Cultural adaptation and randomised evaluation of a multi-component school- based intervention for common mental disorders in Pakistani adolescents
Lead Research Organisation:
University of Liverpool
Department Name: Institute of Psychology Health & Society
Abstract
We are currently working with the WHO to implement school mental health in a number of countries in the Eastern Mediterranean region, including Pakistan. This large-scale programme in collaboration with Ministries of Health and Education seeks to implement evidence-based interventions for children and adolescents in school-settings. The key stakeholders, including teachers and health-care providers, have identified a large unmet need for a targeted intervention to address high levels of anxiety and depression in older adolescents. In response, the WHO after consultation with international experts, and conducting a review of available evidence, have developed a brief transdiagnostic intervention called Early Adolescence Skills for Emotions (EASE). This brief group psychological intervention is based on cognitive behavioural therapy (CBT) recognised to treat anxiety and depression in young people. The intervention is designed to be delivered by non-specialists in low resource settings.
The aim of this project is to adapt and add EASE to the ongoing school mental health programme in Pakistan to address the needs of adolescents with symptoms of depression and anxiety. Following this, we will conduct a study to see if the intervention is effective in improving symptoms of anxiety and depression in school-going adolescents aged 14-16 who receive the intervention, compared to those who don't. We will also evaluate the costs, and barriers and facilitators of integrating such an intervention into the Pakistani school system.
The aim of this project is to adapt and add EASE to the ongoing school mental health programme in Pakistan to address the needs of adolescents with symptoms of depression and anxiety. Following this, we will conduct a study to see if the intervention is effective in improving symptoms of anxiety and depression in school-going adolescents aged 14-16 who receive the intervention, compared to those who don't. We will also evaluate the costs, and barriers and facilitators of integrating such an intervention into the Pakistani school system.
Technical Summary
Depression and anxiety are the leading contributors to health burden among adolescents worldwide. These disorders are associated with increased mortality due to suicide and intentional and unintentional injuries. If untreated, these conditions severely influence children's development, their educational attainments, and their potential to live fulfilling and productive lives. However, globally the treatment gap for mental disorders in adolescence is large. To address this treatment gap, the WHO has developed a brief transdiagnostic, group psychological intervention programme based on empirically supported cognitive behavioural therapy (CBT) techniques. The programme is called Early Adolescence Skills for Emotions (EASE).
Our project has two objectives:
1) Using the MRC Framework for development and evaluation of complex interventions, we seek to understand how the WHO's EASE intervention can be made relevant, feasible and acceptable for school-going adolescents living in low socioeconomic rural settings in Pakistan.
2) Evaluate the effectiveness and cost-effectiveness of EASE using a cluster randomised controlled design. The intervention will be delivered to over 250 adolescents with symptoms of depression and anxiety in 10 schools randomised to the intervention arm, while a similar number of adolescents in 10 control schools will receive routine care and equivalent support groups. A number of questionnaires will measure outcomes at 1-week and 3-month post-intervention. Our primary outcome is psychological distress, and secondary outcomes include depression, anxiety, functioning, self-esteem and coping skills.
The research will inform the WHO's efforts to lower the global mental health treatment gap for common mental disorder in low and middle income countries and help the Pakistani school system implement and establish its school mental health programme.
Our project has two objectives:
1) Using the MRC Framework for development and evaluation of complex interventions, we seek to understand how the WHO's EASE intervention can be made relevant, feasible and acceptable for school-going adolescents living in low socioeconomic rural settings in Pakistan.
2) Evaluate the effectiveness and cost-effectiveness of EASE using a cluster randomised controlled design. The intervention will be delivered to over 250 adolescents with symptoms of depression and anxiety in 10 schools randomised to the intervention arm, while a similar number of adolescents in 10 control schools will receive routine care and equivalent support groups. A number of questionnaires will measure outcomes at 1-week and 3-month post-intervention. Our primary outcome is psychological distress, and secondary outcomes include depression, anxiety, functioning, self-esteem and coping skills.
The research will inform the WHO's efforts to lower the global mental health treatment gap for common mental disorder in low and middle income countries and help the Pakistani school system implement and establish its school mental health programme.
Planned Impact
The findings are likely to inform early interventions that can help prevent mental health problems in later life. The findings are also likely to advance the understanding of how complex interventions should be culturally adapted and feasibly integrated into school and health systems. Our close collaboration with several academic groups (see academic beneficiaries) working in these fields have the potential to inform integrated interventions to reduce the burden from depression and anxiety in young people globally.
Scalable integrated interventions that address adolescent mental health have great promise to improve the developmental potential, physical and mental health of the children of the Eastern Mediterranean Region. Such interventions are necessary to limit the psychosocial consequences of armed conflict and displacement faced by many children in the Eastern Mediterranean region. This is a priority of the WHO's Eastern Mediterranean Regional Office, our partner in this project.
The research findings are likely to assist the Education Department in Pakistan to improve the health of students living in poorer rural settings. The Pakistani Education Department are partners in our project, committed to scaling up school mental health interventions in the District of Rawalpindi. Our co-Investigator in Pakistan, Minhas, leads the WHO Collaborating Centre for Mental Health Research and Training in Rawalpindi, is already engaged with the Education Department to achieve this.
Scalable integrated interventions that address adolescent mental health have great promise to improve the developmental potential, physical and mental health of the children of the Eastern Mediterranean Region. Such interventions are necessary to limit the psychosocial consequences of armed conflict and displacement faced by many children in the Eastern Mediterranean region. This is a priority of the WHO's Eastern Mediterranean Regional Office, our partner in this project.
The research findings are likely to assist the Education Department in Pakistan to improve the health of students living in poorer rural settings. The Pakistani Education Department are partners in our project, committed to scaling up school mental health interventions in the District of Rawalpindi. Our co-Investigator in Pakistan, Minhas, leads the WHO Collaborating Centre for Mental Health Research and Training in Rawalpindi, is already engaged with the Education Department to achieve this.
Publications
Hamdani SU
(2021)
Debate: Child and adolescent mental health services in Pakistan; Do we need in-patient mental health facilities for children and young people?
in Child and adolescent mental health
Rahman A
(2021)
Debate: Implementation Science can help bridge the gap between evidence and policy - a case study from the Eastern Mediterranean Region.
in Child and adolescent mental health
Hamdani SU
(2022)
Feasibility and acceptability of a multicomponent, group psychological intervention for adolescents with psychosocial distress in public schools of Pakistan: a feasibility cluster randomized controlled trial (cRCT).
in Child and adolescent psychiatry and mental health
Mirza Z
(2019)
Mental health care in Pakistan boosted by the highest office.
in Lancet (London, England)
Hamdani, S.U
(2021)
Prevalence of psychosocial distress in school going adolescents in rural Pakistan: Findings from a cross-sectional epidemiological survey
in BJPysch Open
Hamdani SU
(2021)
Scaling-up school mental health services in low resource public schools of rural Pakistan: the Theory of Change (ToC) approach.
in International journal of mental health systems
Description | Expansion of school mental health programme to Federal Areas of Islamabad:- Federal Directorate of Education, Islamabad, School Health Services Expert group: Site-PI, Dr. Hamdani has been invited to the School Health Services Expert Group convened by Federal Directorate of Education, Islamabad Pakistan. As a part of his role he will advise the Federal Directorate of Education, on the integration of school based mental health services in public schools of Islamabad. - Led by the Site-PI Dr. Hamdani, the research team is helping the Federal Directorate of Education, Islamabad and Ministry of National Health Services, Regulations and Coordination (NHS R&C) to sign a five-year letter of understanding to integrate and scale-up school based mental health services in public schools of Islamabad. |
Geographic Reach | Local/Municipal/Regional |
Policy Influence Type | Implementation circular/rapid advice/letter to e.g. Ministry of Health |
Impact | - Federal Directorate of Education, Islamabad, School Health Services Expert group: Site-PI, Dr. Hamdani has been invited to the School Health Services Expert Group convened by Federal Directorate of Education, Islamabad Pakistan. As a part of his role he will advise the Federal Directorate of Education, on the integration of school based mental health services in public schools of Islamabad. - Led by the Site-PI Dr. Hamdani, the research team is helping the Federal Directorate of Education, Islamabad and Ministry of National Health Services, Regulations and Coordination (NHS R&C) to sign a five-year letter of understanding to integrate and scale-up school based mental health services in public schools of Islamabad. |
Description | Integration of School Mental Health Program into Promotion Linked Training (PLT) of teachers from the public schools of Punjab |
Geographic Reach | National |
Policy Influence Type | Contribution to new or Improved professional practice |
Description | Meeting with Education Minister of Punjab province to integrate 'Adolescent Mental Health Services' in public schools of Punjab, post-lockdown |
Geographic Reach | National |
Policy Influence Type | Implementation circular/rapid advice/letter to e.g. Ministry of Health |
Description | School mental health as part of President's Programme to promote mental health of Pakistanis |
Geographic Reach | National |
Policy Influence Type | Participation in a guidance/advisory committee |
Impact | School mental health including interventions for adolescent depression being evaluated in the current MRC award have become part of the President's Progromme to promote the mental health of Pakistanis and recommended for national scale-up. |
Description | Active Ingredients for Global Youth Mental Health |
Amount | £65,000 (GBP) |
Organisation | Wellcome Trust |
Sector | Charity/Non Profit |
Country | United Kingdom |
Start | 10/2020 |
End | 01/2021 |
Description | Delivery of school based mental health program to adolescents studying in public schools of Islamabad as part of the President's Programme to Promote the Mental Health of Pakistanis |
Amount | $35,000 (USD) |
Organisation | World Health Organization (WHO) |
Sector | Public |
Country | Global |
Start | 01/2020 |
End | 12/2020 |
Description | Effectiveness of role of parents and family as an active ingredient to prevent and treat anxiety and depression in young people aged 14-24- Consultation with young people, systematic Review and Meta-Analysis of the literature |
Amount | £45,000 (GBP) |
Organisation | Wellcome Trust |
Sector | Charity/Non Profit |
Country | United Kingdom |
Start | 06/2021 |
End | 12/2021 |
Description | GIAA Award 2018/19 . UKRI GCRF Global Impact Acceleration Account" Accelerating the impact of a School Mental Health program in Rural Pakistan" |
Amount | £19,972 (GBP) |
Organisation | University of Liverpool |
Sector | Academic/University |
Country | United Kingdom |
Start | 11/2018 |
End | 03/2019 |
Description | The Wellcom Trust Active Ingredients Initiative- 1st Commission - Effectiveness of relaxation therapies as an active ingredient of successful interventions for anxiety and depression in young people aged 14-24- a Systematic Review and Meta-Analysis |
Amount | £35,000 (GBP) |
Organisation | Wellcome Trust |
Sector | Charity/Non Profit |
Country | United Kingdom |
Start | 06/2020 |
End | 09/2020 |
Description | Scaling-up child and adolescent mental health services through schools |
Organisation | International Rescue Committee |
Country | United States |
Sector | Charity/Non Profit |
PI Contribution | IRC is exploring the platform of schools to scale-up school based mental health services in Tanzania. Since EASE is being implemented in schools in Pakistan, we are collaborating with IRC to share insights from policy engagement, program adaptation and implementation in Pakistan. |
Collaborator Contribution | IRC is conducting randomised controlled trial of EASE intervention in the Mtendeli Refugee Camp in Tanzania. One aim of the trial is to test the feasibility of schools as part of the referral pathway into the intervention and consider the role of schools as part of wider scale-up. Given the integral role of schools as the implementing agent in our trial in Pakistan we are engaged in two-way learning and collaboration on scaling-up school based mental health services in low-resource settings. |
Impact | HDRF and IRC are now exploring avenues of partnerships and collaborations. IRC is interested in implementing WHO Thinking Healthy program for which we are discussing the proposals. |
Start Year | 2019 |
Description | School Health Implementation Network: Eastern Mediterranean Region (SHINE) |
Organisation | University of Washington |
Country | United States |
Sector | Academic/University |
PI Contribution | School Health Implementation Network: Eastern Mediterranean Region (SHINE) is a collaborative network involving four countries in the World Health Organization's Eastern Mediterranean Region (WHO-EMRO). Its principal focus is scaling up school-based mental health services. An implementation study is taking place in Pakistan, and capacity-building activities are occurring in Pakistan, Egypt, Jordan, and Iran. |
Collaborator Contribution | SHINE provides a platform to disseminate our school mental health activities to the Eastern Mediterranean Region of the WHO. |
Impact | https://www.nimh.nih.gov/about/organization/cgmhr/scaleuphubs/school-health-implementation-network-eastern-mediterranean-region-shine.shtml |
Start Year | 2019 |
Description | WHO School Health Services guidelines development group |
Organisation | World Health Organization (WHO) |
Country | Global |
Sector | Public |
PI Contribution | Rahman and Hamdani are members of the WHO School Health Services expert group and contributing to the school health services guidelines to implement school mental health services as a part of school health services globally. |
Collaborator Contribution | We have attended the Guideline Development Group meetings and commented on the guidelines being developed. |
Impact | Contribution to guidelines for school health services to include adolescent depression interventions. |
Start Year | 2019 |
Title | School based Early Adolescent Skills for Emotions (EASE) |
Description | Based on the available evidence and experts' guidance, WHO has developed a psychological intervention manual - Early Adolescent Skills for Emotions (EASE) - for 10-14 year old adolescents with high distress and impaired functioning. EASE has been designed to be delivered by trained and supervised non-specialist facilitators to groups of adolescents and separately, their caregivers, who are living in adversity. With the funding support from UKRI, EASE is currently undergoing randomised controlled trial testing in school settings of rural Pakistan. |
Type | Therapeutic Intervention - Psychological/Behavioural |
Current Stage Of Development | Initial development |
Year Development Stage Completed | 2019 |
Development Status | Under active development/distribution |
Impact | The WHO EASE intervention is undergoing randomised controlled trial testing in humanitarian settings of Jordan, Lebanon and Tanzania. |
URL | https://www.who.int/mental_health/maternal-child/adolescent/en/ |
Description | Engagement with teachers and head teachers of over 80 schools in Rawalpindi District |
Form Of Engagement Activity | A formal working group, expert panel or dialogue |
Part Of Official Scheme? | No |
Geographic Reach | Regional |
Primary Audience | Schools |
Results and Impact | To engage school teachers and heads in a dialogue about the importance of mental health in the children. |
Year(s) Of Engagement Activity | 2019,2020 |
Description | Harnessing technology to promote positive mental health in pandemics for adolescents- A case study from Pakistan |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Professional Practitioners |
Results and Impact | The Site-Principal Investigator (UH) was invited as a Panelist on Sri Lanka Medical Association, 134th Anniversary International Medical Congress, 2021 to present the work of implementing school based mental health program in rural schools of Pakistan as a case study to promote youth mental health amidst COVID-19. |
Year(s) Of Engagement Activity | 2021 |
Description | Implementation of school based mental health intervention in rural Pakistan |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | National |
Primary Audience | Policymakers/politicians |
Results and Impact | Meeting with Parliamentary Secretary, Chairperson, National Task Force on Mental Health and British Pakistani Psychiatrists Association to implement school based mental health program in Pakistan. |
Year(s) Of Engagement Activity | 2021 |
Description | World Mental Health day- Young People and Mental Health in the Changing World |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | National |
Primary Audience | Professional Practitioners |
Results and Impact | University of Liverpool, UK in collaboration with the Human Development Research Foundation, Pakistan and Institute of Psychiatry WHO Collaborating Centre for Mental Health Research and Training, Rawalpindi, organised a symposium on the World Mental Health day 2018. The theme of the symposium was "Young People and Mental Health in the Changing World". The presenters discussed the problems faced by the youth of Pakistan and its impact on mental health and well being of youngsters. The need for school based early identification and preventative programs was highlighted. The WHO initiative on "Early Adolescents Skills for Emotions(EASE)" was presented to the audience as a potential program to be integrated into school health programs for nation wide scale-up. The symposium concluded by emphasising the need for reframing mental health by forging partnerships with key sectors beyond health sector and specially with the education sector to promote mental health of young population. |
Year(s) Of Engagement Activity | 2018 |
Description | Youth consultations in Australia, Pakistan, Kenya, India, UK and South Africa to inform what works to prevent and treat anxiety and depression in adolescents aged 14-24 years, in which context and why, globally? |
Form Of Engagement Activity | A formal working group, expert panel or dialogue |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Study participants or study members |
Results and Impact | We conducted consultations with young people and their caregivers with lived experiences to examine how young people with lived experiences and their parent/carers define adolescent psychological interventions and involvement of parent(s)/caregiver(s)/family in youth interventions; identify the contextual factors of parenting interventions that are important for them; explore gaps in the existing literature and elucidate their recommendations regarding future research on parenting interventions and involvement of parent(s)/caregiver(s)/family in youth interventions. The youth advisory group consisted of 40 young people (aged 14-24 years) with lived experience of mental health difficulties previously and 16 caregivers, who were recruited from Australia, India, Kenya, Pakistan, South Africa and United Kingdom (UK). |
Year(s) Of Engagement Activity | 2021 |
Description | Youth consultations to inform what works to prevent and treat anxiety and depression in adolescents aged 14-24 years, in which context and why, globally? |
Form Of Engagement Activity | A formal working group, expert panel or dialogue |
Part Of Official Scheme? | No |
Geographic Reach | Local |
Primary Audience | Undergraduate students |
Results and Impact | As part of the Wellcome's grant, we consulted 21 young people with lived-experience of mental health difficulties residing in Pakistan to provide insight into what works to prevent and treat anxiety and depression in adolescents aged 14-24 years, in which context and why, globally? |
Year(s) Of Engagement Activity | 2020 |