<div class="title-block" style="border-bottom-color: #628bb3"><h1><img class="title-image" src="http://www.heart-resources.org/wp-content/themes/heart/images/health.svg">Non-Communicable Diseases and Mental Health</h1><div class="post-type-description"></div></div> – Health and Education Advice and Resource Team http://www.heart-resources.org Providing DFID staff and other development actors with health, education and nutrition knowledge and expertise from around the world Fri, 02 Mar 2018 13:10:49 +0000 en-US hourly 1 https://wordpress.org/?v=4.9.4 Group crisis intervention for children during ongoing war conflict http://www.heart-resources.org/doc_lib/group-crisis-intervention-children-ongoing-war-conflict/ http://www.heart-resources.org/doc_lib/group-crisis-intervention-children-ongoing-war-conflict/#respond Fri, 03 Jun 2016 13:01:18 +0000 http://www.heart-resources.org/?post_type=doc_lib&p=29079 Read more]]> The aim of this study was to evaluate the short-term impact of a group crisis intervention for children aged 9–15 years from five refugee camps in the Gaza Strip during ongoing conflict. Children were selected if they reported moderate to severe post-traumatic stress reactions, and were allocated to group intervention, encouraging expression of experiences and emotions through storytelling, drawing, free play and role-play; education about symptoms or no intervention. No significant impact of the group intervention was established on children’s post-traumatic or depressive symptoms. Possible explanations of the findings are discussed, including the continuing exposure to trauma and the non-active nature of the intervention.

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Child soldiers: children associated with fighting forces http://www.heart-resources.org/doc_lib/child-soldiers-children-associated-fighting-forces/ http://www.heart-resources.org/doc_lib/child-soldiers-children-associated-fighting-forces/#respond Fri, 03 Jun 2016 12:44:09 +0000 http://www.heart-resources.org/?post_type=doc_lib&p=29078 Read more]]> Around the world, an estimated 300,000 to 500,000 children are involved in armed conflict. Children can be abducted into a fighting force to fight or serve as sex slaves. Child soldiers have depression, anxiety, and post-traumatic stress symptoms; however, evidence is mixed because of methodologic limitations. Various mental health interventions have been tried, with promising results. Child and adolescent psychiatrists are uniquely trained in understanding and assisting youth to heal from such extraordinary experiences. A public health paradigm could include interventions that are based on a comprehensive assessment of interweaving developmental, biological, psychological, and sociocultural factors.

This document may be accessible through your organisation or institution. If not, you may have to purchase access. Alternatively, the British Library for Development Studies provides a document delivery service.

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Narrative exposure therapy as a treatment for child war survivors with posttraumatic stress disorder: two case reports and a pilot study in an African refugee settlement http://www.heart-resources.org/doc_lib/narrative-exposure-therapy-treatment-child-war-survivors-posttraumatic-stress-disorder-two-case-reports-pilot-study-african-refugee-settlement/ http://www.heart-resources.org/doc_lib/narrative-exposure-therapy-treatment-child-war-survivors-posttraumatic-stress-disorder-two-case-reports-pilot-study-african-refugee-settlement/#respond Fri, 03 Jun 2016 12:34:49 +0000 http://www.heart-resources.org/?post_type=doc_lib&p=29077 Read more]]> Little data exists on the effectiveness of psychological interventions for children with post-traumatic stress disorder (PTSD) that has resulted from exposure to war or conflict-related violence, especially in non-industrialised countries. The authors created and evaluated the efficacy of KIDNET, a child-friendly version of Narrative Exposure Therapy (NET), as a short-term treatment for children. Six Somali children suffering from PTSD aged 12–17 years resident in a refugee settlement in Uganda were treated with four to six individual sessions of KIDNET by expert clinicians. Symptoms of PTSD and depression were assessed pre-treatment, post-treatment and at nine months follow-up. The study concludes that NET may be safe and effective to treat children with war related PTSD in the setting of refugee settlements in developing countries.

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Trauma, poverty and mental health among Somali and Rwandese refugees living in an African refugee settlement – an epidemiological study http://www.heart-resources.org/doc_lib/trauma-poverty-mental-health-among-somali-rwandese-refugees-living-african-refugee-settlement-epidemiological-study/ http://www.heart-resources.org/doc_lib/trauma-poverty-mental-health-among-somali-rwandese-refugees-living-african-refugee-settlement-epidemiological-study/#respond Fri, 03 Jun 2016 11:57:03 +0000 http://www.heart-resources.org/?post_type=doc_lib&p=29076 Read more]]> The aim of this study was to establish the prevalence of post-traumatic stress disorder (PTSD) and depression among Rwandese and Somali refugees resident in a Ugandan refugee settlement, as a measure of the mental health consequences of armed conflict, as well as to inform a subsequent mental health outreach programme. The study argues that mental health consequences of conflict remain long after the events are over, and therefore mental health intervention is as urgent for post-conflict migrant populations as physical health and other emergency interventions. A mental health outreach programme was initiated based on this study.

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Effective behaviour change interventions http://www.heart-resources.org/2016/04/effective-behaviour-change-interventions/ http://www.heart-resources.org/2016/04/effective-behaviour-change-interventions/#respond Thu, 28 Apr 2016 10:05:38 +0000 http://www.heart-resources.org/?p=28953 Read more]]> This helpdesk provides a rapid analysis on the existing evidence related to effective behaviour change interventions. It has a particular focus on where interventions are related to hygiene and sanitation, nutrition, gender based violence, indoor air pollution, family planning adoption, unsafe sex, motor vehicle driving. The geographic focus is Malawi, but where necessary it draws on evidence from the wider sub-Saharan Africa region and other low income contexts. Where possible it presents information on both the nature of interventions, and evidence based factors that contribute to intervention success/failure.

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Maternal depression http://www.heart-resources.org/reading_pack/maternal-depression/ http://www.heart-resources.org/reading_pack/maternal-depression/#respond Mon, 25 Apr 2016 09:15:47 +0000 http://www.heart-resources.org/?post_type=reading_pack&p=28931 Read more]]> The nature and scale of the problem

Depression is a mental disorder characterised by low mood, loss of interest or enjoyment, and reduced energy, leading to increased fatigue, reduced activity, and marked functional impairment (WHO, 1990). Other common symptoms are reduced concentration, reduced self-esteem, ideas of guilt or unworthiness, pessimistic views of the future, ideas or acts of self-harm or suicide, disturbed sleep, disturbed appetite and irritability. Depression is more severe than everyday fluctuations in mood, and leads to significant personal suffering and impairment in normal functioning.

Maternal depression is defined as depression experienced by a mother during pregnancy or the postnatal period (first 12 months of her baby’s life). The experience of maternal depression may vary substantially across cultures, with a variety of culture-specific idioms of distress. Examples include kufungisisa “thinking too much” in Zimbabwe (Patel et al, 1997), ukudakumba “being sad or unhappy” and ucingakakhulu “thinking too much” in South Africa (Davies et al, 2016), and yandimukuba “being struck by pressure” in Uganda (Nakku et al, forthcoming). These experiences are often accompanied by social isolation, withdrawal and stigma. Prevalence estimates for maternal depression vary. A recent systematic review reported that 16 per cent of pregnant women and 20 per cent of postnatal women experience depression in low- and middle-income countries (LMIC) (Fisher et al, 2012). This is higher than high-income countries, where 10 per cent of pregnant women and 13 per cent of postnatal women experience depression (O’hara and Swain, 1996).

Risk factors for maternal depression include poverty, unintended pregnancy, younger age, being unmarried, lacking intimate partner empathy and support, trauma (especially intimate partner violence), insufficient emotional and practical support, and HIV status (Fisher et al, 2012; Hartley et al, 2011). Conversely, protective factors include, social support, family involvement, planned pregnancy, partner involvement, and individual resilience factors such as optimism (Grote and Bledsoe, 2007).

Impact on the woman and her children

Maternal depression has a number of negative consequences for the woman herself. These include loss of functioning (inability to perform everyday tasks or social roles), loss of interest in self-care and child care, behaviour that affects other health conditions (for example, poor adherence to antiretroviral treatment for HIV), and risk of suicide or self-harm. A global systematic review reports that between 5 per cent and 14 per cent of women report suicide ideation during pregnancy or the postnatal period (Lindahl, Pearson and Colpe, 2005). Most suicides happen in the postnatal period (Gentile, 2011) and the presence of perinatal depression predicts suicide (Lindahl, Pearson and Colpe, 2005). Suicide now surpasses maternal mortality as the leading cause of death in girls aged 15-19 years, globally (Petroni, Patel and Patton, 2015).

Recent research from LMIC has revealed a number of negative consequences of maternal depression for the child. These include effects on children’s general health, development and behaviour (Wachs, Black and Engle, 2009; Hayes and Sharif, 2009), diarrhoeal episodes (Ross et al, 2011), malnutrition (Anoop et al, 2004; Patel, De Souza and Rodrígues, 2002), impaired physical development including significantly reduced height and weight and impaired mental development (Patel, De Souza and Rodrígues, 2002; Hadley et al, 2008), as well as poor mother-infant attachment and impaired mother-child relationships (Tomlinson, Cooper and Murray, 2005; Cooper et al, 1999).

Given the effect of maternal depression on infant and child developmental trajectories, maternal depression may play a key role in maintaining inter-generational cycles of poverty. However, the longitudinal data to support this hypothesis is not yet available in LMIC. Atif Rahman and colleagues in Pakistan are conducting long-term follow-up of children of maternally depressed women and are investigating this area in an ongoing way (Maselko et al, 2015).

Screening and diagnostic tools for maternal depression in low-income settings

A variety of screening tools have been used in low-income settings, including the Edinburgh Postnatal Depression Scale (EPDS) (Cox, Holden and Sagovsky, 1987), which has been validated in many settings (De Bruin et al, 2004) and other general depression screening tools such as the Patient Health Questionnaire (PHQ) (Kroenke and Spitzer, 2002), the Centre for Epidemiological Studies Depression Scale (CESD) (Radloff, 1977) and the Self Reporting Questionnaire (SRQ20) (Beusenberg and Orley, 1994). The benefits of screening tools are that they can facilitate a relatively quick and cheap assessment of potential depression and facilitate access to community-based care. General health practitioners such as nurses or community health workers can be trained to administer screening tools. The risks are that such tools may lack local cultural validity: with inadequate sensitivity they may miss real cases of depression and with inadequate specificity they may overburden services with ‘false positive’ cases (Kagee et al, 2013). A further risk is that if adequate resources are not in place in the health system, the system may be flooded by new referrals whose needs cannot be met. Careful consideration of the broader health system requirements of introducing routine screening is therefore essential.

A more rigorous but also more costly alternative is a diagnostic assessment by a mental health professional (for example using the WHO ICD10) (WHO, 1990), or the use of diagnostic assessment instruments such as the Mini International Neuropsychiatric Interview (Sheehan et al, 1998) or the Composite International Diagnostic Interview (CIDI) (Kessler and Ustun, 2004). The latter instruments take longer to administer than screening tools, require more skilled personnel and are therefore more costly. They may also suffer from similar problems of inadequate local cultural validity if they have not been properly adapted and translated into the local language.

A third alternative (and relatively recent innovation) is the use of idioms of distress to generate vignette based detection tools such as the Community Informant Detection Tool in Nepal (Jordans et al, 2015). This approach marks a step forward in identifying culturally valid experiences of depression, although substantial adaptation may be required for local cultural settings.

When should one screen? Some researchers have argued that the perinatal period is a time of high risk for women and their infants, and that routine antenatal screening for mental health, particularly in communities where high prevalence has been reported, should be mandatory (Honikman et al, 2012). Recently, the US Prevention Task Force published findings in the Journal of the American Medical Association (JAMA) recommending routine screening for depression, especially for pregnant and postpartum women (Siu et al, 2016). The final decision on whether to introduce routine antenatal or postnatal depression screening should depend on a number of considerations, including the prevalence of maternal depression in the local setting, the local validity of screening tools, and the availability of resources for detection and treatment.

What is good practice? Interventions in low resource settings

There is good emerging evidence for the cost-effectiveness of adapted psychological interventions, such as cognitive behaviour therapy (CBT), delivered by community health workers or lay counsellors, using a task shifting or task sharing approach (Chowdhary et al, 2014). For example, a large randomised controlled trial using Lady Health Workers to deliver a Thinking Healthy intervention in Pakistan demonstrated a significant improvement in depression outcomes (Rahman et al, 2008). As a result, the WHO has endorsed this approach and published a Thinking Healthy manual for maternal depression (WHO, 2015). Other trials are underway currently, for example, using peer counsellors in India and Pakistan (Sikander et al, 2015), and community health workers in South Africa (Lund et al, 2014).

How can maternal depression interventions be integrated into general maternal health programmes?

Integration is possible and there are several best practice examples, for example, the Perinatal Mental Health Project in Cape Town, South Africa (Honikman et al, 2012). Steps for integrating maternal depression interventions into wider maternal health programmes include the following:

  • Select a suitable locally relevant screening or detection tool. Examples of screening tools include the EPDS or PHQ9 (see above) and clinical algorithms include the WHO mhGAP Intervention Guide (WHO 2010).
  • Adapt and translate the screening tool if necessary.
  • Conduct a needs assessment: administer the screening tool to all antenatal and postnatal mothers over a specified period of time to determine prevalence.
  • Based on the identified need, design a stepped care approach, appropriate to the local setting:
    • Step 1: routine or selected antenatal and postnatal screening
    • Step 2: screen positives referred for evidence-based counselling
    • Step 3: referral of mothers who are not responsive to counselling for assessment by a medical doctor or a suitably qualified prescribing practitioner for potential anti-depressant medication
  • Note:
    • Five-day training (for example, using the WHO Thinking Healthy manual) (WHO, 2015), plus ongoing supervision of counsellors is essential. Appropriately selected lay counsellors or community health workers within the existing health system may be able to take on this role, although careful attention should be paid to potential counsellors’ personal capacity, motivation and skills (Honikman et al, 2012). Counsellors can include psychological counsellors and community health workers such as the Lady Health Workers in Pakistan (Rahman et al, 2008). Currently trials are under way in Pakistan and India to assess the effectiveness and cost-effectiveness of peer counsellors for perinatal depression (Sikander et al, 2015). The time required for counsellors to provide counseling will depend on the caseload, whether group or individual sessions are conducted and the number of sessions attended by each woman detected with depression.
    • It is also important that the broader health system is strengthened to cope with the possible additional demand. This should include appropriately trained medical personnel and the supply of appropriate anti-depressant medication for mothers who do not respond to psychological interventions. See other models, such as the Perinatal Mental Health Project (PMHP) for an indication of possible demand for medical personnel and medication – in the case of the PMHP only 2 per cent of women who received counseling were referred and seen by a psychiatrist (Honikman et al, 2012), but needs are likely to vary substantially based on a variety of contextual factors.
    • Costs to the health system are likely to vary substantially depending on demand, coverage and local health system costs (including personnel, medication and facilities). Estimates of the costs of integrating maternal mental healthcare into general primary care systems in LMIC are the subject of ongoing studies, such as the PRogramme for Improving Mental health carE (PRIME) study, which generated estimates of between US$5.05 in Ethiopia and US$14.48 in India per perinatally depressed woman treated with psychosocial care (Chisholm et al, 2016).

Some research and innovation groups working in maternal mental health in LMIC are:

  • Atif Rahman, Vikram Patel and colleagues at the University of Liverpool, working in Pakistan and India
  • Simone Honikman and colleagues at the Perinatal Mental Health Project in Cape Town, South Africa
  • Jane Fisher and colleagues at Monash University, Australia
  • Ricardo Araya and colleagues at the Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, United Kingdom, with projects in Brazil and Chile
  • Juliet Nakku and colleagues at Makerere University, Kampala, Uganda
  • Charlotte Hanlon and colleagues at Addis Ababa University, Ethiopia

Funders who have supported research in this area include the Wellcome Trust, Grand Challenges Canada, the National Institute of Mental Health and the Department for International Development (DFID).

For more on global mental health innovations, see the Mental Health Innovation Network: http://mhinnovation.net

Key readings

Reading 1: Fisher J, Mello MCd, Patel V, et al. Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review. Bull World Health Organ 2012; 90(2): 139-49. http://www.heart-resources.org/doc_lib/prevalence-determinants-common-perinatal-mental-disorders-women-low-lower-middle-income-countries-systematic-review/

Reading 2: Patel V, De Souza N, Rodrígues M. Postnatal depression and infant growth and development in low income countries: a cohort study from Goa, India. Arch Dis Child 2002; 87: 1-4. http://www.heart-resources.org/doc_lib/postnatal-depression-infant-growth-development-low-income-countries-cohort-study-goa-india/

Reading 3: Rahman A, Malik A, Sikander S, Roberts C, Creed F. Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised control trial. Lancet 2008; 372: 902-9. http://www.heart-resources.org/doc_lib/cognitive-behaviour-therapy-based-intervention-community-health-workers-mothers-depression-infants-rural-pakistan-cluster-randomised-controlled-trial/

Reading 4: Honikman S, van Heyningen T, Field S, Baron E, Tomlinson M. Stepped care for maternal mental health: a case study of the perinatal mental health project in South Africa. PLoS Med 2012; 9(5): e1001222. http://www.heart-resources.org/doc_lib/stepped-care-maternal-mental-health-case-study-perinatal-mental-health-project-south-africa/

Reading 5: WHO (2015). Thinking Healthy: A manual for psychological management of perinatal depression. Geneva: WHO. http://www.heart-resources.org/doc_lib/thinking-healthy-manual-psychosocial-management-perinatal-depression/

Reading 6: Kagee A, Tsai AC, Lund C, Tomlinson M. Screening for common mental disorders in low resource settings: reasons for caution and a way forward. International Health 2013; 5(1): 11-4. http://www.heart-resources.org/doc_lib/screening-common-mental-disorders-low-resource-settings-reasons-caution-way-forward/


  • Anoop S, Saravanan B, Joseph A, Cherian A, Jacob K. Maternal depression and low maternal intelligence as risk factors for malnutrition in children: a community based case-control study from South India. Arch Dis Child 2004; 89(4): 325-9.
  • Beusenberg M, Orley J. A user’s guide to the Self-Reporting Questionnaire (SRQ). Geneva: World Health Organization; 1994.
  • Chisholm D, Burman-Roy S, Fekadu A, et al. Estimating the cost of implementing district mental healthcare plans in five low- and middle-income countries: the PRIME study. The British Journal of Psychiatry: The Journal of Mental Science 2016; 208 Suppl 56: s71-8.
  • Chowdhary N, Sikander S, Atif N, et al. The content and delivery of psychological interventions for perinatal depression by non-specialist health workers in low and middle income countries: a systematic review. Best Practice & Research Clinical Obstetrics & Gynaecology 2014; 28(1): 113-33.
  • Cooper PJ, Tomlinson M, Swartz L, Woolgar M, Murray L, Molteno C. Post-partum depression and the mother-infant relationship in a South African peri-urban settlement. The British Journal of Psychiatry 1999; 175(6): 554-8.
  • Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. The British Journal of Psychiatry 1987; 150(6): 782-6.
  • Davies T, Schneider M, Nyatsanza M, Lund C. “The sun has set even though it is morning”: Experiences and explanations of perinatal depression in an urban township, Cape Town. Transcultural Psychiatry
  • De Bruin G, Swartz L, Tomlinson M, Cooper P, Molteno C. The factor structure of the Edinburgh Postnatal Depression scale in a South African peri-urban settlement. South African Journal of Psychology 2004; 34: 113-21.
  • Fisher J, Mello MCd, Patel V, et al. Prevalence and determinants of common perinatal mental disorders in women in low-and lower-middle-income countries: a systematic review. Bull World Health Organ 2012; 90(2): 139-49.
  • Gentile S. Suicidal mothers. Journal of Injury and Violence Research 2011; 3(2): 90.
  • Grote NK, Bledsoe SE. Predicting postpartum depressive symptoms in new mothers: the role of optimism and stress frequency during pregnancy. Health & Social Work 2007; 32(2): 107-18.
  • Hadley C, Tegegn A, Tessema F, Asefa M, Galea S. Parental symptoms of common mental disorders and children’s social, motor, and language development in sub-Saharan Africa. Ann Hum Biol 2008; 35(3): 259-75.
  • Hartley M, Tomlinson M, Greco E, et al. Depressed mood in pregnancy: prevalence and correlates in two Cape Town peri-urban settlements. Reprod Health 2011; 8: 9.
  • Hayes B, Sharif F. Behavioural and emotional outcome of very low birth weight infants–literature review. The Journal of Maternal-fetal & Neonatal Medicine 2009; 22(10): 849-56.
  • Honikman S, van Heyningen T, Field S, Baron E, Tomlinson M. Stepped care for maternal mental health: a case study of the perinatal mental health project in South Africa. PLoS Med 2012; 9(5): e1001222.
  • Kagee A, Tsai AC, Lund C, Tomlinson M. Screening for common mental disorders in low resource settings: reasons for caution and a way forward. International Health 2013; 5(1): 11-4.
  • Kessler RC, Ustun TB. The World Mental Health (WMH) survey initiative version of the WHO-CIDI. International Journal of Methods in Psychiatric Research 2004; 13: 95-121.
  • Kroenke K, Spitzer RL. The PHQ-9: A new depression diagnostic and severity measure. Psychiat Ann 2002; 32(9): 509-15.
  • Jordans MJ, Kohrt BA, Luitel NP, Komproe IH, Lund C. Accuracy of proactive case finding for mental disorders by community informants in Nepal. The British Journal of Psychiatry: The Journal of Mental Science 2015; 207(6): 501-6.
  • Lindahl V, Pearson JL, Colpe L. Prevalence of suicidality during pregnancy and the postpartum. Archives of Women’s Mental Health 2005; 8(2): 77-87.
  • Lund C, Schneider M, Davies T, et al. Task sharing of a psychological intervention for maternal depression in Khayelitsha, South Africa: study protocol for a randomized controlled trial. Trials 2014; 15: 457.
  • Maselko J, Sikander S, Bhalotra S, et al. Effect of an early perinatal depression intervention on long-term child development outcomes: follow-up of the Thinking Healthy Programme randomised controlled trial. The Lancet Psychiatry 2015; 2(7): 609-17.
  • Nakku J, Elialilia O, Kizza D, et al. Maternal mental health care in a rural district, Uganda: A qualitative study of barriers, facilitators and needs. BMC Health Services Research Under review.
  • O’hara MW, Swain AM. Rates and risk of postpartum depression-a meta-analysis. Int Rev Psychiatry 1996; 8(1): 37-54.
  • Radloff LS. The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement 1977; 1(3): 385-401.
  • Ross J, Hanlon C, Medhin G, et al. Perinatal mental distress and infant morbidity in Ethiopia: a cohort study. Archives of Disease in Childhood-fetal and Neonatal Edition 2011; 96(1): F59-F64.
  • Patel V, Todd C, Winston M, et al. Common mental disorders in primary care in Harare, Zimbabwe: associations and risk factors. The British Journal of Psychiatry 1997; 171: 60-4
  • Patel V, De Souza N, Rodrígues M. Postnatal depression and infant growth and development in low income countries: a cohort study from Goa, India. Arch Dis Child 2002; 87: 1-4.
  • Petroni S, Patel V, Patton G. Why is suicide the leading killer of older adolescent girls? Lancet 2015; 386(10008): 2031-2.
  • Rahman A, Malik A, Sikander S, Roberts C, Creed F. Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised control trial. Lancet 2008; 372: 902-9.
  • Sheehan DV, Lecrubier Y, Sheehan KH, et al. The Mini-International Neuropsychiatric Interview (MINI): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 1998; 59: 22-33.
  • Sikander S, Lazarus A, Bangash O, et al. The effectiveness and cost-effectiveness of the peer-delivered Thinking Healthy Programme for perinatal depression in Pakistan and India: the SHARE study protocol for randomised controlled trials. Trials 2015; 16: 534.
  • Siu AL, Force USPST, Bibbins-Domingo K, et al. Screening for Depression in Adults: US Preventive Services Task Force Recommendation Statement. Jama 2016; 315(4): 380-7.
  • Tomlinson M, Cooper P, Murray L. The mother–infant relationship and infant attachment in a South African peri‐urban settlement. Child Dev 2005; 76(5): 1044-54.
  • Wachs TD, Black MM, Engle PL. Maternal depression: a global threat to children’s health, development, and behavior and to human rights. Child Development Perspectives 2009; 3(1): 51-9.
  • ICD-10 Classification of Mental and Behavioural Disorders. Geneva: WHO; 1990.
  • mhGAP Intervention Guide for Mental, Neurological and Substance Use Disorders in non-specialized health settings: Mental health Gap Action Programme (mmhGAP). Geneva: WHO; 2010.
  • Thinking Healthy: A manual for psychological management of perinatal depression. Geneva: WHO; 2015.
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Situational analysis of FGM/C stakeholders and interventions in Somalia http://www.heart-resources.org/assignment/situational-anons-in-somalia/ http://www.heart-resources.org/assignment/situational-anons-in-somalia/#comments Mon, 23 Nov 2015 12:54:29 +0000 http://www.heart-resources.org/?post_type=assignment&p=28221 Read more]]> The overall aim of the Situational Analysis in Somalia is for government, donors and the UN to gain a greater understanding of existing interventions towards ending Female Genital Mutilation/Cutting (FGM/C), and to identify gaps so as to be able to strengthen the current interventions and inform future programming. There are two parts to the report: Part 1, “The Silence is Broken”, is the overall report, which amalgamates key findings from a Participatory Community Perspectives Study (CPS) into analysis of the institutional policy and practice environments at the zonal level. Part 2, The CPS, is a report on views and opinions about FGM/C from those who are the focus of end-FGM/C activities in the zones, and those who work to carry out those activities.

Emerging recommendations for government, donors and the UN include:

  • Encourage full understanding of zero tolerance; support embedding of zero tolerance throughout policy
  • Strengthen the implementation of policy and encourage the end of medicalisation of FGM/C
  • Support the clarification of all roles and responsibilities amongst all actors who need to be involved in ending FGM/C in Somalia
  • Be pro-active in shaping the research agenda and ensure that research carried out under the FGM/C shows good fit to national and zonal identified needs
  • Support Somalia in becoming a model UNFPA-UNICEF Joint Programme on ending FGM/C (UNJP) country
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Affordability of Non-Communicable Disease (NCD) prevention http://www.heart-resources.org/2015/11/affordability-of-non-communicable-disease-ncd-prevention/ http://www.heart-resources.org/2015/11/affordability-of-non-communicable-disease-ncd-prevention/#respond Tue, 10 Nov 2015 10:00:25 +0000 http://www.heart-resources.org/?p=28056 Read more]]> This helpdesk reviews key studies on multiple primary and secondary prevention strategies, cardio-vascular disease (CVD) prevention drugs, and cancer prevention and early detection, in order to determine what the evidence says about the affordability of managing NCDs in low income countries. One key document reviewed the WHO Global action plan for the prevention and control of non-communicable diseases, 2013-2020. This outlines a combination of population-wide and individual interventions for prevention and control of Non-Communicable Diseases (NCDs) deemed to be ‘very cost-effective’. They estimate the cost of this, in terms of current health spending, to be 4% in low-income countries and 2% in lower middle-income countries. Highlighted as affordable are:

  • Tobacco: increasing pricing, creating smoke-free laws, health warnings/media campaigns, banning advertising.
  • Alcohol: regulating availability, restricting advertising, taxation.
  • Health, diet and activity: reducing salt, replacing trans fats with unsaturated fats, public awareness programmes.
  • CVD and diabetes prevention: Drug therapy (including glycaemic control for diabetes mellitus and control of hypertension using a total risk approach) and counselling for high-risk individuals.
  • Cancer prevention: Hepatitis B immunisation, cervical cancer screening.


Some cost estimates for specific interventions are identified in the literature. For example:

  • Reduced salt intake intervention and the four WHO tobacco control provisions could be implemented for less than USD $0.40 per person per year in Low and Middle Income Countries (LMICs)
  • Monthly costs from a 2013 price guide: Aspirin for CVD prevention ($0.084), Simvastatin for stroke prevention ($0.705), Atenolol to prevent cardiac complications ($0.354).
  • Population-based demand reduction measures for tobacco control, US$ 0.11 per head of population for low- and middle income countries; for reducing harmful alchohol use in Africa, US$ 0.14 per person; and for health diet and exercise in Africa, less than US$ 0.10 per person.
  • A one-month supply of standard generic CVD secondary prevention drugs cost 1.5 days’ wages of the lowest-level government worker in Sri Lanka; more than 5 days’ wages in Brazil, Nepal, and Pakistan; and more than 18 days’ wages in Malawi. Prices could be reduced by improving purchasing efficiency, eliminating taxes and regulating mark-ups. Combination drugs such as polypills could improve affordability.
  • The Gavi Alliance is supporting the introduction of vaccines to reduce human papillomavirus (HPV), the leading cause of cervical cancer, US$ 4.50 per dose.
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Global action plan for the prevention and control of noncommunicable diseases http://www.heart-resources.org/doc_lib/global-action-plan-for-the-prevention-and-control-of-noncommunicable-diseases/ http://www.heart-resources.org/doc_lib/global-action-plan-for-the-prevention-and-control-of-noncommunicable-diseases/#respond Tue, 10 Nov 2015 09:27:37 +0000 http://www.heart-resources.org/?post_type=doc_lib&p=28055 Read more]]> Noncommunicable diseases (NCDs) – mainly cardiovascular diseases, cancers, chronic respiratory diseases and diabetes – are the biggest cause of death worldwide. More than 36 million die annually from NCDs (63% of global deaths), including 14 million people who die too young before the age of 70. More than 90% of these premature deaths from NCDs occur in low- and middle-income countries, and could have largely been prevented. Most premature deaths are linked to common risk factors, namely tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol.

To strengthen national efforts to address the burden of NCDs, the 66th World Health Assembly endorsed the WHO Global Action Plan for the Prevention and Control of NCDs 2013-2020 (resolution WHA66.10). The global action plan offers a paradigm shift by providing a road map and a menu of policy options for Member States, WHO, other UN organizations and intergovernmental organizations, NGOs and the private sector which, when implemented collectively between 2013 and 2020, will attain 9 voluntary global targets, including that of a 25% relative reduction in premature mortality from NCDs by 2025.

The WHO Global NCD Action Plan 2013-2020 follows on from commitments made by Heads of State and Government in the United Nations Political Declaration on the Prevention and Control of NCDs (resolution A/RES/66/2), recognizing the primary role and responsibility of Governments in responding to the challenge of NCDs and the important role of international cooperation to support national efforts.

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The Political Economy of NCDs in Low- and Middle-Income Countries http://www.heart-resources.org/2015/09/the-political-economy-of-ncds-in-low-and-middle-income-countries/ http://www.heart-resources.org/2015/09/the-political-economy-of-ncds-in-low-and-middle-income-countries/#respond Tue, 01 Sep 2015 17:03:28 +0000 http://www.heart-resources.org/?p=26908 Read more]]> There is a growing movement advocating for an increased focus on resourcing the control and treatment of non-communicable diseases (NCDs), ie The Lancet NCD Action Group and the NCD Alliance. The proponents of tackling NCDs often quote figures for NCD impact in LMICs without discussing disparities between socio-economic groups. The rapid search for this report identified some literature that questions the notion that NCD rates are more prevalent in wealthier socio-economic groups.

National NCD policies should be geared to addressing primary prevention and equity of health systems. Health systems need reconfiguration to ensure equitable access to essential NCD interventions. Context-specific research is identified as a requirement to address implementation gaps in NCD policy, as policy development and implementation are driven by political realities and cultural specificities.

Maher and Sridhar (2012) use a political policy priority framework to look at why funding for NCDs is inadequate and why plans to stop the spread of NCDs has been so difficult. They find that struggles for influence and determining which issues to champion is “informed by subjectively held notions of the right, the good, and the just”.

Negin and Robinson (2010) compare funding for HIV and NCDs to disease burdens in the Pacific Region. They find higher rates of mortality for NCDs but higher external funding for HIV. The authors do not investigate socio-economic groupings within this.

On a more practical level, Stenberg and Chisholm (2012) review various investment strategies related to prevention and control of NCDs. They suggest integrating NCDs into the process for national strategic health planning. Miranda et al (2008) propose reintegration of current vertical programmes (e.g. for malaria, polio, tuberculosis, HIV) into novel forms of family-orientated primary care to include NCDs. HIV advocates reject attempts to create divisions and competition between health agendas. They aim to communicate and reinforce coalitions with allied agendas, including coalitions focused on other diseases.

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