Browsing by Author "Kohrt, Brandon A"

Background: Indigenous People around the world experience inequalities in health care. In Brazil, Indigenous inequalities in health are exacerbated by the poor system of health care delivery. The aim of this study is to understand barriers to care as defined from the Indigenous perspective.

Methods: This study was conducted on three Indigenous reserves of the Xavante people in Mato Grosso, Brazil. We utilized a mixed methods approach. In the quantitative portion of the study, we surveyed 50 individuals using an adapted version of the World Health Organization 2002 World Health Survey. Participants for the quantitative survey were recruited from a randomized list of prospective patients for a medical outreach mission. In the qualitative portion of the study, we interviewed 37 individuals, including patients, health care providers, and village chiefs, about their experiences with health care. Participants for the qualitative interviews were recruited randomly from a medical outreach patient listing (Expedicionários da Saúde).

Results: Overall, participants reported dissatisfaction with health-seeking experiences. We identified five barriers to obtaining satisfactory care: lack of transportation, lack of health care services and medication, attitudes of health care workers, lack of culturally appropriate services, and social determinants.

Conclusions: Given an overall sense of dissatisfaction with health care use among indigenous people, future research should focus on identifying interventions to help overcome key barriers to accessing care. Private-public partnerships and other innovative health systems models should be explored to meet the needs of underserved indigenous communities.

Background: Emotions are shaped through the internalization of culturally relevant values. Contextualized systems of meaning influence an individual’s experience of emotion, the consequences of a given response, and their connection to long-term functional outcomes. The present study aims to explore the socioemotional world of Nepali adolescents, in order to understand emotional needs and identify opportunities for psychosocial intervention. Methods: A tablet-based battery of quantitative assessments was administered to 102 students in grades 7-9 (age 12-18) in an earthquake affected region of the Kathmandu Valley. Assessments included measures of anxiety, PTSD, functional impairment, and a local idiom of distress (problems in the heart-mind). Semi-structured interviews were conducted with 21 students and explored the emotional experience of a recent stressor. Results: Three domains of emotion experience emerged: cognitive, physical, and social. While key differences in emotional distress across gender and cultural groups emerged, similarities in the overarching model suggest a shared understanding of negative emotion among Nepali adolescents. Of particular note is the social domain, involving both interpersonal and communal elements, which included the local idiom of distress, which has previously been linked to depression risk. Conclusion: This tripartite conceptualization of emotion is a critical step toward understanding cultural meanings of emotional wellbeing, and the connection between socially experienced emotion and psychopathology underlines the importance of psychosocial integration in future interventions.

Background: The burden of mental health is increased in humanitarian settings, and needs to be addressed in emergency situations. The World Health Organization has recently released the mental health Global Action Programme Humanitarian Intervention Guide (mhGAP-HIG) in order to scale up mental health service delivery in humanitarian settings through task-shifting. This study aims to evaluate, contextualize and identify possible barriers and challenges to mhGAP-HIG manual content, training and implementation in post-earthquake Nepal.

Methods: This qualitative study was conducted in Kathmandu, Nepal. Key informant interviews were conducted with fourteen psychiatrists involved in a mhGAP-HIG Training of Trainers and Supervisors (ToTS) in order to assess the mhGAP-HIG, ToTS training, and the potential challenges and barriers to mhGAP-HIG implementation. Themes identified by informants were supplemented by process notes taken by the researcher during observed training sessions and meetings.

Results: Key themes emerging from key informant interviews include the need to take three factors into account in manual contextualization: culture, health systems and the humanitarian setting. This includes translation of the manual into the local language, adding or expanding upon conditions prevalent in Nepal, and more consideration to improving feasibility of manual use by non-specialists.

Conclusion: The mhGAP-HIG must be tailored to specific humanitarian settings for effective implementation. This study shows the importance of conducting a manual contextualization workshop prior to training in order to maximize the feasibility and success in training health care workers in mhGAP.

Background: Many health providers worldwide stigmatize people living with mental illness, creating a barrier to providing quality mental health services. Interventions aiming to reduce stigma during medical school have utilized education and contact-based methods to improve student attitudes towards mental illness. However, the effectiveness of these methods has never before been compared in medical schools in low-income countries. The aim of this study was to evaluate a video featuring a mental health service user with depression in a randomized controlled pilot trial among medical students in Nepal. Methods: In a three-armed randomized controlled pilot trial, participants were randomized to one of three conditions: a didactic video lecture based on the mental health Gap Action Programme Implementation Guide (mhGAP-IG) depression module, a service user testimonial video about living with depression, and a condition with no video presentation. Participants were 94 second and third year medical students in Nepal. All of the measures were collected post-intervention. The primary outcome was explicit attitudes measured on the Social Distance Scale (SDS). Additional outcomes were implicit attitudes on two Implicit Association Tests (IAT), diagnostic accuracy, treatment knowledge, and symptom knowledge. Results: Both the didactic lesson (SDS mean score, M = 33.32; standard deviation, SD = 9.57) and the service user videos (M= 30.13; SD= 9.16) had lower explicit stigma after the video presentations compared to the control (M= 39.10; SD= 11.14) (F2,91= 6.37, p= 0.003, R2= 0.12), but there was no difference between the two intervention conditions (F1,61= 1.55, p= 0.23, R2= 0.02). There were no significant differences on implicit associations (IAT d score), depression diagnosis, treatment knowledge, and symptom knowledge. Conclusions: Prerecorded videos (whether didactic or service user testimonials) are scalable learning tools that have potential to reduce explicit stigma among medical students in low resources settings. Additional research is necessary to explore the differences between both didactic education and service user testimonial interventions, as well as the potential outcomes when the videos are combined. A full scale randomized controlled trial will be conducted based on these findings.

Clinical Trials Registration: CTRN NCT03231761