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BackgroundUnmet needs for mental health treatment in low income countries are pervasive. If mental health is to be effectively integrated into primary health care in low income countries like India then grass-roots workers need to acquire relevant knowledge and skills to be able to recognise, refer and support people experiencing mental disorders in their own communities. This study aims to provide a mental health training intervention to community health workers in Bangalore Rural District, Karnataka, India, and to evaluate the impact of this training on mental health literacy. MethodsA pre-test post-test study design was undertaken with assessment of mental health literacy at three time points; baseline, completion of the training, and three month follow-up. Mental health literacy was assessed using the interviewer-administered Mental Health Literacy Survey. The training intervention was a four day course based on a facilitator's manual developed specifically for community health workers in India.
Results70 community health workers from Doddaballapur, Bangalore Rural District were recuited for the study. The training course improved participants' ability to recognize a mental disorder in a vignette, and reduced participants' faith in unhelpful and potentially harmful pharmacological interventions.
There was evidence of a minor reduction in stigmatizing attitudes, and it was unclear if the training resulted in a change in participants' faith in recovery following treatment. ConclusionThe findings from this study indicate that the training course demonstrated potential to be an effective way to improve some aspects of mental health literacy, and highlights strategies for strengthening the training course. Mental disorders are both disabling and costly for affected individuals, their families and the community. Mental disorders are increasingly recognised as a major contributor to the global health burden, including in low income countries (LICs), and they are often co-morbid with communicable and non-communicable diseases ,. Mental health remains a low priority in most LICs, and unmet needs for mental health treatment are pervasive –. Up to 90% of persons with mental disorders in low and middle-income countries do not receive even basic mental health care ,.
This neglect continues despite overwhelming evidence that effective low-cost treatments (drugs, psychological treatments, and community based rehabilitation) are feasible, affordable and cost-effective for many mental disorders, and could be successfully delivered in primary health care (PHC) settings , –.In India, approximately 6% of the population have a mental disorder such as schizophrenia. Suicide is a major public health problem, with over 100,000 suicides annually. Mental disorders in India are not necessarily experienced and understood in the same way as in Western countries –, and the vast majority of care is provided by the family. Many remain untreated, and those families who do seek treatment will often turn to non-allopathic providers including practitioners of Indian traditional medicine, religious healers, faith healers and astrologers ,. The scarcity of mental health professionals, particularly in rural areas, places specialist psychiatric care out of the reach of most people ,.The World Health Organization (WHO) advocates the need to integration of mental health into PHC as the optimal strategy for addressing the global burden of disease ,. In India, the National Mental Health Program also advocates the integration of mental health into PHC; however, there has been limited success in realising this policy in practice with only 24 of 600 districts currently covered by this program ,. Due to the overlap between mental and physical health, people with mental disorders frequently present to PHC settings.
For example, a survey in a Mumbai slum found that 28% of patients aged 18 years attending a health centre suffered from psychiatric problems. However, PHC staff lack the skills required to make an appropriate diagnosis and provide a reasonable standard of care when people present with such problems. Effective training programs are required to develop the mental health skills of generalist PHC staff.If mental health is to be successfully integrated into PHC in low-income countries like India then grass-roots workers need to acquire relevant knowledge and skills so that they are able to recognise, refer and support people experiencing mental health disorders in their own communities. Task shifting of effective mental health interventions to non-specialist health workers has been proposed to increase the coverage of mental health care in both low and high-income settings –.Mental Health Literacy (MHL) is defined as 'knowledge and beliefs about mental disorders which aid their recognition, management and prevention' (p.396).
Studies in India have indicated that knowledge and understanding of mental disorders is poor in many communities, including among community health workers –. Improved awareness of mental disorders among community health workers is likely to assist affected people to access treatment and improve the quality of the care they receive ,. Having the knowledge and skills to support people in the community who may be developing a mental disorder or experiencing a mental health crisis is referred to as Mental Health First Aid.A small number of studies investigating various components of integrating mental health into PHC settings in India, have been conducted , – and this is creating an opportunity and momentum for achieving real changes in practice, leading to better outcomes for people with mental disorders. This study makes a contribution to this emerging body of evidence as it evaluates the effectiveness of a mental health training manual for grass-roots community health workers (CHWs). Mental health training was delivered to CHWs who had minimal knowledge about mental health, and the impact of the training on their level of MHL was evaluated. The hypothesis of the study was that community health workers would demonstrate improved MHL as assessed at completion of the training program and three months later. Study designThis study involved an evaluation of a mental health training program using a pre-test post-test design.
Assessment of participants' MHL was undertaken at baseline, at completion of the course and three months later. The training and data collection was conducted between May and October 2010.
Ethics approval was obtained from the University of Melbourne Health Sciences Human Ethics Sub-Committee. Participants and facilitatorsTraining participants were community health workers sourced through Gramina Abrudaya Seva Samstha (GASS), an NGO operating in Doddaballapur Taluk, Bangalore Rural District, Karnataka, India. The types of community health workers included Junior Health Assistants, Village Rehabilitation Workers, and ASHA workers. These are all categories of government-funded community health workers operating in Doddaballapur Taluk, that each have a range of tasks to undertake from the provision of maternal and child health care, to building community awareness about communicable and non-communicable diseases, to disability rehabilitation.
The participants were trained in three separate groups of between 23 and 24 participants by the same two facilitators who were both local health professionals with a moderate level of experience and understanding of community mental health. The level of experience of the facilitators reflected a 'real world' scenario given that experienced mental health professionals are rare in rural settings in India. The interventionThe mental health training program is a four-day course that aims to increase recognition of mental disorders, enhance appropriate response and referral, support people with mental disorders and their families, and improve mental health promotion in communities. It is not intended as a training program for mental health practitioners, but rather as an introduction to mental health for uninitiated community health workers. The training program is based on a facilitator's manual developed by some of the study investigators, the design and content of which was informed by the literature , –. The content of the training program includes an introduction to mental health and mental disorders, mental health first aid, practice-based skills, and mental health promotion (detailed in Table ).
The facilitator's manual is designed to provide: 1) a plan for each training session including the purpose, timing and required materials, 2) background information for each session, 3) a series of case studies that provide realistic scenarios describing people possibly experiencing mental disorders, 4) suggestions for participatory activities and role-plays, and 5) images and diagrams to assist in explaining concepts and frameworks. Questionnaire design and outcome measuresTo assess changes in the participants' level of MHL, we adapted a MHL survey previously used in rural India – and in Australia , , including with migrant communities ,. This MHL survey involves presentation of two vignettes, each describing people experiencing symptoms of mental disorders (depression, psychosis) (Figure ). Using a combination of open-ended and structured questions, participants were asked to identify the problems, their causes, and effective sources of help. They were also asked about attitudes towards people with mental disorders, and anticipated outcomes for them.
Only responses to structured questions with pre-coded response options are reported on in this paper. The MHL survey was administered face-to-face by trained interviewers (due to limited literacy of some participants), and took about 30 minutes to complete. Each participant was matched to the same interviewer at each point of measurement. To ensure the MHL survey was appropriately translated for the local setting, the English version was reviewed with local psychiatrists, and the relevance of concepts and categories and the appropriate form of translation into the local language (Kannada) were extensively discussed. The survey was then translated and back-translated into English to check for equivalence of meaning, and subsequently piloted. Sample sizeBased on a change in the percentage of respondents who were able to correctly recognise a mental disorder in a vignette, we estimated that we would require a total of 63 training participants to detect a medium effect size (Cohen's h = 0.5, approximately a 20-25% difference) with a power of 80%, alpha of 0.05, and making the conservative assumption of no correlation between pre-test and post-test. The sample size of 70 was chosen based on both the power analysis and feasibility, since this was the maximum possible given the time and financial constraints, and would result in training being provided to the majority of government-funded community health workers operating in Doddaballapur Taluk, Bangalore Rural District.
AnalysisStatistical analysis was performed with SPSS version 18. Dichotomous variables were analysed using the Cochran's Q test to test for variation between the three points of measurement; baseline, post-course, and three month follow-up. McNemar's test for two paired proportions was used to specifically examine changes between baseline and post-course, and between baseline and three month follow-up. All tests were performed separately for responses to questions about each of the two vignettes (i.e.
Depression and psychosis) in the MHL questionnaire. Respondents who didn't complete all three points of measurement were omitted from the analysis. Participant characteristicsThere were 70 participants recruited for the study and only one participant did not complete the training. A further three participants were not available at the three month follow-up leaving 66 (94.3%) participants who had completed the MHL survey at all three points of measurement. Table presents the characteristics of these 66 study participants. The mean age of participants was 37 years, with a range of 21 to 59 years. The majority were female (86.4%) and married (75.8%).
Approximately half the participants (46.9%) had not completed high school (i.e. 12 years of education). More than half of the participants (66.7%) were Junior Health Assistants, 24.2% were Village Rehabilitation Workers (VRWs), and 9.1% were Asha workers. Recognition of disorders in vignettesParticipants were read the two vignettes and asked to name the problem (more than one response was possible). Only 'depression', 'schizophrenia' or 'psychosis' were considered correct responses to the relevant vignettes.
A substantial improvement in the participants' ability to recognise mental disorders was observed at the completion of the training and sustained for the three-month follow-up assessment (Table ). Prior to receiving the training program, few respondents (9.1%) were able to correctly recognise the disorder in the psychosis vignette, and less than a quarter (22.7%) were able to correctly recognise the disorder in the depression vignette. There was a statistically significant increase in the percentage of participants able to correctly identify depression and psychosis after receiving the training intervention. There was a drop in the percentage of participants who could correctly identify depression between post-course and follow-up measurements, however, the difference between baseline and follow-up (22.7% to 43.9%) was found to be statistically significant (McNemar's test, p = 0.022).
Perceived helpfulness of interventionsParticipants were asked about the helpfulness or otherwise of a range of possible pharmacological and non-pharmacological interventions for the problems identified in the vignettes (Table ). Regarding pharmacological interventions, there was a sustained decrease in the percentage of participants endorsing potentially useless pharmacological interventions such as vitamins including tonics and herbal medicines, appetite stimulants, and sleeping pills, and a sustained but small increase in those endorsing other pharmacological treatments. There were no clear and sustained changes in the endorsement of various non-pharmacological interventions, other than a decrease in the percentage of participants endorsing a special diet as helpful for the psychosis vignette. At baseline, psychosocial interventions such as physical activity, distraction, love and affection and listening were strongly endorsed as being helpful for both vignettes, and this was sustained across both points of follow-up.There was a statistically significant change in the percentage of participants endorsing hospital admission as a helpful response for the depression vignette between the three points of measurement, however, the greatest difference was between post-course and follow-up measurement.
The decreased endorsement of hospital admission for the depression vignette between baseline and follow-up (60.6% to 43.9%) was not statistically significant (McNemar's test, p = 0.063).There was a substantial reduction in the percentage of participants endorsing marriage as a helpful intervention for the person in the psychosis vignette between baseline and post-course measurement (McNemar's test, p =. Attitudes to people with mental disordersParticipants were asked whether they agreed with a range of attitudinal statements relating to the persons described in the vignettes, and while some improvements in attitudes were observed, others remained largely unchanged (Table ). For both the depression and the psychosis vignettes at baseline, a majority of participants agreed that the person could 'snap out of it', that the problem was a sign of personal weakness, and that people with this problem are erratic.
Additionally, a significant minority perceived the persons described in the vignettes as dangerous and approximately half said they would not vote for people with these problems, and this did not change after receiving the training. With respect to the depression vignette, the training resulted in a marked decrease in the percentage agreeing that it is best to avoid people with these problems. Additionally, there was a reduction between baseline and follow-up (84.8% to 62.1%) in the percentage who agreed that the problems described in the depression vignette were a sign of personal weakness (McNemar's Test, p = 0.009); however, there was no statistically significant change between baseline and post-course measurement (McNemar's Test, p = 0.057).In the case of the psychosis vignette, there were no sustained changes in responses to the attitudinal statements that could be clearly attributed to the training intervention.
Fewer participants agreed that the person could 'snap out of it' at post-course (42.4%) measurement than at baseline (67.2%) (McNemar's Test, p = 0.002), however the decrease between baseline and follow-up (51.5%) was not statistically significant (McNemar's Test, p = 0.089) indicating that the improved attitude had not been sustained. The Cochran's Q test indicated a statistically significant change in the percentage of participants agreeing that the problem is a sign of personal weakness; however, this was due to the change between the results at post-course and follow-up measurements. There was no statistically significant change in the proportion agreeing with this statement between baseline and post-course measurement (McNemar's test, p = 0.057) or between baseline and follow-up (McNemar's test, p = 0.210).At baseline, approximately half the participants agreed that the problems described in both the depression and psychosis vignettes were not real medical illnesses.
There was no real change in this belief in the case of the depression vignette, but there was some statistically significant variation over time in relation to psychosis as identified by the Cochran's Q test. However, this was due to the changes between the results at post-course and follow-up measurements. There was no statistically significant change in the proportion agreeing with this statement between baseline and post-course measurement (McNemar's test, p = 0.458) or between baseline and follow-up (McNemar's test, p = 0.100). The issue of providing practical mental health training for primary health care workers in low-income countries is of broad interest to many working in the field of global mental health. This study makes an important contribution to the related literature by conducting an evaluation of a training program for community health workers in rural India using an existing facilitator's mental health training manual.The findings suggest that the mental health training program had mixed success in achieving its stated aims, but there were some encouraging outcomes. Importantly, there was only one participant out of seventy who did not complete the training program despite the extensive travel required for many participants to attend, and the considerable demands of participants' daily working and living duties.The training increased the ability of the community health workers to recognize depression and psychosis in vignettes, and reduced their faith in unhelpful pharmacological interventions.
There was evidence of a minor reduction in stigmatising attitudes, although the changes were very limited and largely isolated to the depression vignette. It was unclear if the training resulted in a change in the participant's faith in recovery.The percentage of respondents correctly identifying the disorders in the vignettes in the baseline questionnaire was low relative to a previous survey of village health workers in a rural area of Maharashtra, India (depression, 56.7%) , and much lower than a sample of Australian community members trained in Mental Health First Aid (depression, 91.4%; psychosis 56.6%). The results suggest that the training increased the ability of the participants to recognise depression and psychosis in vignettes, yet despite this improvement, more than half of the participants were still unable to correctly identify either disorder at the three month follow-up. However, an evaluation of a mental health first aid training program conducted in Australia (delivered by an experienced mental health instructor) with a community sample of immigrants of Chinese-speaking background found results comparable to our study; recognition of depression and psychosis increased from 19.0% to 63.1% and 9.5% to 21.4% respectively immediately after the training (no three month follow-up was conducted).
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Release Notes Usher 2.0 Beta 4520 - Mar 9 2020Heads up! Usher 2 is a fundamental change for Usher, both in terms of functionality and underlying technology. The change is necessary to facilitate compatibility with macOS 10.15 Catalina, but it may be jarring depending on which Usher features you rely on the most. To avoid disappointment, please read the following carefully, starting with the list of changes in Usher 2.0 Beta 4485.
There's some bad news, but even more good news, if we say so ourselves — the best news, of course, being that Usher won't actually die this fall, as it's now a 64-bit application.For those who update to the Usher 2 Beta now, but decide they'd rather revert to Usher 1.1.17 later, Usher 1.1.17 will remain available for download from our. Please keep the following caveat in mind, though:Staying on Usher 1.1.17, or any version older than that, is only an option if you don't plan on upgrading to macOS 10.15 Catalina.
Those older Ushers are 32-bit apps, and they will not run on macOS 10.15 Catalina.
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