each was randomly assigned to receive a multi-component intervention and the other wait-listed. The intervention comprised educational institution-based peer education and teacher training (in the urban community), community peer education, and health information materials. Effectiveness was assessed through beforeafter population surveys at baseline and at 18 months. Outcomes were measured using a structured interview schedule with all eligible youth. Logistic regression compared each pair, adjusted for baseline differences, on prevalence of outcomes in the domains of reproductive and sexual health (RSH), violence, mental health, substance use, and help seeking for health concerns. Results In both intervention communities, prevalence of violence perpetrated and probable depression was significantly lower and knowledge and attitudes about RSH significantly higher (p < .05). The rural sample also reported fewer menstrual complaints and higher levels of help-seeking for RSH complaints by women, and knowledge and attitudes about emotional health and substance use; and, the urban sample reported significantly lower levels of substance use, suicidal behavior, sexual abuse, and RSH complaints. Although information materials were acceptable and feasible in both communities, community peer education was feasible only in the rural community. The institution-based interventions were generally acceptable and feasible. Conclusions Multicomponent interventions comprising information materials, educational-institution interventions and, in rural contexts, community peer interventions are acceptable and feasible and likely to be effective for youth health promotion. © 2011 Society for Adolescent Health and Medicine.

Divan G.,Sangath | Vajaratkar V.,Sangath | Desai M.U.,Sangath | Desai M.U.,Fordham University | And 3 more authors.
Autism Research | Year: 2012

Autism Spectrum Disorders (ASD) are increasingly recognized in developing countries like India. However, little is known about the experiences of parents raising a child with ASD. This study aimed to describe the experiences of families in Goa, India with a view to understanding the unmet needs of families raising a child with ASD. Twenty in-depth interviews and nine focus group discussions were carried out with families of children with ASD and key community stakeholders such as special educators, teachers, and parents of typically developing children. This qualitative data was triangulated to explore the experiences, life impact, and unmet needs of raising a child with ASD. Key findings suggest that raising a child with ASD puts a tremendous strain on families due to competing commitments, often leading to initial social withdrawal with later reintegration into social networks. Second, the impact is multidimensional, involving the personal sphere but also extending into the wider community with negative experiences of discrimination. Third, parents actively respond to these challenges through a range of approaches with help from existing and new social support networks and health care providers. Fourth, professionals from the health, education, and religious sectors have a low awareness of the unique needs of families living with ASD which leads to a considerable economic and emotional burden on families. Finally, as a consequence of these experiences, several unmet needs can be identified, notably for supporting increasingly isolated families and the limited access to multidisciplinary evidence-based services for ASD. © 2012 International Society for Autism Research, Wiley Periodicals, Inc.

De Silva M.J.,London School of Hygiene and Tropical Medicine | Breuer E.,University of Cape Town | Lee L.,London School of Hygiene and Tropical Medicine | Asher L.,London School of Hygiene and Tropical Medicine | And 3 more authors.
Trials | Year: 2014

Background: The Medical Research Councils' framework for complex interventions has been criticized for not including theory-driven approaches to evaluation. Although the framework does include broad guidance on the use of theory, it contains little practical guidance for implementers and there have been calls to develop a more comprehensive approach. A prospective, theory-driven process of intervention design and evaluation is required to develop complex healthcare interventions which are more likely to be effective, sustainable and scalable.Methods: We propose a theory-driven approach to the design and evaluation of complex interventions by adapting and integrating a programmatic design and evaluation tool, Theory of Change (ToC), into the MRC framework for complex interventions. We provide a guide to what ToC is, how to construct one, and how to integrate its use into research projects seeking to design, implement and evaluate complex interventions using the MRC framework. We test this approach by using ToC within two randomized controlled trials and one non-randomized evaluation of complex interventions. Results: Our application of ToC in three research projects has shown that ToC can strengthen key stages of the MRC framework. It can aid the development of interventions by providing a framework for enhanced stakeholder engagement and by explicitly designing an intervention that is embedded in the local context. For the feasibility and piloting stage, ToC enables the systematic identification of knowledge gaps to generate research questions that strengthen intervention design. ToC may improve the evaluation of interventions by providing a comprehensive set of indicators to evaluate all stages of the causal pathway through which an intervention achieves impact, combining evaluations of intervention effectiveness with detailed process evaluations into one theoretical framework. Conclusions: Incorporating a ToC approach into the MRC framework holds promise for improving the design and evaluation of complex interventions, thereby increasing the likelihood that the intervention will be ultimately effective, sustainable and scalable. We urge researchers developing and evaluating complex interventions to consider using this approach, to evaluate its usefulness and to build an evidence base to further refine the methodology. Trial registration: Clinical NCT02160249. © 2014 De Silva et al.; licensee BioMed Central Ltd.

Desai M.U.,Fordham University | Divan G.,Sangath | Wertz F.J.,Fordham University | Patel V.,London School of Hygiene and Tropical Medicine
Transcultural Psychiatry | Year: 2012

The current study investigated the lived experience of 12 parents of children with an Autism Spectrum Disorder in everyday cultural contexts in Goa, India. Narratives from parents collected between 2009 and 2010 were analyzed using the procedures of phenomenological psychology. Four temporal phases of parents' experience emerged from these data. Findings showed that the earliest phase of the child's life was a period of relative normalcy and social cohesion. In the second phase, the child's behaviors began to disrupt the everyday social order, but parents viewed these unexpected behaviors as temporary. In the third phase, parents' observations in public situations, along with assessments of others, led to a qualitative shift in which parents began to perceive that there was a persisting problem interfering with their child's social and practical activities. In the fourth phase, parents grappled with developing their child's capacities to meet existing practical opportunities in the local society, while attempting to reshape the social world to accommodate the abilities and limits of children like their own. Parents' fundamental concerns throughout their journey were: learning to meet new and unfamiliar challenges as parents, caring for their child's basic needs, and finding an engaging niche with a sense of belonging for their child in the everyday milieu. Both culture-specific and potentially universal levels of experience are delineated in the overall findings. Implications for culturally sensitive research and practice in India and other low- and middle-income countries are discussed. © The Author(s) 2012 Reprints and permissions:

Shidhaye R.,Public Health Foundation of India | Shrivastava S.,Sangath | Murhar V.,Sangath | Samudre S.,Public Health Foundation of India | And 3 more authors.
British Journal of Psychiatry | Year: 2016

Background The large treatment gap for mental disorders in India underlines the need for integration of mental health in primary care. Aims To operationalise the delivery of the World Health Organization Mental Health Gap Action Plan interventions for priority mental disorders and to design an integrated mental healthcare plan (MHCP) comprising packages of care for primary healthcare in one district. Method Mixed methods were used including theory of change workshops, qualitative research to develop the MHCP and piloting of specific packages of care in a single facility. Results The MHCP comprises three enabling packages: programme management, capacity building and community mobilisation; and four service delivery packages: awareness for mental disorders, identification, treatment and recovery. Challenges were encountered in training primary care workers to improve identification and treatment. Conclusions There are a number of challenges to integrating mental health into primary care, which can be addressed through the injection of new resources and collaborative care models. © The Royal College of Psychiatrists 2016.

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