Publications by authors named "Emily E Haroz"

25 Publications

  • Page 1 of 1

Development and Dissemination of a Strengths-Based Indigenous Children's Storybook: "Our Smallest Warriors, Our Strongest Medicine: Overcoming COVID-19".

Front Sociol 2021 23;6:611356. Epub 2021 Mar 23.

Center for American Indian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States.

The traditions, strengths, and resilience of communities have carried Indigenous peoples for generations. However, collective traumatic memories of past infectious diseases and the current impact of the coronavirus disease 2019 (COVID-19) pandemic in many Indigenous communities point to the need for Indigenous strengths-based public health resources. Further, recent data suggest that COVID-19 is escalating mental health and psychosocial health inequities for Indigenous communities. To align with the intergenerational strengths of Indigenous communities in the face of the pandemic, we developed a strengths- and culturally-based public health education and mental health coping resource for Indigenous children and families. Using a community-engaged process, the Johns Hopkins Center for American Indian Health collaborated with 14 Indigenous and allied child development, mental health, health communications experts and public health professionals, as well as a Native American youth artist. Indigenous collaborators and Indigenous Johns Hopkins project team members collectively represented 12 tribes, and reservation-based, off-reservation, and urban geographies. This group shared responsibility for culturally adapting the children's book "My Hero is You: How Kids Can Fight COVID-19!" developed by the Inter-Agency Standing Committee Reference Group on Mental Health and Psychosocial Support in Emergency Settings and developing ancillary materials. Through an iterative process, we produced the storybook titled "Our Smallest Warriors, Our Strongest Medicine: Overcoming COVID-19" with content and illustrations representing Indigenous values, experiences with COVID-19, and strengths to persevere. In addition, parent resource materials, children's activities, and corresponding coloring pages were created. The book has been disseminated online for free, and 42,364 printed copies were distributed to early childhood home visiting and tribal head start programs, Indian Health Service units, tribal health departments, intertribal, and urban Indigenous health organizations, Johns Hopkins Center for American Indian Health project sites in partnering communities, schools, and libraries. The demand for and response to "Our Smallest Warriors, Our Strongest Medicine: Overcoming COVID-19" demonstrates the desire for Indigenous storytelling and the elevation of cultural strengths to maintain physical, mental, emotional, and spiritual health during the COVID-19 pandemic.
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http://dx.doi.org/10.3389/fsoc.2021.611356DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8022673PMC
March 2021

Precision Family Spirit: a pilot randomized implementation trial of a precision home visiting approach with families in Michigan-trial rationale and study protocol.

Pilot Feasibility Stud 2021 Jan 6;7(1). Epub 2021 Jan 6.

Center for American Indian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.

Background: Home visiting is a well-supported strategy for addressing maternal and child health disparities. However, evidence-based models generally share implementation challenges at scale, including engagement and retention of families. Precision home visiting may address this issue. This paper describes the first known pilot randomized implementation trial of a precision home visiting approach vs. standard implementation. Primary aims are to: 1) explore the acceptability and feasibility of a precision approach to home visiting and 2) examine the difference between Standard Family Spirit and Precision Family Spirit on participants' program satisfaction, client-home visitor relationship, goal alliance, and the impact of these factors on participant engagement and retention. Secondary aims are to explore potential differences on maternal behavioral and mental health outcomes and child development outcomes to inform sample size estimations for a fully powered study.

Methods: This is a pilot Hybrid Type 3 implementation trial. Four Michigan communities primarily serving the Native American families and already using Family Spirit were randomized by site to receive Standard Family Spirit or Precision Family Spirit. Participants include N = 60 mothers at least 14 years of age (pregnant or with a newborn < 2 months of age) currently enrolled in Family Spirit. Precision Family Spirit participants receive core lessons plus additional lessons based on needs identified at baseline and that emerge during the trial. Control mothers receive the standard sequence of Family Spirit lessons. Data is collected at baseline (< 2 months postpartum), and 2, 6, and 12 months postpartum. All Precision Family Spirit participants are invited to complete qualitative interviews at study midpoint and endpoint. All home visitors are invited to participate in focus groups between study midpoint and endpoint. Exploratory data analysis will assess feasibility, acceptability, client-home visitor relationship, retention, adherence, and potential differences in intervention outcomes.

Discussion: This trial will provide new information about the acceptability and feasibility of precision home visiting and pilot data on program satisfaction, client-home visitor relationship, goal alliance, retention, and targeted maternal-child intervention outcomes. Findings will inform the design of a fully powered randomized implementation trial of precision vs. standard home visiting.

Trial Registration: ClinicalTrials.gov # NCT03975530 ; Registered on June 5, 2019.
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http://dx.doi.org/10.1186/s40814-020-00753-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7786970PMC
January 2021

Precision Family Spirit: a pilot randomized implementation trial of a precision home visiting approach with families in Michigan-trial rationale and study protocol.

Pilot Feasibility Stud 2021 Jan 6;7(1). Epub 2021 Jan 6.

Center for American Indian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.

Background: Home visiting is a well-supported strategy for addressing maternal and child health disparities. However, evidence-based models generally share implementation challenges at scale, including engagement and retention of families. Precision home visiting may address this issue. This paper describes the first known pilot randomized implementation trial of a precision home visiting approach vs. standard implementation. Primary aims are to: 1) explore the acceptability and feasibility of a precision approach to home visiting and 2) examine the difference between Standard Family Spirit and Precision Family Spirit on participants' program satisfaction, client-home visitor relationship, goal alliance, and the impact of these factors on participant engagement and retention. Secondary aims are to explore potential differences on maternal behavioral and mental health outcomes and child development outcomes to inform sample size estimations for a fully powered study.

Methods: This is a pilot Hybrid Type 3 implementation trial. Four Michigan communities primarily serving the Native American families and already using Family Spirit were randomized by site to receive Standard Family Spirit or Precision Family Spirit. Participants include N = 60 mothers at least 14 years of age (pregnant or with a newborn < 2 months of age) currently enrolled in Family Spirit. Precision Family Spirit participants receive core lessons plus additional lessons based on needs identified at baseline and that emerge during the trial. Control mothers receive the standard sequence of Family Spirit lessons. Data is collected at baseline (< 2 months postpartum), and 2, 6, and 12 months postpartum. All Precision Family Spirit participants are invited to complete qualitative interviews at study midpoint and endpoint. All home visitors are invited to participate in focus groups between study midpoint and endpoint. Exploratory data analysis will assess feasibility, acceptability, client-home visitor relationship, retention, adherence, and potential differences in intervention outcomes.

Discussion: This trial will provide new information about the acceptability and feasibility of precision home visiting and pilot data on program satisfaction, client-home visitor relationship, goal alliance, retention, and targeted maternal-child intervention outcomes. Findings will inform the design of a fully powered randomized implementation trial of precision vs. standard home visiting.

Trial Registration: ClinicalTrials.gov # NCT03975530 ; Registered on June 5, 2019.
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http://dx.doi.org/10.1186/s40814-020-00753-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7786970PMC
January 2021

Patient Health Questionnaire-9 scores do not accurately estimate depression prevalence: individual participant data meta-analysis.

J Clin Epidemiol 2020 06 24;122:115-128.e1. Epub 2020 Feb 24.

Centre for Rural Health, School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa; Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.

Objectives: Depression symptom questionnaires are not for diagnostic classification. Patient Health Questionnaire-9 (PHQ-9) scores ≥10 are nonetheless often used to estimate depression prevalence. We compared PHQ-9 ≥10 prevalence to Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (SCID) major depression prevalence and assessed whether an alternative PHQ-9 cutoff could more accurately estimate prevalence.

Study Design And Setting: Individual participant data meta-analysis of datasets comparing PHQ-9 scores to SCID major depression status.

Results: A total of 9,242 participants (1,389 SCID major depression cases) from 44 primary studies were included. Pooled PHQ-9 ≥10 prevalence was 24.6% (95% confidence interval [CI]: 20.8%, 28.9%); pooled SCID major depression prevalence was 12.1% (95% CI: 9.6%, 15.2%); and pooled difference was 11.9% (95% CI: 9.3%, 14.6%). The mean study-level PHQ-9 ≥10 to SCID-based prevalence ratio was 2.5 times. PHQ-9 ≥14 and the PHQ-9 diagnostic algorithm provided prevalence closest to SCID major depression prevalence, but study-level prevalence differed from SCID-based prevalence by an average absolute difference of 4.8% for PHQ-9 ≥14 (95% prediction interval: -13.6%, 14.5%) and 5.6% for the PHQ-9 diagnostic algorithm (95% prediction interval: -16.4%, 15.0%).

Conclusion: PHQ-9 ≥10 substantially overestimates depression prevalence. There is too much heterogeneity to correct statistically in individual studies.
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http://dx.doi.org/10.1016/j.jclinepi.2020.02.002DOI Listing
June 2020

When less is more: reducing redundancy in mental health and psychosocial instruments using Item Response Theory.

Glob Ment Health (Camb) 2020 9;7:e3. Epub 2020 Jan 9.

Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.

Background: There is a need for accurate and efficient assessment tools that cover a range of mental health and psychosocial problems. Existing, lengthy self-report assessments may reduce accuracy due to respondent fatigue. Using data from a sample of adults enrolled in a psychotherapy randomized trial in Thailand and a cross-sectional sample of adolescents in Zambia, we leveraged Item Response Theory (IRT) methods to create brief, psychometrically sound, mental health measures.

Methods: We used graded-response models to refine scales by identifying and removing poor performing items that were not well correlated with the underlying trait, and by identifying well-performing items at varying levels of a latent trait to assist in screening or monitoring purposes.

Results: In Thailand, the original 17-item depression scale was shortened to seven items and the 30-item Posttraumatic Stress Scale (PTS) was shortened to 10. In Zambia, the Child Posttraumatic Stress Scale (CPSS) was shortened from 17 items to six. Shortened scales in both settings retained the strength of their psychometric properties. When examining longitudinal intervention effects in Thailand, effect sizes were comparable in magnitude for the shortened and standard versions.

Conclusions: Using Item Response Theory (IRT) we created shortened valid measures that can be used to help guide clinical decisions and function as longitudinal research tools. The results of this analysis demonstrate the reliability and validity of shortened scales in each of the two settings and an approach that can be generalized more broadly to help improve screening, monitoring, and evaluation of mental health and psychosocial programs globally.
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http://dx.doi.org/10.1017/gmh.2019.30DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7003529PMC
January 2020

Utilizing broad-based partnerships to design a precision approach to implementing evidence-based home visiting.

J Community Psychol 2020 05 23;48(4):1100-1113. Epub 2020 Jan 23.

Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland.

The aim of this paper is to describe a participatory process for adapting an implementation strategy, using a precision approach, for an evidence-based home visiting program, Family Spirit. Family Spirit serves Native American and low-income communities nationwide. To redesign Family Spirit's implementation strategy, we used workshops (n = 5) with key stakeholders and conducted an online survey with implementers (n = 81) to identify hypothesized active ingredients and "pivot points" to guide when to tailor the program and for whom. Active ingredients identified included the relationship between the home visitor and clients, lessons ensuring child safety and healthy development, parent-child communication, and goal setting. Pivot points included whether the client is a first-time mother who has substance abuse history, has a baby at risk for childhood obesity, and/or has sexual or reproductive health concerns. These results are informing the adaptation of Family Spirit' implementation strategy making it more responsive to diverse families while balancing fidelity to the previously proven standard model.
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http://dx.doi.org/10.1002/jcop.22281DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8082059PMC
May 2020

Utilizing broad-based partnerships to design a precision approach to implementing evidence-based home visiting.

J Community Psychol 2020 05 23;48(4):1100-1113. Epub 2020 Jan 23.

Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland.

The aim of this paper is to describe a participatory process for adapting an implementation strategy, using a precision approach, for an evidence-based home visiting program, Family Spirit. Family Spirit serves Native American and low-income communities nationwide. To redesign Family Spirit's implementation strategy, we used workshops (n = 5) with key stakeholders and conducted an online survey with implementers (n = 81) to identify hypothesized active ingredients and "pivot points" to guide when to tailor the program and for whom. Active ingredients identified included the relationship between the home visitor and clients, lessons ensuring child safety and healthy development, parent-child communication, and goal setting. Pivot points included whether the client is a first-time mother who has substance abuse history, has a baby at risk for childhood obesity, and/or has sexual or reproductive health concerns. These results are informing the adaptation of Family Spirit' implementation strategy making it more responsive to diverse families while balancing fidelity to the previously proven standard model.
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http://dx.doi.org/10.1002/jcop.22281DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8082059PMC
May 2020

Utilizing broad-based partnerships to design a precision approach to implementing evidence-based home visiting.

J Community Psychol 2020 05 23;48(4):1100-1113. Epub 2020 Jan 23.

Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland.

The aim of this paper is to describe a participatory process for adapting an implementation strategy, using a precision approach, for an evidence-based home visiting program, Family Spirit. Family Spirit serves Native American and low-income communities nationwide. To redesign Family Spirit's implementation strategy, we used workshops (n = 5) with key stakeholders and conducted an online survey with implementers (n = 81) to identify hypothesized active ingredients and "pivot points" to guide when to tailor the program and for whom. Active ingredients identified included the relationship between the home visitor and clients, lessons ensuring child safety and healthy development, parent-child communication, and goal setting. Pivot points included whether the client is a first-time mother who has substance abuse history, has a baby at risk for childhood obesity, and/or has sexual or reproductive health concerns. These results are informing the adaptation of Family Spirit' implementation strategy making it more responsive to diverse families while balancing fidelity to the previously proven standard model.
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http://dx.doi.org/10.1002/jcop.22281DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8082059PMC
May 2020

Expanding Hybrid Studies for Implementation Research: Intervention, Implementation Strategy, and Context.

Front Public Health 2019 8;7:325. Epub 2019 Nov 8.

Department of International Health, Johns Hopkins University, Baltimore, MD, United States.

Successful implementation reflects the interplay between intervention, implementation strategy, and context. Hybrid effectiveness-implementation studies allow investigators to assess the effects of both intervention and implementation strategy, though the role of context as a third independent variable (IV) is incompletely specified. Our objective is to expand the hybrid typology to include mixtures of all three types of IVs: intervention, implementation strategy, and context. We propose to use to represent the IV of intervention, to represent implementation strategy, and to represent context. Primary IVs are written first and in upper case. Secondary IVs are written after a forward slash and in lower case; co-primary IVs are written after a dash and in upper case. The expanded framework specifies nine two-variable hybrid types: , , , , , , , , and . We describe four in detail: , , , and . We also specify seven three-variable hybrid types. We argue that many studies already meet our definitions of two- or three-variable hybrids. Our proposal builds from the typology proposed by Curran et al. (1), but offers a more complete specification of hybrid study types. We need studies that measure the implementation-related effects of variations in contextual determinants, both to advance the science and to optimize intervention delivery in the real world. Prototypical implementation studies that evaluate the effectiveness of an implementation strategy, in isolation from its context, risk perpetuating the gap between evidence and practice, as they will not generate context-specific knowledge around implementation, scale-up, and de-implementation.
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http://dx.doi.org/10.3389/fpubh.2019.00325DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6857476PMC
November 2019

Expanding Hybrid Studies for Implementation Research: Intervention, Implementation Strategy, and Context.

Front Public Health 2019 8;7:325. Epub 2019 Nov 8.

Department of International Health, Johns Hopkins University, Baltimore, MD, United States.

Successful implementation reflects the interplay between intervention, implementation strategy, and context. Hybrid effectiveness-implementation studies allow investigators to assess the effects of both intervention and implementation strategy, though the role of context as a third independent variable (IV) is incompletely specified. Our objective is to expand the hybrid typology to include mixtures of all three types of IVs: intervention, implementation strategy, and context. We propose to use to represent the IV of intervention, to represent implementation strategy, and to represent context. Primary IVs are written first and in upper case. Secondary IVs are written after a forward slash and in lower case; co-primary IVs are written after a dash and in upper case. The expanded framework specifies nine two-variable hybrid types: , , , , , , , , and . We describe four in detail: , , , and . We also specify seven three-variable hybrid types. We argue that many studies already meet our definitions of two- or three-variable hybrids. Our proposal builds from the typology proposed by Curran et al. (1), but offers a more complete specification of hybrid study types. We need studies that measure the implementation-related effects of variations in contextual determinants, both to advance the science and to optimize intervention delivery in the real world. Prototypical implementation studies that evaluate the effectiveness of an implementation strategy, in isolation from its context, risk perpetuating the gap between evidence and practice, as they will not generate context-specific knowledge around implementation, scale-up, and de-implementation.
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http://dx.doi.org/10.3389/fpubh.2019.00325DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6857476PMC
November 2019

'Global mental health': systematic review of the term and its implicit priorities.

BJPsych Open 2019 May 31;5(3):e47. Epub 2019 May 31.

Professor, Department of Epidemiology, Harvard T.H. Chan School of Public Health, USA.

Background: The term 'global mental health' came to the fore in 2007, when the Lancet published a series by that name.

Aims: To review all peer-reviewed articles using the term 'global mental health' and determine the implicit priorities of scientific literature that self-identifies with this term.

Method: We conducted a systematic review to quantify all peer-reviewed articles using the English term 'global mental health' in their text published between 1 January 2007 and 31 December 2016, including by geographic regions and by mental health conditions.

Results: A total of 467 articles met criteria. Use of the term 'global mental health' increased from 12 articles in 2007 to 114 articles in 2016. For the 111 empirical studies (23.8% of articles), the majority (78.4%) took place in low- and middle-income countries (LMICs), with the most in Sub-Saharan Africa (28.4%) and South Asia (25.5%) and none from Central Asia. The most commonly studied mental health conditions were depression (29.7%), psychoses (12.6%) and conditions specifically related to stress (12.6%), with fewer studies on epilepsy (2.7%), self-harm and suicide (1.8%) and dementia (0.9%). The majority of studies lacked contextual information, including specific region(s) within countries where studies took place (20.7% missing), specific language(s) in which studies were conducted (36.9% missing), and details on ethnic identities such as ethnicity, caste and/or tribe (79.6% missing) and on socioeconomic status (85.4% missing).

Conclusions: Research identifying itself as 'global mental health' has focused predominantly on depression in LMICs and lacked contextual and sociodemographic data that limit interpretation and application of findings.

Declaration Of Interest: None.
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http://dx.doi.org/10.1192/bjo.2019.39DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6582218PMC
May 2019

Under the hood: lay counsellor element use in a modular multi-problem transdiagnostic intervention in lower resource countries.

Cogn Behav Therap 2019 10;12. Epub 2019 Jan 10.

Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, 8th Floor, Baltimore, MD 21205, USA.

The use of transdiagnostic mental health treatments in low resource settings has been proposed as a possible aid in scaling up mental health services. Modular, multi-problem transdiagnostic treatments can be used to treat a range of mental health problems and are designed to handle comorbidity. Two randomized controlled trials have been completed on one treatment - the Common Elements Treatment Approach, or CETA - delivered by lay counsellors in Iraq and Thailand. This paper utilizes data from two clinical trials to explore the delivery of CETA by lay providers, examining fidelity and flexibility of element use. Data were collected at every therapy session. Clients completed a short symptom assessment and providers described the clinical elements delivered during sessions. Analyses included descriptive statistics of delivery including selection and sequencing of treatment elements, and the variance in element dose, clustering at the counsellor level, using multi-level models. Results indicate that lay providers in low resource settings (with supervision) demonstrated fidelity to the recommended CETA elements, order and dose, and occasionally added in elements and flexed dosage based on client presentation (i.e. flexibility). This modular approach did not result in significantly longer treatment duration. Our analysis suggests that lay providers were able to learn decision-making processes of CETA based on client presentation and adjust treatment as needed with supervision. As modular multi-problem transdiagnostic treatments continue to be explored in low resource settings, research should continue to focus on 'unpacking' lay counsellor delivery of these interventions, decision-making processes, and the level of supervision required.
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http://dx.doi.org/10.1017/S1754470X18000144DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6567986PMC
January 2019

Increasing culturally responsive care and mental health equity with indigenous community mental health workers.

Psychol Serv 2021 Feb 2;18(1):84-92. Epub 2019 May 2.

Department of International Health.

There are 600 diverse American Indian/Alaska Native communities that represent strong and resilient nations throughout Indian Country. However, a history of genocidal practices, cultural assaults, and continuing oppression contribute to high rates of mental health and substance use disorders. Underresourced mental health care and numerous barriers to services maintain these disparities. Indigenous community mental health workers hold local understandings of history, culture, and traditional views of health and wellness and may reduce barriers to care while promoting tribal health and economic self-determination and sovereignty. The combination of Native community mental health workers alongside a growing workforce of Indigenous mental health professionals may create an ideal system in which tribal communities are empowered to restore balance and overall wellness, aligning with Native worldviews and healing traditions. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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http://dx.doi.org/10.1037/ser0000358DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6824928PMC
February 2021

Validation of a cross-cultural instrument for child behavior problems: the Disruptive Behavior International Scale - Nepal version.

BMC Psychol 2018 Nov 3;6(1):51. Epub 2018 Nov 3.

Research Department, War Child, and Amsterdam Institute for Social Science Research, University of Amsterdam, Amsterdam, Netherlands.

Background: Obtaining accurate and valid measurements of disruptive behavior disorders remains a challenge in non-Western settings due to variability in societal norms for child behavior and a lack of tools developed outside of Western contexts. This paper assesses the reliability and construct validity of the Disruptive Behavior International Scale - Nepal version (DBIS-N)-a scale developed using ethnographic research in Nepal-and compares it with a widely used Western-derived scale in assessing locally defined child behavior problems.

Methods: We assessed a population-based sample of 268 children ages 5-15 years old in Nepal for behavior problems with a pool of candidate items developed from ethnographic research. We selected final items for the DBIS-N using exploratory factor analysis in a randomly selected half of the sample and then evaluated the model fit using confirmatory factor analysis in the remaining half. We compared the classification accuracy and incremental validity of the DBIS-N and Eyberg Child Behavior Inventory (ECBI) using local defined behavior problems as criteria. Local criteria were assessed via parent report using: 1) local behavior problem terms, and 2) a locally developed vignette-based assessment.

Results: Ten items were selected for the final scale. The DBIS-N had good internal consistency (Cronbach's α: 0.84) and excellent test-retest reliability (intraclass correlation 0.93, r = .93). Classification accuracy and area under the curve (AUC) were similar and high for both the ECBI (AUC: 0.83 and 0.85) and DBIS-N (AUC: 0.83 and 0.85) on both local criteria. The DBIS-N added predictive value above the ECBI in logistic regression models, supporting its incremental validity.

Conclusions: While both the DBIS-N and the ECBI had high classification accuracy for local idioms for behavior problems, the DBIS-N had a more coherent factor structure and added predictive value above the ECBI. Items from the DBIS-N were more consistent with cultural themes identified in qualitative research, whereas multiple items in the ECBI that did not fit with these themes performed poorly in factor analysis. In conjunction with practical considerations such as price and scale length, our results lend support for the utility of the DBIS-N for the assessment of locally prioritized behavior problems in Nepal.
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http://dx.doi.org/10.1186/s40359-018-0262-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6215604PMC
November 2018

Mental health comorbidity in low-income and middle-income countries: a call for improved measurement and treatment.

Lancet Psychiatry 2018 11 30;5(11):864-866. Epub 2018 Aug 30.

Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA.

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http://dx.doi.org/10.1016/S2215-0366(18)30301-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6644038PMC
November 2018

Adaptation and testing of an assessment for mental health and alcohol use problems among conflict-affected adults in Ukraine.

Confl Health 2018 15;12:34. Epub 2018 Aug 15.

1Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA.

Background: In Ukraine, a large number of internally displaced persons (IDPs) and veterans experience social and psychological problems as a result of the ongoing conflict between Ukraine and Russia. Our purpose was to develop reliable and valid instruments to screen for common mental health and alcohol use problems in these populations.

Methods: We used a three-step process of instrument adaptation and testing. The instrument-the Mental Health Assessment Inventory (MHAI)-combines adapted standard screeners with items derived locally in Ukraine. A validity study was conducted using a sample of 153 adults (54% male) ages 18 years and older. All participants in the sample were IDPs or veterans living in or near the major urban areas of Kyiv and Zaporizhia. Reliability testing (internal consistency, test-retest) and validity testing (construct, criterion) of the MHAI were conducted using classical test theory. After initial testing, we used Item Response Theory (IRT) to shorten and further refine the instrument.

Results: The MHAI showed good internal consistency and test-retest reliability for the main outcomes: depression ( = 0.94;  = .84), post-traumatic stress (PTS;  = 0.97;  = 0.87), anxiety ( = 0.90;  = 0.80), and alcohol use ( = 0.86;  = 0.91). There was good evidence of convergent construct validity among the scales for depression, PTS, and anxiety, but not for alcohol use. Item Response Theory (IRT) analysis supported use of shortened versions of the scales for depression, PTS, and anxiety, as they retained comparable psychometric properties to the full scales of the MHAI.

Conclusion: The findings support the reliability and validity of the assessment-the MHAI-for screening of common mental health problems among Ukrainian IDPs and veterans. Use of IRT shortened the instrument to improve practicality and potential sustainability.
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http://dx.doi.org/10.1186/s13031-018-0169-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6092824PMC
August 2018

Testing the effectiveness and implementation of a brief version of the Common Elements Treatment Approach (CETA) in Ukraine: a study protocol for a randomized controlled trial.

Trials 2018 Aug 3;19(1):418. Epub 2018 Aug 3.

Department of International Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Wolfe Street, Baltimore, MD, 21205, USA.

Background: Mental illness is a major public health concern. Despite progress understanding which treatments work, a significant treatment gap remains. An ongoing concern is treatment length. Modular, flexible, transdiagnostic approaches have been offered as one solution to scalability challenges. The Common Elements Treatment Approach (CETA) is one such approach and offers the ability to treat a wide range of common mental health problems. CETA is supported by two randomized trials from low- and middle-income countries showing strong effectiveness and implementation outcomes.

Methods/design: This trial evaluates the effectiveness and implementation of two versions of CETA using a non-inferiority design to test two primary hypotheses: (1) a brief five-session version of CETA (Brief CETA) will provide similar effectiveness for reducing the severity of common mental health problems such as depression, post-traumatic stress, impaired functioning, anxiety, and substance use problems compared with the standard 8-12-session version of CETA (Standard CETA); and (2) both Brief and Standard CETA will have superior impact on the outcomes compared to a wait-list control condition. For both hypotheses, the main effect will be assessed using longitudinal data and mixed-effects regression models over a 6-month period post baseline. A secondary aim includes exploration of implementation factors. Additional planned analyses will include exploration of: moderators of treatment impact by disorder severity and comorbidity; the impact of individual therapeutic components; and trends in symptom change between end of treatment and 6-month assessment for all participants.

Discussion: This trial is the first rigorous study comparing a standard-length (8-12 sessions) modular, flexible, transdiagnostic, cognitive-behavioral approach to a shortened version of the approach (five sessions). Brief CETA entails "front-loading" with elements that research suggests are strong mechanisms of change. The study design will allow us to draw conclusions about the effects of both Brief and Standard CETA as well as which elements are integral to their mechanisms of action, informing future implementation and fidelity efforts. The results from this trial will inform future dissemination, implementation and scale-up of CETA in Ukraine and contribute to our understanding of the effects of modular, flexible, transdiagnostic approaches in similar contexts.

Trial Registration: ClinicalTrials.gov, ID: NCT03058302 (U.S. National Library of Medicine). Registered on 20 February 2017.
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http://dx.doi.org/10.1186/s13063-018-2752-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6090833PMC
August 2018

Symptom Endorsement and Sociodemographic Correlates of Postnatal Distress in Three Low Income Countries.

Depress Res Treat 2016 15;2016:1823836. Epub 2016 Feb 15.

Department of Mental Health, Johns Hopkins School of Public Health, 624 North Broadway, 8th Floor, Baltimore, MD 21205, USA.

Background. Maternal mental illness has been implicated in adverse child development outcomes. Factors such as context and culture may influence experiences of maternal distress and explain differences in outcomes across settings. Methods. We analyzed baseline data from 5,647 mothers in Ethiopia, India (Andhra Pradesh), and Vietnam participating in an ongoing cohort study (Young Lives) to compare symptom endorsement and sociodemographic correlates of distress. Maternal distress was assessed using the Self-Reporting Questionnaire-20 Items (cutoff: ≥8). Logistic regressions were stratified by sample to identify correlates of distress. Results. Symptom endorsement was similar among distressed women, particularly with regard to feeling unhappy (76%, 80%, and 79%). Notable differences were observed in three items assessing Depressive Thoughts, which were most highly endorsed in Ethiopia (49%-56%). Having a child experiencing a life-threatening event was correlated with distress in all three samples. A variety of correlates were unique to only one sample. Conclusions. There were multiple similarities but also notable differences across sites in the expression and correlates of maternal distress. Feeling unhappy appears to be a hallmark feature of distress. Correlates highlight the relationship between distress and indicators of poverty, child wellbeing, and economic shocks. Differences demonstrate the value of further exploration of cross-cultural differences.
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http://dx.doi.org/10.1155/2016/1823836DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4770125PMC
March 2016

Impact of a Father Figure's Presence in the Household on Children's Psychiatric Diagnoses and Functioning in Families at High Risk for Depression.

J Child Fam Stud 2016 Feb 27;25(2):588-597. Epub 2015 Jun 27.

Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, NY, USA.

The consequences of living in single-parent households on children's wellbeing are well documented, but less is known about the impact of living in single-mother households among children with high familial risk for depression. Utilizing data from an ongoing three-generation study of high-risk families, this preliminary study examined a sample of 161 grandchildren of probands diagnosed with major depressive disorder, comparing those in single-parent households to those in dual-parent households with household status defined as the full-time presence of a resident male in the home. High-risk children were compared across households in terms of psychiatric diagnoses (measured by Schedule for Affective Disorders and Schizophrenia for School-Age Children; K-SADS-PL) and global functioning (assessed by Global Assessment Scale, child version; C-GAS). Results indicated that high-risk children in single-parent households had 4.7 times greater odds for developing a mood disorder and had significantly lower mean C-GAS scores ( = 0.01) compared to those in dual-parent households. Differences remained significant when controlling for household income, child's age, and either parent's depression status. There were no significant differences between high-risk children across households when household status was instead defined as legal marital status. This study has several limitations: sample size was small, pro-bands were recruited from a clinical population, and participants had not passed completely through the period of risk for adult psychiatric disorders. These findings point towards the importance of identifying and closely monitoring children at risk for depression, particularly if they reside in households without a resident father figure.
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http://dx.doi.org/10.1007/s10826-015-0239-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5648344PMC
February 2016

"Thinking too much": A systematic review of a common idiom of distress.

Soc Sci Med 2015 Dec 21;147:170-83. Epub 2015 Oct 21.

Department of Psychiatry, Massachusetts General Hospital, 15 Parkman Street, WACC 812, Boston, MA 02114, USA; Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA.

Idioms of distress communicate suffering via reference to shared ethnopsychologies, and better understanding of idioms of distress can contribute to effective clinical and public health communication. This systematic review is a qualitative synthesis of "thinking too much" idioms globally, to determine their applicability and variability across cultures. We searched eight databases and retained publications if they included empirical quantitative, qualitative, or mixed-methods research regarding a "thinking too much" idiom and were in English. In total, 138 publications from 1979 to 2014 met inclusion criteria. We examined the descriptive epidemiology, phenomenology, etiology, and course of "thinking too much" idioms and compared them to psychiatric constructs. "Thinking too much" idioms typically reference ruminative, intrusive, and anxious thoughts and result in a range of perceived complications, physical and mental illnesses, or even death. These idioms appear to have variable overlap with common psychiatric constructs, including depression, anxiety, and PTSD. However, "thinking too much" idioms reflect aspects of experience, distress, and social positioning not captured by psychiatric diagnoses and often show wide within-cultural variation, in addition to between-cultural differences. Taken together, these findings suggest that "thinking too much" should not be interpreted as a gloss for psychiatric disorder nor assumed to be a unitary symptom or syndrome within a culture. We suggest five key ways in which engagement with "thinking too much" idioms can improve global mental health research and interventions: it (1) incorporates a key idiom of distress into measurement and screening to improve validity of efforts at identifying those in need of services and tracking treatment outcomes; (2) facilitates exploration of ethnopsychology in order to bolster cultural appropriateness of interventions; (3) strengthens public health communication to encourage engagement in treatment; (4) reduces stigma by enhancing understanding, promoting treatment-seeking, and avoiding unintentionally contributing to stigmatization; and (5) identifies a key locally salient treatment target.
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http://dx.doi.org/10.1016/j.socscimed.2015.10.044DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4689615PMC
December 2015

Measuring Hope Among Children Affected by Armed Conflict: Cross-Cultural Construct Validity of the Children's Hope Scale.

Assessment 2017 Jun 27;24(4):528-539. Epub 2015 Oct 27.

1 Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.

We investigated the cross-cultural construct validity of hope, a factor associated with mental health protection and promotion, using the Children's Hope Scale (CHS). The sample ( n = 1,057; 48% girls) included baseline data from three cluster-randomized controlled trials with children affected by armed conflict ( n = 329 Burundi; n = 403 Indonesia; n = 325 Nepal). The confirmatory factor analysis in each country indicated good fit for the hypothesized two-factor model. Analysis by gender indicated that configural invariance was supported and that scalar invariance was demonstrated in Indonesia. However, metric and scalar invariance were not supported in Burundi and Nepal. In country comparisons, configural and metric invariance were met, but scalar invariance was not supported. Evidence from this study supports the use of the CHS within various sociocultural settings and across genders, but direct comparisons of CHS scores across groups should be done with caution. Rigorous evaluations of the measurement properties of mental health protective and promotive factors are necessary to inform both research and practice.
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http://dx.doi.org/10.1177/1073191115612924DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5835958PMC
June 2017

Adaptation and testing of psychosocial assessment instruments for cross-cultural use: an example from the Thailand Burma border.

BMC Psychol 2014 31;2(1):31. Epub 2014 Aug 31.

Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA.

Background: The purpose of this study was to develop valid and reliable instruments to assess priority psychosocial problems and functioning among adult survivors of systematic violence from Burma living in Thailand.

Methods: The process involved four steps: 1) instrument drafting and piloting; 2) reliability and validity testing; 3) instrument revision; and 4) retesting revised instrument.

Results: A total of N = 158 interviews were completed. Overall subscales showed good internal consistency (0.73-0.92) and satisfactory combined test-retest/inter rater reliability (0.63-0.84). Criterion validity, was not demonstrated for any scale. The alcohol and functioning scales underperformed and were revised (step 3) and retested (step 4). Upon retesting, the function scale showed good internal consistency reliability (0.91-0.92), and the alcohol scale showed acceptable internal consistency (0.79) and strong test-retest/inter-rater reliability (0.86-0.89).

Conclusions: This paper describes the importance and process of adaptation and testing, illustrated by the experiences and results for selected instruments in this population.
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http://dx.doi.org/10.1186/s40359-014-0031-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4317135PMC
February 2015

A transdiagnostic community-based mental health treatment for comorbid disorders: development and outcomes of a randomized controlled trial among Burmese refugees in Thailand.

PLoS Med 2014 Nov 11;11(11):e1001757. Epub 2014 Nov 11.

Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.

Background: Existing studies of mental health interventions in low-resource settings have employed highly structured interventions delivered by non-professionals that typically do not vary by client. Given high comorbidity among mental health problems and implementation challenges with scaling up multiple structured evidence-based treatments (EBTs), a transdiagnostic treatment could provide an additional option for approaching community-based treatment of mental health problems. Our objective was to test such an approach specifically designed for flexible treatments of varying and comorbid disorders among trauma survivors in a low-resource setting.

Methods And Findings: We conducted a single-blinded, wait-list randomized controlled trial of a newly developed transdiagnostic psychotherapy, Common Elements Treatment Approach (CETA), for low-resource settings, compared with wait-list control (WLC). CETA was delivered by lay workers to Burmese survivors of imprisonment, torture, and related traumas, with flexibility based on client presentation. Eligible participants reported trauma exposure and met severity criteria for depression and/or posttraumatic stress (PTS). Participants were randomly assigned to CETA (n = 182) or WLC (n = 165). Outcomes were assessed by interviewers blinded to participant allocation using locally adapted standard measures of depression and PTS (primary outcomes) and functional impairment, anxiety symptoms, aggression, and alcohol use (secondary outcomes). Primary analysis was intent-to-treat (n = 347), including 73 participants lost to follow-up. CETA participants experienced significantly greater reductions of baseline symptoms across all outcomes with the exception of alcohol use (alcohol use analysis was confined to problem drinkers). The difference in mean change from pre-intervention to post-intervention between intervention and control groups was -0.49 (95% CI: -0.59, -0.40) for depression, -0.43 (95% CI: -0.51, -0.35) for PTS, -0.42 (95% CI: -0.58, -0.27) for functional impairment, -0.48 (95% CI: -0.61, -0.34) for anxiety, -0.24 (95% CI: -0.34, -0.15) for aggression, and -0.03 (95% CI: -0.44, 0.50) for alcohol use. This corresponds to a 77% reduction in mean baseline depression score among CETA participants compared to a 40% reduction among controls, with respective values for the other outcomes of 76% and 41% for anxiety, 75% and 37% for PTS, 67% and 22% for functional impairment, and 71% and 32% for aggression. Effect sizes (Cohen's d) were large for depression (d = 1.16) and PTS (d = 1.19); moderate for impaired function (d = 0.63), anxiety (d = 0.79), and aggression (d = 0.58); and none for alcohol use. There were no adverse events. Limitations of the study include the lack of long-term follow-up, non-blinding of service providers and participants, and no placebo or active comparison intervention.

Conclusions: CETA provided by lay counselors was highly effective across disorders among trauma survivors compared to WLCs. These results support the further development and testing of transdiagnostic approaches as possible treatment options alongside existing EBTs.

Trial Registration: ClinicalTrials.gov NCT01459068 Please see later in the article for the Editors' Summary.
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http://dx.doi.org/10.1371/journal.pmed.1001757DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4227644PMC
November 2014

Psychometric evaluation of a self-report scale to measure adolescent depression: the CESDR-10 in two national adolescent samples in the United States.

J Affect Disord 2014 Apr 10;158:154-60. Epub 2014 Feb 10.

Johns Hopkins Bloomberg School of Public Health, Department of Mental Health, Baltimore, MD, United States.

Background: There is a need for brief instruments to screen for depression in adolescents that are valid, reliable and freely available. The aim of this study was to investigate the psychometric properties of a 10-item version of the CESD-R (CESDR-10) in two national adolescent samples.

Methods: Sample 1 consisted of N=3777 youths (mean age 15.7) and Sample 2 contained N=1150 adolescents (mean age 14.5). We performed confirmatory factor analysis, evaluated construct validity, examined differential item functioning, and assessed internal consistency reliability (α).

Results: The results suggest generally strong psychometric properties for the CESDR-10. The CFA 1-factor model showed good model fit. Construct validity was partially supported in Sample 1 and mostly supported for Sample 2 based upon the characteristics examined. The CESDR-10 showed configural and metric invariance across both samples and full measurement invariance across sex. There were no notable differences in discrimination parameters or clinically significant differential item functioning between samples or sexes.

Limitations: Criterion related validity was not assessed in this study. Further studies should evaluate the scale in comparison to a psychiatric diagnosis. In addition, this study utilized a web-based format of administration which may influence participants׳ answers. In future studies, the CESDR-10 should be administered in other settings to more thoroughly establish its generalizability.

Conclusion: In clinical and non-clinical settings alike, time pressures make the availability of brief but valid screening measures critical. Findings support future use of the CESDR-10.
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http://dx.doi.org/10.1016/j.jad.2014.02.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4366134PMC
April 2014

Cultural concepts of distress and psychiatric disorders: literature review and research recommendations for global mental health epidemiology.

Int J Epidemiol 2014 Apr 23;43(2):365-406. Epub 2013 Dec 23.

Duke Global Health Institute, Department of Psychiatry and Behavioral Sciences, Durham, NC, USA, Department of Psychology, Fordham University, New York, USA, Department of Anthropology, Department of Epidemiology, Emory University, Atlanta, GA, USA, Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA, Department of Psychology, Tribhuvan University, Kirtipur, Nepal, Butabika National Referral Mental and Teaching Hospital, Kampala, Uganda, AISSR, University of Amsterdam, The Netherlands and Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.

Background: Burgeoning global mental health endeavors have renewed debates about cultural applicability of psychiatric categories. This study's goal is to review strengths and limitations of literature comparing psychiatric categories with cultural concepts of distress (CCD) such as cultural syndromes, culture-bound syndromes, and idioms of distress.

Methods: The Systematic Assessment of Quality in Observational Research (SAQOR) was adapted based on cultural psychiatry principles to develop a Cultural Psychiatry Epidemiology version (SAQOR-CPE), which was used to rate quality of quantitative studies comparing CCD and psychiatric categories. A meta-analysis was performed for each psychiatric category.

Results: Forty-five studies met inclusion criteria, with 18 782 unique participants. Primary objectives of the studies included comparing CCD and psychiatric disorders (51%), assessing risk factors for CCD (18%) and instrument validation (16%). Only 27% of studies met SAQOR-CPE criteria for medium quality, with the remainder low or very low quality. Only 29% of studies employed representative samples, 53% used validated outcome measures, 44% included function assessments and 44% controlled for confounding. Meta-analyses for anxiety, depression, PTSD and somatization revealed high heterogeneity (I(2) > 75%). Only general psychological distress had low heterogeneity (I(2) = 8%) with a summary effect odds ratio of 5.39 (95% CI 4.71-6.17). Associations between CCD and psychiatric disorders were influenced by methodological issues, such as validation designs (β = 16.27, 95%CI 12.75-19.79) and use of CCD multi-item checklists (β = 6.10, 95%CI 1.89-10.31). Higher quality studies demonstrated weaker associations of CCD and psychiatric disorders.

Conclusions: Cultural concepts of distress are not inherently unamenable to epidemiological study. However, poor study quality impedes conceptual advancement and service application. With improved study design and reporting using guidelines such as the SAQOR-CPE, CCD research can enhance detection of mental health problems, reduce cultural biases in diagnostic criteria and increase cultural salience of intervention trial outcomes.
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http://dx.doi.org/10.1093/ije/dyt227DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3997373PMC
April 2014