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Population mental health science: Guiding principles and initial agenda

Dodge, Kenneth A; Prinstein, Mitchell J; Evans, Arthur C; Ahuvia, Isaac L; Alvarez, Kiara; Beidas, Rinad S; Brown, Ashanti J; Cuijpers, Pim; Denton, Ellen-Ge; Hoagwood, Kimberly Eaton; Johnson, Christina; Kazdin, Alan E; McDanal, Riley; Metzger, Isha W; Rowley, Sonia N; Schleider, Jessica; Shaw, Daniel S
A recent American Psychological Association Summit provided an urgent call to transform psychological science and practice away from a solely individual-level focus to become accountable for population-level impact on health and mental health. A population focus ensures the mental health of all children, adolescents, and adults and the elimination of inequities across groups. Science must guide three components of this transformation. First, effective individual-level interventions must be scaled up to the population level using principles from implementation science, investing in novel intervention delivery systems (e.g., online, mobile application, text, interactive voice response, and machine learning-based), harnessing the strength of diverse providers, and forging culturally informed adaptations. Second, policy-driven community-level interventions must be innovated and tested, such as public efforts to promote physical activity, public policies to support families in early life, and regulation of corporal punishment in schools. Third, transformation is needed to create a new system of universal primary care for mental health, based on models such as Family Connects, Triple P, PROmoting School-community-university Partnerships to Enhance Resilience, Communities That Care, and the Early Childhood Collaborative of the Pittsburgh Study. This new system must incorporate valid measurement, universal screening, and a community-based infrastructure for service delivery. Addressing tasks ahead, including scientific creativity and discovery, rigorous evaluation, and community accountability, will lead to a comprehensive strategic plan to shape the emergent field of public mental health. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
PMID: 38829360
ISSN: 1935-990x
CID: 5664972

Implementation Feasibility and Hidden Costs of Statewide Scaling of Evidence-Based Therapies for Children and Adolescents

Hoagwood, Kimberly Eaton; Richards-Rachlin, Shira; Baier, Meaghan; Vilgorin, Boris; Horwitz, Sarah McCue; Narcisse, Iriane; Diedrich, Nadege; Cleek, Andrew
OBJECTIVE/UNASSIGNED:State mental health systems are retraining their workforces to deliver services supported by research. Knowledge about evidence-based therapies (EBTs) for child and adolescent disorders is robust, but the feasibility of their statewide scaling has not been examined. The authors reviewed implementation feasibility for 12 commonly used EBTs, defining feasibility for statewide scaling as an EBT having at least one study documenting acceptability, facilitators and barriers, or fidelity; at least one study with a racially and ethnically diverse sample; an entity for training, certification, or licensing; and fiscal data reflecting the costs of implementation. METHODS/UNASSIGNED:The authors reviewed materials for 12 EBTs being scaled in New York State and conducted a literature review with search terms relevant to their implementation. Costs and certification information were supplemented by discussions with treatment developers and implementers. RESULTS/UNASSIGNED:All 12 EBTs had been examined for implementation feasibility, but only three had been examined for statewide scaling. Eleven had been studied in populations reflecting racial-ethnic diversity, but few had sufficient power for subgroup analyses to demonstrate effectiveness with these samples. All had certifying or licensing entities. The per-clinician costs of implementation ranged from $500 to $3,500, with overall ongoing costs ranging from $100 to $6,000. A fiscal analysis of three EBTs revealed hidden costs ranging from $5,000 to $24,000 per clinician, potentially limiting sustainability. CONCLUSIONS/UNASSIGNED:The evidence necessary for embedding EBTs in state systems has notable gaps that may hinder sustainability. Research-funding agencies should prioritize studies that focus on the practical aspects of scaling to assist states as they retrain their workforces.
PMID: 38268465
ISSN: 1557-9700
CID: 5625082

Volunteer Engagement within Equine Assisted Services

Vincent, Aviva; Morrissey, Meghan; Acri, Mary; Guo, Fei; Hoagwood, Kimberly
This study examines the effect of volunteering within a Professional Association of Therapeutic Horsemanship International (PATH Intl) premiere accredited center by exploring the experiences of volunteers leading horses in adaptive riding lessons. Adaptive Riding lessons are horseback riding lessons for individuals ages four through the lifespan, with special needs, varying from cognitive, physical, social-emotional, or other challenges. Volunteers directly impact the rider-horse bond by increasing accessibility to horseback riding for individuals with disabilities, fostering a meaningful bond between the rider and horse. The research questions were as follows: (1) do saliva measures of cortisol and alpha-amylase (stress), and oxytocin (affiliative bonding) change over time for volunteers; and (2) how satisfied are volunteers with volunteering for Equine Assisted Services (EAS)? Forty-one volunteers participated in Reining in Anxiety, an intervention combining adaptive riding and cognitive behavioral therapy. Physiological data (i.e., pooled saliva, saliva combined from various glands throughout the mouth, resting under the tongue prior to collection) were collected pre/post riding session at four time points during the 10-session intervention, measuring oxytocin, cortisol, and alpha-amylase. Post-intervention, volunteers completed a survey about their experiences as volunteers and as participants in the study. All saliva samples were collected successfully. There was a non-significant, positive trend in oxytocin and alpha-amylase, while cortisol remained level. The responses in the survey suggested that volunteers perceive their role positively, with nuanced experiences of a sense of responsibility to ensure safety, and enjoyment in assisting the riders. Volunteers are vital to the safety of the rider and horse. While their perceived and internalized responsibility is evidenced by an increase in stress (e.g., cortisol remaining level and an increase in alpha-amylase), it is not necessarily negative stress, as there is simultaneously affiliative bonding expressed (oxytocin). The complex emotions and experiences of volunteers are important to understand to create meaningful, sustainable volunteer engagement. This is particularly important in the EAS industry, which is reliant on volunteerism.
PMCID:10812477
PMID: 38254419
ISSN: 2076-2615
CID: 5624762

Volunteer Engagement within Equine Assisted Services

Vincent, Aviva; Morrissey, Meghan; Acri, Mary; Guo, Fei; Hoagwood, Kimberly
This study examines the effect of volunteering within a Professional Association of Therapeutic Horsemanship International (PATH Intl) premiere accredited center by exploring the experiences of volunteers leading horses in adaptive riding lessons. Adaptive Riding lessons are horseback riding lessons for individuals ages four through the lifespan, with special needs, varying from cognitive, physical, social-emotional, or other challenges. Volunteers directly impact the rider-horse bond by increasing accessibility to horseback riding for individuals with disabilities, fostering a meaningful bond between the rider and horse. The research questions were as follows: (1) do saliva measures of cortisol and alpha-amylase (stress), and oxytocin (affiliative bonding) change over time for volunteers; and (2) how satisfied are volunteers with volunteering for Equine Assisted Services (EAS)? Forty-one volunteers participated in Reining in Anxiety, an intervention combining adaptive riding and cognitive behavioral therapy. Physiological data (i.e., pooled saliva, saliva combined from various glands throughout the mouth, resting under the tongue prior to collection) were collected pre/post riding session at four time points during the 10-session intervention, measuring oxytocin, cortisol, and alpha-amylase. Post-intervention, volunteers completed a survey about their experiences as volunteers and as participants in the study. All saliva samples were collected successfully. There was a non-significant, positive trend in oxytocin and alpha-amylase, while cortisol remained level. The responses in the survey suggested that volunteers perceive their role positively, with nuanced experiences of a sense of responsibility to ensure safety, and enjoyment in assisting the riders. Volunteers are vital to the safety of the rider and horse. While their perceived and internalized responsibility is evidenced by an increase in stress (e.g., cortisol remaining level and an increase in alpha-amylase), it is not necessarily negative stress, as there is simultaneously affiliative bonding expressed (oxytocin). The complex emotions and experiences of volunteers are important to understand to create meaningful, sustainable volunteer engagement. This is particularly important in the EAS industry, which is reliant on volunteerism.
SCOPUS:85183141768
ISSN: 2076-2615
CID: 5629212

The longitudinal impact of an evidence-based multiple family group intervention (Amaka Amasanyufu) on family cohesion among children in Uganda: Analysis of the cluster randomized SMART Africa-Uganda scale-up study (2016"“2022)

Byansi, William; Sensoy Bahar, Ozge; Small, Latoya; Namatovu, Phionah; Nabayinda, Josephine; Kiyingi, Joshua; Mwebembezi, Abel; Nakigozi, Gertrude; Hoagwood, Kimberly; McKay, Mary M.; Ssewamala, Fred M.
Family functioning plays a critical role in childhood disruptive behavior disorders (The Family Journal, 2003, 11(1), 33"“41; Research in Nursing and Health, 2016, 39(4), 229"“243). Yet, there is limited research on the impact of evidence-based family strengthening interventions on improving family cohesion as a protective factor among children experiencing behavioral challenges. To address this gap, we analyzed data (N = 636) from the SMART Africa-Uganda study (2016"“2022), a cluster randomized clinical trial testing an evidence-based family-strengthening intervention called Amaka Amasanyufu (translated as "Happy Families" in the local language). Children aged 8"“13 and their caregivers were recruited from 26 public primary schools that were randomized to: (1) control condition receiving generalized psychosocial literature (10 schools), (2) intervention delivered via parent peers (eight schools), and (3) intervention delivered via community healthcare workers (eight schools). Children completed the family cohesion questionnaire at baseline, 8 weeks, 16 weeks, and 6 months post-intervention completion. The intervention effectiveness was evaluated via a three-level logistic mixed effects model with pairwise comparisons across study conditions within each time point. Participants in the parent"“peer intervention group had greater odds of being in the higher family cohesion group than participants in the control group at 8 weeks (OR = 3.24), 16 weeks (OR = 1.88) and 6 months (OR = 2.07). At 8 weeks, 16 weeks, and 6 months, participants in the community health worker group had 3.98, 2.08, and 1.79 times greater odds of being in the higher family cohesion group than participants in the control group, respectively. Our findings strengthen the evidence base for Amaka Amansayufu as an effective intervention that can be utilized in SSA to improve family cohesion in families with children experiencing behavioral challenges.
SCOPUS:85193631866
ISSN: 0014-7370
CID: 5660782

"I decided to participate"¦.because I saw it as benefiting our community and families": a qualitative study of lay providers"™ experiences with delivering an evidence-based mental health intervention for families in Uganda

Sensoy Bahar, Ozge; Byansi, William; Nabayinda, Josephine; Kiyingi, Joshua; Namatovu, Phionah; Embaye, Fithi; McKay, Mary M.; Hoagwood, Kimberly; Ssewamala, Fred M.
Background: Children and adolescents who live in resource-limited communities in sub-Saharan Africa (SSA) experience significant mental health problems, including behavioral problems. In SSA, one of the most significant impediments to expanding services is a scarcity of mental health specialists. Task-shifting can effectively solve the mental health care gap in low-resource settings, yet it is underutilized in child and adolescent mental health. Moreover, the experiences of lay providers are understudied in global mental health, despite their potential impact on intervention effectiveness. In this study, we examined the experiences of community health workers and parent peers with the task-shifting of an evidence-based family strengthening intervention in Uganda. Methods: As part of a larger randomized clinical trial, semi-structured in-depth interviews were conducted with 24 facilitators selected using stratified purposive sampling. Interviews explored their decision to participate in the program; experiences with the training; and experiences with intervention delivery. All interviews were conducted in Luganda (local language) and audio recorded. They were transcribed verbatim and translated into English. Thematic analysis was used to analyze the data. Results: Despite concerns around lack of previous experience and time commitment, facilitators reported high relevance of the intervention to the families in their communities as well as their own as a motivation to participate. They also identified financial incentives as a motivating factor. These two factors also ensured their attendance at the training. They were satisfied with the content and skills provided during the training and felt prepared to deliver the intervention. During intervention delivery, they enjoyed seeing the families engaged and participating actively in the sessions as well as observing positive changes in the families. Some challenges with family attendance and engagement were noted. The facilitators reported an increased sense of self-efficacy and competence over time; and expressed high satisfaction with supervision. Conclusion: Facilitators"™ positive experiences point to the high acceptability and appropriateness of task-shifting this intervention in low-resource settings. As the global mental health field continues to be interested in task-shifting interventions to lay providers, successful examples should be studied so that evidence-based models can be put in place to support them through the process.
SCOPUS:85168424689
ISSN: 1752-4458
CID: 5561172

Community-based family peer navigator programme to facilitate linkage to coordinated specialty care for early psychosis among Black families in the USA: A protocol for a hybrid type I feasibility study

Oluwoye, Oladunni; Stokes, Bryony I; Burduli, Ekaterina; Kriegel, Liat S; Hoagwood, Kimberly E
BACKGROUND:Approximately 70% of Black/African American family members report no contact with mental health providers prior to initial diagnosis and the receipt of services for early psychosis. Black families often encounter barriers and experience delays on the pathway to coordinated specialty care programmes for early psychosis. METHODS AND ANALYSIS:This mixed-methods study will (1) develop and refine a family peer navigator (FPN) for Black families designed to increase access and engagement in coordinated specialty care and (2) pilot-test FPN for Black families with 40 family members with loved ones at risk for psychosis in a randomised trial to assess the acceptability and feasibility. Families will be randomised to FPN (n=20) or a low-intensive care coordination (n=20). Other outcomes include proposed treatment targets (eg, knowledge, social connectedness), preliminary impact outcomes (time to coordinated specialty care programmes, initial family engagement), and implementation outcomes (acceptability, feasibility, appropriateness). ETHICS AND DISSEMINATION:Ethics approval has been obtained from Washington State University Institutional Review Board and informed consent will be obtained from all participants. This study will establish an innovative culturally responsive FPN programme and implementation strategy, and generate preliminary data to support a larger hybrid effectiveness-implementation trial. Study findings will be presented at conferences and in peer-reviewed journals. TRIAL REGISTRATION NUMBER:NCT05284721.
PMCID:10335551
PMID: 37407058
ISSN: 2044-6055
CID: 5536842

The longitudinal impact of an evidence-based multiple family group intervention (Amaka Amasanyufu) on oppositional defiant disorder and impaired functioning among children in Uganda: analysis of a cluster randomized trial from the SMART Africa-Uganda scale-up study (2016-2022)

Brathwaite, Rachel; Ssewamala, Fred M; Sensoy Bahar, Ozge; McKay, Mary M; Neilands, Torsten B; Namatovu, Phionah; Kiyingi, Joshua; Zmachinski, Lily; Nabayinda, Josephine; Huang, Keng-Yen; Kivumbi, Apollo; Bhana, Arvin; Mwebembezi, Abel; Petersen, Inge; Hoagwood, Kimberly
BACKGROUND:Oppositional Defiant Disorders (ODDs) and other Disruptive Behavior Disorders (DBDs) are common among children and adolescents in poverty-impacted communities in sub-Saharan Africa. Without early intervention, its progression into adulthood can result in dire consequences. We examined the impact of a manualized family strengthening intervention called Amaka Amasanyufu designed to reduce ODDs and other DBDs among school-going children residing in low-resource communities in Uganda. METHODS:We used longitudinal data from the SMART Africa-Uganda study (2016-2022). Public primary schools were randomized to: (1) Control condition (receiving usual care comprising generalized psychosocial functioning literature), 10 schools; (2) intervention delivered via parent peers (Amaka-parents), 8 schools or; (3) intervention delivered via community healthcare workers (Amaka-community), 8 schools. All the participants were blinded. At baseline, 8- and 16-weeks postintervention initiation, caregivers completed the Iowa Conners Scale, which measured Oppositional Defiant Disorder (ODD) and Impairment Rating Scale to evaluate children's overall impairment and impaired functioning with peers, siblings, and parents; impaired academic progress, self-esteem, and family functioning. Three-level linear mixed-effects models were fitted to each outcome. Pairwise comparisons of postbaseline group means within each time point were performed using Sidak's adjustment for multiple comparisons. Only children positive for ODD and other DBDs were analyzed. RESULTS:Six hundred and thirty-six children screened positive for ODDs and other DBDs (Controls: n = 243; Amaka-parents: n = 194; Amaka-community: n = 199). At 8 weeks, Amaka-parents' children had significantly lower mean scores for overall impairment compared to controls, (mean difference: -0.71, p = .001), while Amaka-community children performed better on ODD (mean difference: -0.84, p = .016). At 16 weeks, children in both groups were performing better on ODD and IRS than controls, and there were no significant differences between the two intervention groups. CONCLUSIONS:The Amaka Amasanyufu intervention was efficacious in reducing ODD and impaired functioning relative to usual care. Hence, the Amaka Amasanyufu intervention delivered either by Amaka-community or Amaka-parents has the potential to reduce negative behavioral health outcomes among young people in resource-limited settings and improve family functioning. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov, ID: NCT03081195. Registered on 16 March 2017.
PMID: 34989404
ISSN: 1469-7610
CID: 5107242

Reducing Anxiety and Stress among Youth in a CBT-Based Equine-Assisted Adaptive Riding Program

Hoagwood, Kimberly; Vincent, Aviva; Acri, Mary; Morrissey, Meghan; Seibel, Lauren; Guo, Fei; Flores, Chelsea; Seag, Dana; Peth Pierce, Robin; Horwitz, Sarah
Reining in Anxiety (RiA) is a therapeutic program for youth with mild to moderate anxiety delivered in a therapeutic riding setting by Certified Therapeutic Riding Instructors. RiA was developed after a review of the evidence base for youth anxiety, is manualized, and includes five core CBT components: in vivo exposure, cognitive restructuring, youth psychoeducation, relaxation, and caregiver psychoeducation about anxiety. This study extended findings from a prior RCT that examined (1) the feasibility of collecting saliva samples from horses and children to measure stress (cortisol) and relaxation (oxytocin); (2) whether changes in stress and relaxation occurred both during each lesson and over the course of the 10-week intervention for horses and youth; (3) whether changes in anxiety symptoms, emotional regulation, and self-efficacy found in the first trial were comparable; and (4) if fidelity to the program was reliable. Youth participants (n = 39) ages 6"“17 with caregiver-identified mild-to-moderate anxiety participated in a ten-week therapeutic intervention (RiA), which combined adaptive riding and components of CBT. Physiological data and self-report measures were taken at weeks one, four, seven, and ten for the youth and horses. Saliva assays assessed cortisol as a physiological marker of stress and anxiety, and oxytocin as a measure of relaxation. Fidelity data were recorded per session. Anxiety, as measured by caregiver self-reporting, significantly decreased from pre- to post-test, while emotional regulation scores increased. No significant changes in self-efficacy from pre- to post-test were observed. Saliva samples obtained from participants before and after riding sessions showed a consistent decrease in cortisol and a significant increase in oxytocin at two of the four timepoints (Week 1 and Week 7), but no overall pre- to post-test changes. Horse saliva data were collected using a modified bit; there were no significant changes in oxytocin or cortisol, suggesting that the horses did not have an increase in stress from the intervention. RiA may be a promising approach for reducing anxiety and stress among youth, as measured both by self-reported and by physiological measures. Collection of salivary assays for both youth and horses is feasible, and the intervention does not increase stress in the horses. Importantly, RiA can be delivered by adaptive/therapeutic horseback riding instructors in naturalistic (e.g., non-clinic-based) settings. As youth anxiety is a growing public health problem, novel interventions, such as RiA, that can be delivered naturalistically may have the potential to reach more youth and thus improve their quality of life. Further research is needed to examine the comparative value of RiA with other animal-assisted interventions and to assess its cost-effectiveness.
SCOPUS:85139785963
ISSN: 2076-2615
CID: 5350082

Review: Structural Racism, Children's Mental Health Service Systems, and Recommendations for Policy and Practice Change

Alvarez, Kiara; Cervantes, Paige E; Nelson, Katherine L; Seag, Dana E M; McCue Horwitz, Sarah; Hoagwood, Kimberly Eaton
OBJECTIVE:Racism is a public health crisis impacting children's mental health, yet mental health service systems are insufficiently focused on addressing racism. Moreover, a focus on interpersonal racism and on individual coping with the impacts of racism has been prioritized over addressing structural racism at the level of the service system and associated institutions. In this paper, we examine strategies to address structural racism via policies impacting children's mental health services. METHOD/METHODS:First, we identify and analyze federal and state policies focused on racism and mental health equity. Second, we evaluate areas of focus in these policies and discuss the evidence base informing their implementation. Finally, we provide recommendations for what states, counties, cities, and mental health systems can do to promote antiracist evidence-based practices in children's mental health. RESULTS:Our analysis highlights gaps and opportunities in the evidence base for policy implementation strategies including: mental health services for youth of color, interventions addressing interpersonal racism and bias in the mental health service system, interventions addressing structural racism, changes to provider licensure and license renewal, and development of the community health workforce. CONCLUSION/CONCLUSIONS:Recommendations are provided both within and across systems to catalyze broader systems transformation.
PMID: 34971730
ISSN: 1527-5418
CID: 5152092