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      The long road to equality in mental healthcare for Young People in Africa

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      EBioMedicine
      Elsevier

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          Abstract

          Adolescence and early adulthood is marked by several transitions of life; economic, biological, social, and psychological [1]. These factors, separately and combined, become the determinants of health inequalities in young people, particularly in Low and Middle Income Countries (LMIC) [2]. Young people in Africa have been systematically disempowered from birth due to issues such as structural racism and poverty embedded in the societies they are born into [3]. The environment a young person grows up in determines whether they succeed or enter the vicious cycle of poverty, stigma and social injustice which can lead to mental health challenges. Social disenfranchisement, structural barriers and a lack of personal agency can impact negatively on a young person's ability to access mental health services [2]. Globally, a significant shift to online mental health services has occurred during the COVID-19 crisis to enable continuity and delivery of care. However, a significant proportion of young people in LMIC lack internet access or appropriate devices, and they also have low levels of digital literacy [4]. So, whilst the digital solution may be effective for a few young people in LMIC, it also exacerbates inequalities through digital exclusion. Whilst I am privileged to be making a career for myself studying the ethics of digital mental healthcare for young people in Africa, I come from an LMIC background and have experienced and witnessed the impacts of health inequalities in mental health, as well as the micro-aggressions that propagate these inequalities. I believe my contribution as a Black woman in academia is to advocate for ethical reflection on digital inclusion, the digital divide, poor digital literacy, data ethics, acceptability and trustworthiness [5]. I am part of a young-people led network in Africa looking into the Ethics of Digital Innovation in Mental Health of Young People in Africa (EMDIYA). It focuses on putting ethical reflection at the centre of mental health intervention development. The network will explore how ethical challenges serve as barriers to digital mental health care. To reduce the development of another health inequality in itself, my goal is working to turn the transformative promise of the Sustainable Development Goals into reality: “Leave no person behind” means that we must overcome these inequalities in mental healthcare delivery for young people in Africa. Declaration of Competing Interest Author declares no conflict of interest.

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          Poverty and common mental disorders in low and middle income countries: A systematic review.

          In spite of high levels of poverty in low and middle income countries (LMIC), and the high burden posed by common mental disorders (CMD), it is only in the last two decades that research has emerged that empirically addresses the relationship between poverty and CMD in these countries. We conducted a systematic review of the epidemiological literature in LMIC, with the aim of examining this relationship. Of 115 studies that were reviewed, most reported positive associations between a range of poverty indicators and CMD. In community-based studies, 73% and 79% of studies reported positive associations between a variety of poverty measures and CMD, 19% and 15% reported null associations and 8% and 6% reported negative associations, using bivariate and multivariate analyses respectively. However, closer examination of specific poverty dimensions revealed a complex picture, in which there was substantial variation between these dimensions. While variables such as education, food insecurity, housing, social class, socio-economic status and financial stress exhibit a relatively consistent and strong association with CMD, others such as income, employment and particularly consumption are more equivocal. There are several measurement and population factors that may explain variation in the strength of the relationship between poverty and CMD. By presenting a systematic review of the literature, this paper attempts to shift the debate from questions about whether poverty is associated with CMD in LMIC, to questions about which particular dimensions of poverty carry the strongest (or weakest) association. The relatively consistent association between CMD and a variety of poverty dimensions in LMIC serves to strengthen the case for the inclusion of mental health on the agenda of development agencies and in international targets such as the millenium development goals. Copyright 2010 Elsevier Ltd. All rights reserved.
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            Barriers and facilitators of mental health programmes in primary care in low-income and middle-income countries

            Integration of services into primary health care for people with common mental disorders is considered a key strategy to improve access to mental health care in low-income and middle-income countries, yet services at the primary care level are largely unavailable. We did a systematic review to understand the barriers and facilitators in the implementation of mental health programmes. We searched five databases and included studies published between Jan 1, 1990, and Sept 1, 2017, that used qualitative methods to assess the implementation of programmes for adults with common mental disorders at primary health-care settings in low-income and middle-income countries. The Critical Appraisal Skills Programme Qualitative Checklist was used to assess the quality of eligible papers. We used the so-called best fit framework approach to synthesise findings according to the Consolidated Framework for Implementation Research. We identified 24 papers for inclusion. These papers described the implementation of nine programmes in 11 countries. Key factors included: the extent to which an organisation is ready for implementation; the attributes, knowledge, and beliefs of providers; complex service user needs; adaptability and perceived advantage of interventions; and the processes of planning and evaluating the implementation. Evidence on implementation of mental health programmes in low-income and middle-income countries is scarce. Synthesising results according to the Consolidated Framework for Implementation Research helped to identify key areas for future action, including investment in primary health-care strengthening, capacity building for health providers, and increased support to address the social needs of service users.
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              Multidisciplinary research priorities for the COVID-19 pandemic

              We appreciate the proactive outlook of Emily Holmes and colleagues 1 in setting priorities for mental health science in the COVID-19 pandemic in their Lancet Psychiatry Position Paper. 1 A paper of this kind necessarily uses a broad brush, and we agree particularly with the need for harmonised data and interdisciplinarity. We further agree that the pandemic is likely to have pervasive and diverse effects on the mental health of young people globally, including those in education and those not in education. Measures must be taken to ensure young people's resilience during this pandemic. However, mental health science must go further, to fully account for young people's values and capabilities. In what follows, we suggest how to do it, through working collaboratively with young people. First, mental health science should innovate measurement across the continuum of mental health and illness to reflect outcomes that young people find meaningful, relevant, and empowering. The measurement of standard mental health concepts is important. Equally important are novel measures for aspects of positive functioning—courage, compassion, hope, agency—that young people value highly and that matter to the current crisis. 2 If flourishing is not measured as part of mental health in the evolving pandemic, we won't see it. Second, young people's existing networks and initiatives should be harnessed, and young people should be empowered to co-design and co-implement research on mental health, during and beyond the COVID-19 crisis. Worldwide, young people are leading the crisis response in their communities. 3 Young people in Sudan have launched #221CHECK, a platform to combat coronavirus misinformation online. Our group of Young Leaders for the 2018 Lancet Commission on Global Mental Health and Sustainable Development have led webinars in low-income and middle-income countries to share knowledge and experiences around the pandemic. Third, mental health science should continuously evaluate the acceptability and trustworthiness of digital interventions that are directed towards young people at global and national levels. Scarcity of evidence is not the only problem in digital mental health. Emerging studies in our group and elsewhere suggest that young people have considerable concerns about the ethical and moral aspects of digital mental health. 4 Young people should contribute to digital mental health research and innovation from the outset, to avoid interventions that fail to engage and thereby fail to deliver on potential. Mental health science should motivate and mobilise young people's agency during this time of pervasive uncertainty and lack of control. Young people are a strong asset for science, and a considerable source of global resilience in this crisis and in its aftermath.
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                Author and article information

                Contributors
                Journal
                EBioMedicine
                EBioMedicine
                EBioMedicine
                Elsevier
                2352-3964
                06 January 2021
                January 2021
                06 January 2021
                : 63
                : 103201
                Affiliations
                [0001]Department of Psychiatry, Warneford Hospital, University of Oxford, UK
                Article
                S2352-3964(20)30577-6 103201
                10.1016/j.ebiom.2020.103201
                7804974
                33418495
                8fd0c960-9e40-4a36-896a-c796cdb1cc83
                © 2020 The Author

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                History
                : 17 December 2020
                : 18 December 2020
                Categories
                Letter

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