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Scholarly Works (5 results)

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UCLA Electronic Theses and Dissertations (2021)

The gap between the need for mental health treatment and access to services is vast, especially in low- and middle-income countries (LMICs; Wang et al., 2007), and particularly among children and adolescents in these under-resourced settings (Patel et al., 2008). Closing the gap has become a public health priority in recent years (Lancet Global Mental Health Group, 2007). Task sharing and scaling up evidence-based treatments (EBTs) have been identified as two possible strategies to addressing the gap, with promising results (Singla et al., 2014). However, questions remain concerning the transportability of treatments developed in the West to populations for whom they were not initially intended, and in contexts that bear little resemblance to the highly controlled research settings in which they were conceived. The goal of this dissertation was to describe the process of building a context-sensitive, context-centered intervention using an evidence-informed design system and to evaluate user acceptability, satisfaction, and engagement. The first study used qualitative methods to document the iterative process of developing a treatment protocol in collaboration with local stakeholders and experts. Results demonstrate the central role that cultural/contextual considerations, protocol material and content, and complexity played in the design process, providing a blueprint for bringing together established treatment design principles with local knowledge to develop an intervention that is acceptable to providers and satisfying for youth participants in low-resource settings. The second study evaluated youth engagement in the intervention, as well the overall acceptability, feasibility, and fit of treatment from the youth and provider perspectives. Findings revealed that youth and providers largely perceived the treatment to be engaging, acceptable, and appropriate for the context. These results, along with participant recommendations for improvements, have the potential to inform the development of resources that promote youth engagement in the intervention. Taken together, these studies provide an inside look at the collaborative design-in-context approach of building an intervention in a low-resource setting along with users’ experience with the intervention in an initial pilot. Findings have the potential to narrow the treatment gap through promoting the development and scale up of acceptable, effective, and sustainable mental health treatments for one of the most vulnerable populations: children and adolescents in LMICs.

    Cover page: Designing Context-Specific Interventions: Maximizing Treatment Fit and Engagement in Low- and Middle-Income Countries
    • Article
    • Peer Reviewed
    UC San Diego Previously Published Works (2023)

    Objective

    This observational study characterizes youth and caregiver behaviors that may pose challenges to engagement within a system-driven implementation of multiple evidence-based practices (EBPs). We examined links between Engagement Challenges and therapist EBP implementation outcomes.

    Method

    Community therapists (N = 102) provided audio recordings of EBP sessions (N = 666) for youth (N = 267; 71.54%, Latinx; 51.69%, female; Mage = 9.85, Range: 1-18). Observers rated the extent to which youth and/or caregivers engaged in the following behaviors: Caregiver and/or Youth Expressed Concerns about interventions, and Youth Disruptive Behaviors. Multilevel modeling was used to identify predictors of observable Engagement Challenges, and examine associations between Engagement Challenges, and therapist-reported ability to deliver planned activities, and observer-rated extensiveness of EBP strategy delivery.

    Results

    At least one Engagement Challenge was observed in 43.99% of sessions. Youth Engagement Challenges were not associated with outcomes. Caregiver Expressed Concerns were negatively associated with therapist-reported ability to carry out planned session activities (B = -.21, 95% CI[-.39-(-.02)], p < .05). However, Caregiver Expressed Concerns were positively associated with extensiveness of EBP Content strategy delivery (B = .08, 95% CI[.01-.15], p < .05).

    Conclusions

    Results suggest that Youth Engagement Challenges have little observed impact on EBP delivery. In contrast, although therapists perceive that Caregiver Expressed Concerns derail their planned activities, Caregiver Expressed Concerns are associated with more extensive delivery of content about therapeutic interventions. Community therapists' implementation of EBPs appear unaffected by common youth in-session behavioral challenges, but future research is needed to clarify whether caregivers' concerns about interventions prompt, or are prompted by, more intensive therapist EBP content instruction.
      Cover page: Observed Engagement in Community Implemented Evidence-Based Practices for Children and Adolescents: Implications for Practice Delivery
      • Article
      • Peer Reviewed
      UCLA Previously Published Works (2020)
      BACKGROUND: Adolescents in low and middle-income countries experience pronounced mental health needs in contexts where infrastructure and resources are scarce. While evidence-based treatment are readily available, they may not fit the unique needs of certain contexts. OBJECTIVE: This manuscript illustrates the systematic process of applying relevance mapping methodology to leverage the youth mental health evidence base to identify candidate practices for inclusion in the development of a contextually appropriate psychological treatment protocol for common adolescent mental health problems in India. METHODS: The practice identification was informed by two datasets obtained from adolescent samples in India. The first was an epidemiological dataset from a large community sample in Goa (N = 2,048); the second incorporated youth top problems reported by service-seeking students presenting to school counsellors in Goa and Delhi (N = 78). Problems identified in each dataset were categorized using structured codes. Problem codes and youth demographics were then indexed against a database of hundreds of evidence-based psychological treatments and their associated clinical trials. This methodology revealed the most common practice elements (discrete therapeutic strategies) and their most efficient combinations with evidence of effectiveness matching the demographics and diagnostic category (anxiety, disruptive behaviors and depression) prevalent in the planned treatment population. RESULTS: For anxiety, the most common practice elements for this age group were exposure, cognitive coping, and psychoeducation. For disruptive behaviors, the most common practices were problem-solving, goal-setting, and rapport-building. For depression, cognitive coping, behavioral activation, and psychoeducation were the most common practice elements. CONCLUSION: These practice elements provided the treatment development team with a preliminary list of candidate content for the development of an intensive psychological treatment within a stepped care service model to address common adolescent mental health problems in schools in India.
        Cover page: Using relevance mapping methodology to design an adolescent mental health intervention in India.
        • Article
        • Peer Reviewed
        UC Santa Barbara Previously Published Works (2018)
        Burnout among community mental health (CMH) therapists has been associated with poorer therapist health, high agency turnover, poorer client outcomes, and compromised quality of care. Recent mandates to learn and implement multiple evidence-based practices (EBPs) within CMH settings are intended to improve the quality of community care, yet there is mixed evidence concerning the impacts on workforce burnout. The current study sought to identify correlates of therapist emotional exhaustion, a key aspect of burnout, during the sustainment phase of a system-driven implementation of multiple EBPs in children's mental health services. We hypothesized that high workload and unfavorable organizational climate would relate to therapist emotional exhaustion, but that positive experiences with EBPs adopted would relate to lower exhaustion. Although agency-level indices of organizational climate were unrelated to exhaustion, a multilevel model revealed that therapists' weekly work hours, caseload, and number of EBPs delivered were associated with increased emotional exhaustion. Additionally, activities associated with the EBP implementation efforts (e.g., hours spent in EBP-related activities, supervision or consultation, or outcome monitoring), were not associated with emotional exhaustion. Therapists' knowledge and confidence delivering EBPs and their positive perceptions of EBPs were protective against emotional exhaustion, but these perceptions did not buffer the risks associated with heavy workload. Findings point to implementation strategies to prevent burnout and associated turnover that compromise the returns on investments in EBP implementation.
          Cover page: Predictors of Burnout Among Community Therapists in the Sustainment Phase of a System-Driven Implementation of Multiple Evidence-Based Practices in Children’s Mental Health
          • Article
          • Peer Reviewed
          UCLA Previously Published Works (2022)
          INTRODUCTION: In low- and middle-income countries (LMICs), the gap between need for mental health (MH) treatment and access to services is stark, particularly among children and adolescents. In service of addressing this treatment gap, the current study provides an in-depth illustration of later-stage collaborative design of a school-based, transdiagnostic MH intervention in New Delhi and Goa, India, using a combination of contextual insights from local stakeholders and knowledge derived from the global evidence base. METHODS: Using an inductive-deductive approach to qualitative thematic analysis, we examined coded data from qualitative sources related to experiences of developing and implementing an intervention prototype. These sources included notes from meetings attended by treatment development team members and providers, written feedback on protocol materials (e.g., provider manual, student handouts), field notes reflecting researcher observations, and minutes from weekly clinical supervision meetings. RESULTS: Results revealed that codes involving cultural/contextual considerations, protocol material and content, and intervention complexity arose consistently throughout treatment development and across document types, illustrating their central role in finalizing protocol design. DISCUSSION: These findings have implications for the future of mental health treatment development and implementation globally.
            Cover page: A qualitative analysis of collaborative efforts to build a school-based intervention for multiple common adolescent mental health difficulties in India.
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