Chapter 3 key findings: Using PSYCHLOPS in Kenya and Pakistan
This study constituted the largest data set of PSYCHLOPS ever published. In both Kenya and Pakistan, the responses to the PSYCHLOPS PGOM gave rise to problems that were not found in the
nomothetics used as outcome measures in the two efficacy trials. Furthermore, the problems cited were different in both of the settings. For example, people in Pakistan did not cite unemployment as a life problem and rarely mentioned finances, whereas in Kenya, financial difficulty was the most frequent problem cited, with unemployment also very common. In Pakistan, they cited emotional or psychological problems (sadness and importantly, anger or irritation) much more frequently than Kenyan participants did. A relatively large proportion of Pakistani participants cited headaches as a major life problem (perhaps as an idiom of mental distress), but this was rarely cited in Kenya. These diverging results, both between sites and in comparison to nomothetic measures of common mental disorders, show that asking participants about their self-perceived problems brings additional insight about the values of participants in mental health research. For further discussion of the
interpretation of the results found, see chapter three.
Chapter 4 key findings: Cultural adaptation of self-help interventions, meta-analysis
The systematic review carried out on self-help interventions showed that published research does not include enough detail about the adaptation processes used. This prevents replications, reduces transparency, and limits clear understanding of methodologies used. Of the 3886 studied screened for inclusion, we included eight randomised controlled trials studies of self-help interventions in the meta-analysis (four on e-mental health interventions and four on bibliotherapy). The pooled
standardised mean difference (effect size) of the interventions from retrieved studies was -0.81 (95%
CI -0.10 to -0.62) in favour of the active intervention compared to a control, with low to moderate heterogeneity between the studies (I2=28.9%, p=0.188). Using the assigned adaptation score of each study in the meta-regression we found that a one-point increase in the adaptation score of a study was significantly associated with an increase in standardised mean difference of 0.117 (p=0.04).
Chapter 5 key findings: Designing a scalable e-mental health intervention
Step-by-Step was created as a five session, behavioural activation intervention for depression that is delivered through smartphones, tablets or computers. Self-report outcome measures are
incorporated into the intervention after sign-up and after completion. It uses the story of a person who suffers depression symptoms and gets help to relieve their symptoms, with interactive activities to enable users to integrate strategies into their own life. Step-by-step was designed to be delivered with the option of a non-specialist support person to accompany the user through the intervention via up to 15 minutes phone or text-based support sessions. Other implementation considerations were incorporated, such as open-source software and vector graphics to illustrate the story for easy of widespread use in the future.
186 Chapter 6 key findings: Cultural adaptation of Step-by-Step in Lebanon and Macau
Using a bottom-up community driven approach, we adapted Step-by-Step for Lebanon (general population) and for Macau (specifically for Pilipino migrant workers). Using key informant interviews with health workers and focus groups (followed by key informant interviews where necessary) with community members, we gathered data on the acceptability, comprehensibility and relevance of the intervention content.
Example contextual and cultural adaptations can be found in Table 3. More details can be found in chapter six.
Table 3. Examples of cultural and contextual adaptations made to Step-by-Step in two settings.
Lebanon Macau
Acceptability A doctor was the wise character who imparted the therapeutic content to the story-telling character (a doctor is very trusted figure in Lebanon) and their tone should be prescriptive and direct. associated with a particular political party.
Hand gestures and reference to illicit drugs associated with a particular political party/the current president’s war on drugs.
Rest emphasised as a positive coping strategy due to fast pace of life in Lebanon.
Negative coping and coping
behaviours modified e.g., for migrant domestic workers, staying in bed is restorative not a negative strategy.
Illustrations of males in distress were made more masculine, e.g., head in hands as opposed to crying.
Illustrations of males in distress were made more masculine, e.g., head in hands as opposed to crying.
Make videos/voice overs so less reading is required.
Change intervention goal from helping to better cope with difficult emotions, to helping to become a better overseas worker for the family’s sake. This is less
pathologising and more focused to the life goals of Philipinos in Macau.
‘Satisfaction’ in Arabic had sexual
connotations so it was replaced by ‘feeling of joy or peace’.
Relevance Names of characters needed to be relevant to all religious groups.
Selected names were meaningful in Philipino, e.g., wise-person or fighter
187 and were modern for younger characters.
Male and female characters as parents and female as a homemaker is not relevant to all users.
Characters wore simple clothes but with jewellery to show status so that users would want to be like them.
In Lebanon, wives and husbands prefer to talk to friends about their problems, rather than to each other.
Warmth and hospitality are important, so the tone of the story was made more personal.
Problems in the story were updated to include financial problems, work stress and violence and conflict.
Problems in the story were updated to include missing their family, conflicts with peers and employers and needing a break from working hard.
Some activities were revised., e.g., going for a walk alone is not an option for some Syrian women, or playing with children was not deemed a restorative activity.
Listen to favourite singer was changed to favourite music as in some religious sub-groups, music is restricted to instrumental and traditional music.
Activities were revised to include low-cost and not too time consuming activities like eating mereinda, videoke and visiting sites in Macau.
We excluded unfeasible or unfulfilling activities like gardening.
Some activities remained gendered despite trying to make them gender neutral, as some activities are considered typically male or female in Lebanon e.g., women cooking and men going to a café to play board games.
Comprehensibility Intervention in both Arabic and English as many younger participants use apps and speak in English with peers.
Intervention in both Tagalog and English as many younger participants use apps and speak in English with peers.
Some sentences were made shorter and simpler.
Some sentences were made shorter and simpler.
Remove repetition and cut the length of the story by at least one third as people don’t like to read a lot of text.
Remove repetition.
Change simple coping strategy of drinking a cup of tea as some misunderstood that
188 the tea was a herbal treatment for
depression.
“Tired psyche” was used as a local idiom of distress, with less focus on inactivity as a symptom.
Chapter 7 key findings: Feasibility testing of Step-by-Step
This uncontrolled feasibility test found that completing Step-by-Step lead to statistically significant changes in depression and anxiety symptoms using the PHQ-8 and the GAD-7. It increased wellbeing (WHO-5) and functioning (WHODAS) and decreased the magnitude of self-perceived problems (PSYCHLOPS) scores. Overall, the intervention was accepted and process evaluation interviews with users, drop-outs and other key stakeholders provided a number of insights which will impact future testing and use of Step-by-Step. For example, to avoid cited technical problems, an app will be made to replace delivery through a website. Process evaluation showed that three of the four drop-outs interviewed dropped out partly because the website was not easy to use. Adherence was a major issue in this feasibility test phase and many participants interviewed cited motivation issues and forgetting to log in, which could potentially be remedied by push notifications on an app (optional, to protect the privacy of those using a shared phone). Younger, single users mentioned that they found it hard to relate to the story because the main character had a different family and occupational status to them. Recruitment was a major challenge, so future recruitment for subsequent studies will be more focused on sub-groups of users and through wider social media channels. It is important to note that the study was uncontrolled, and the sample size was very small, so further, controlled and fully powered testing is currently being undertaken.