To assist policy-makers in improving access to eye care in under-served areas by analysing the relationship between motivational factors affecting the uptake of task-shifting in eye care and the recruitment and retention of optometrists in remote and rural areas.

The World Health Organization recommends two key strategies in tackling preventable blindness in under-served areas: improving human resources for health and task-shifting. The relationship between task-shifting and recruitment and retention of eye care workers in under-served areas is unknown. Ghana and Scotland are two countries from different levels of economic development that have notably expanded the roles of optometrists and struggle with rural recruitment and retention.

Motivation was explored through semi-structured interviews with 19 optometrists in Ghana and Scotland with experience in remote and rural practice. Framework analysis was used to analyse interviews, explore the relationship between task-shifting and recruitment and retention and create recommendations for policy.

The main motivational considerations included altruism, quality of life, learning and career opportunities, fulfilling potential, remuneration, stress of decision-making and collaboration. Motivational and demotivational factors for task-shifting and recruitment/retention shared many similar aspects.

Recruitment and retention in remote and rural areas require staff be incentivised to take up those positions, motivated to remain and given the adequate resources for personal and professional fulfilment. Task-shifting also requires incentivisation, motivation to continue and the resources to be productive. Many motivational factors influencing recruitment/retention and task-shifting are similar suggesting these two strategies can be compatible and complementary in improving access to eye care, although some factors are culture and context specific. Understanding optometrists’ motivation can help policy-makers improve rural recruitment and retention and plan services.

Few studies provide clear rationale for and the reception of adaptations of evidence-based interventions. To address this gap, we describe the context-dependent adaptations in critical time intervention-task shifting (CTI-TS), a manualized recovery program for individuals with psychosis in Rio de Janeiro, Brazil and Santiago, Chile. Implications of the adaptations – incorporating a task-shifting approach and modifying the mode of community-based service delivery – are examined from users' perspectives.

A secondary analysis of in-depth interviews with CTI-TS users (n = 9 in Brazil; n = 15 in Chile) was conducted. Using the framework method, we thematically compared how participants from each site perceived the main adapted components of CTI-TS.

Users of both sites appreciated the task-shifting worker pair to provide personalized, flexible, and relatable support. They wanted CTI-TS to be longer and experienced difficulty maintaining intervention benefits in the long-term. In Chile, stigma and a perceived professional hierarchy toward the task-shifting providers were more profound than in Brazil. Engagement with community-based services delivery in homes and neighborhoods (Chile), and at community mental health centers (Brazil) were influenced by various personal, familial, financial, and social factors. Uniquely, community violence was a significant barrier to engagement in Brazil.

CTI-TS’ major adaptations were informed by the distinct mental health systems and social context of Santiago and Rio. Evaluation of user experiences with these adaptations provides insights into implementing and scaling-up task-shifting and community-oriented interventions in the region through the creation of specialized roles for the worker pair, targeting sustained intervention effects, and addressing socio-cultural barriers.

Empirical evidence on the longer-term effectiveness of evidence-based treatments for adolescents with post-traumatic stress disorder (PTSD) in low-resource settings is needed. The aim of the study was to evaluate the maintenance of treatment gains achieved in a comparative study of effectiveness of prolonged exposure therapy for adolescents (PE-A) and supportive counselling (SC) in adolescents with PTSD up to 24-months post-treatment.

Sixty-three adolescents (13–18 years) with PTSD were randomly assigned to receive either of the interventions comprising 7–14 sessions of treatment provided by trained and supervised non-specialist health workers (NSHWs). The primary outcome measure was PTSD symptom severity, as independently assessed on the Child PTSD Symptom Scale, at pretreatment, post-treatment, and at 3-, 6-, 12- and 24-months post-treatment follow-up (FU) evaluations.

Participants in both the prolonged exposure and SC treatment groups attained a significant reduction in PTSD symptoms and maintained this reduction in PTSD symptoms at 12- and 24-month assessment. Participants receiving prolonged exposure experienced greater improvement on the PTSD symptom severity scale than those receiving SC at 12-months FU [difference in PE-A v. SC mean scores = 9.24, 95% CI (3.66–14.83), p < 0.001; g = 0.88] and at 24-months FU [difference in PE-A v. SC mean scores = 9.35, 95% CI (3.53–15.17), p = 0.002; g = 0.68].

Adolescents with PTSD continued to experience greater benefit from prolonged exposure treatment than SC provided by NSHWs in a community setting 12 and 24 months after completion of treatment.

Globally, nearly 140 million children have experienced the death of one or both parents, and as a result many experience higher rates of mental health problems. Trauma-focused cognitive behavioral therapy (TF-CBT) delivered by lay counselors has been shown to improve mental health outcomes for children experiencing traumatic grief due to parental loss; however, challenges with treatment attendance limit the public health impact of mental health services. This study used qualitative methods to assess barriers and facilitators of child and guardian attendance of school-based lay counselor delivered TF-CBT.

Semi-structured interviews were conducted with 36 lay counselors (18 teachers; 18 community health volunteers) who delivered TF-CBT to explore their perceptions of barriers of facilitators of child and guardian attendance of group-based sessions delivered in schools.

Counselors identified attendance barriers and facilitators related to the delivery setting, resources, participant characteristics, intervention characteristics and counselor behaviors. The findings revealed a greater number of facilitators than barriers. Common facilitators included participant and counselor resources, counselor commitment behaviors and communication efforts to encourage attendance. Barriers were less frequently endorsed, with participant resources, child or guardian illness and communication challenges most commonly mentioned.

Attention to barriers and facilitators of attendance in the context in which mental health interventions are delivered allows for identification of ways to improve attendance and treatment engagement and achieve the potential promise of providing accessible mental health services.

Empirical evidence on the effectiveness of evidence-based treatments for adolescents with post-traumatic stress disorder (PTSD) in low-resource settings is needed.

To evaluate the comparative effectiveness of prolonged exposure and supportive counselling in adolescents with PTSD.

Sixty-three adolescents (13–18 years) with PTSD were randomly assigned to receive either of the interventions comprising 7–14 sessions of treatment (trial registration in the Pan African Clinical Trials Registry: PACTR201511001345372). The primary outcome measure was PTSD symptom severity, as independently assessed on the Child PTSD Symptom Scale at pre-treatment, post-treatment, and at 3- and 6-month follow-up.

Participants receiving prolonged exposure experienced greater improvement on the PTSD symptom severity scale than those receiving supportive counselling (between group differences at post-intervention, mean 12.49, 95% CI 6.82–18.17, P<0.001; d = 1.22). A similar effect size was maintained at 3-month (d = 0.85) and 6-month (d = 1.02) follow-up assessments.

Adolescents with PTSD experienced greater benefit from prolonged exposure treatment when provided by non-specialist health workers (nurses) in a community setting.

None.

Task-shifting mental health into general medical care requires more than brief provider training. Generalists need long-term support to master new skills and changes to work context are required to sustain change in the face of competing priorities. We examined program and context factors promoting sustainability of a mental health task-shifting training for hospital-based HIV providers in Ethiopia.

Convergent mixed-methods quasi-experimental study. Sustained impact was measured by trained/not-trained provider differences in case detection and management 16 months following the end of formal support. Factors related to sustainability were examined through interviews with trained providers.

Extent of sustained impact: Trained providers demonstrated modest but better agreement with standardized screeners (greater sensitivity with similar specificity). They were more likely to request that patients with mental health problems return to see them v. making a referral. Factors promoting sustainability (reported in semi-structured interviews): provider belief that the treatments they had learned were effective. New interactions with on-site mental health staff were a source of ongoing learning and encouragement. Factors diminishing sustainability: providers feelings of isolation when mental health partners left for work elsewhere, failure to incorporate mental health indicators into administrative data, to re-stock staff education materials, and to build formal mechanisms for generalist-mental health staff interaction.

An intervention seen as feasible and effective, and promotion of relationships across professional lines, helped generalists sustain new skills. Failure to address key system context issues made use of the skills unsustainable as external supports ended.

This paper seeks to review the available evidence to determine whether a systems approach is employed in the implementation and evaluation of task shifting for mental health using lay providers in low- and middle-income countries, and to highlight system-wide effects of task-shifting strategies in order to better inform efforts to strength community mental health systems.

Pubmed, CINAHL, and Cochrane Library databases were searched. Articles were screened by two independent reviewers with a third reviewer resolving discrepancies. Two stages of screens were done to ensure sensitivity. Studies were analysed using the World Health Organization's building blocks framework with the addition of a community building block, and systems thinking characteristics to determine the extent to which system-wide effects had been considered.

Thirty studies were included. Almost all studies displayed positive findings on mental health using task shifting. One study showed no effect. No studies explicitly employed systems thinking tools, but some demonstrated systems thinking characteristics, such as exploring various stakeholder perspectives, capturing unintended consequences, and looking across sectors for system-wide impact. Twenty-five of the 30 studies captured elements other than the most directly relevant building blocks of service delivery and health workforce.

There is a lack of systematic approaches to exploring complexity in the evaluation of task-shifting interventions. Systems thinking tools should support evidence-informed decision making for a more complete understanding of community-based systems strengthening interventions for mental health.