Background Task-shifting and technology in psychological interventions are two solutions to increasing access to mental health intervention and overcoming the treatment gap in low and middle-income countries. The CONEMO intervention combines a smartphone app with support from non-specialized professionals, aiming to treat depression in patients with diabetes and/or hypertension. The aim of this paper is to describe the process of recruitment, training and supervision of the non-specialized professionals who participated in the CONEMO task-shifting intervention in Brazil and Peru. Methods We described and analyzed data related to the recruitment, training and supervision of 62 nurse assistants from the health system in Sao Paulo, Brazil, and three hired nurses in Lima, Peru. The data were collected from information provided by nurses and nurse assistants, supervisor records from supervision meetings and the CONEMO platform database. Results We found that task-shifting was feasible using existing resources in Sao Paulo and additional human resources in Lima. Training and supervision were found to be crucial and well received by the staff; however, time was a limitation when using existing human resources. Ensuring technological competence prior to the start of the intervention was essential. Group supervision meetings allowed non-specialized professionals to learn from each other’s experiences. Conclusion Carefully considering recruitment, training and supervision of non-specialized professionals is important for effective task-shifting when delivering an mHealth intervention for depression. Opportunities and challenges of working in different health systems are described, which should be considered in future implementation, either for research or real settings. Trial registration NCT028406662 (Sao Paulo), NCT03026426 (Peru).

Background: Behavioral Activation (BA) is an evidence-based treatment that aims to help the individual to stay active and reduce avoidance behaviors, as a means to reduce depressive symptoms. This study aims to describe the adaptation process and evaluate the psychometric properties of the Behavioral Activation for Depression Scale Short Form (BADS-SF) in its Brazilian and Peruvian version.Methods: Data were collected as part of a randomized trial with 880 participants in Brazil and 432 in Peru. The content validity was assessed using the Content Validity Index (CVI). Principal Component Analysis (PCA) method was applied to evaluate the factorial distribution. Sampling adequacy was assessed by Bartlett’s test of Sphericity and Kaiser-Meyer-Olkin measure. Cronbach’s alpha coefficient was calculated to assess internal consistency.Results: CVI in Brazil was 0.92 and in Peru 0.87. The two-factor solution of the original scale is sustained (activation and avoidance), accounting for 50.6 and 54% of the total variance in Brazil and Peru, respectively. Cronbach’s alpha in Brazil was 0.55 and 0.66 in Peru for the overall scale. KMO was 0.769 and 0.790 for Brazil and Peru, respectively. Bartlett’s test of Sphericity had significance of 0.000 for both samples. Conclusion: Both studied versions of the BAD-SF showed coherent structure and internal consistency. We recommend different distribution of the items into the subscales.

Two randomized controlled trials (RCTs) in Brazil and Peru demonstrated the effectiveness of CONEMO, a digital intervention supported by trained nurses or nurse assistants (NAs), to reduce depressive symptoms in people with diabetes and/or hypertension. This paper extends the RCTs findings by reflecting on the conditions needed for its wider implementation in routine care services. A qualitative study using semi-structured interviews and content analysis was conducted with nurses/NAs, clinicians, healthcare administrators, and policymakers. Informants reported that CONEMO would be feasible to implement in their health services, but some conditions could be improved before its scale-up: reducing workloads of healthcare workers; raising mental health awareness among clinicians and administrators; being able to inform, deliver and accompany the intervention; assuring appropriate training and supervision of nurses/NAs; and supporting the use of technology in public health services and by patients, especially older ones. We discuss some suggestions on how to overcome these challenges.

BACKGROUND Mobile health (mHealth) interventions provide significant strategies for improving access to health services [1], offering one potential solution to reduce the mental health treatment gap. Economic evaluation can contribute with evidence to the local policy of and program development in mental health. OBJECTIVE This paper presents the protocol for an economic evaluation conducted alongside two randomized controlled trials (RCTs) to evaluate the effectiveness of a psychological intervention delivered through a technological platform (CONEMO) to treat depressive symptoms in people with diabetes and/or hypertension. METHODS The economic evaluation uses a within-trial analysis to evaluate the incremental costs and health outcomes of CONEMO compared to usual enhanced care from society and public health system perspectives. We recruited participants from the public health systems in Sao Paulo, Brazil (n=880), and Lima, Peru (n=432), and randomized to intervention or enhanced usual care groups RCTs. We will conduct cost-effectiveness and cost-utility analyses, providing estimates of the cost to decrease depressive symptoms by 50% or more. The cost per quality-adjusted life-year (QALY) gained. For effectiveness, our primary outcome is the proportion of participants with a 50% reduction in the Patient Health Questionnaire (PHQ- 9) score at 3-month - calculated through logistic regression. For utility, our primary outcome is the QALYs gained, measured by the EQ-5D-3L. We assessed each dimension at months 3 and 6. Costs will include both direct and indirect costs. The method of measurement will be mixed methods, with a combination of the Top-down and Bottom-up approaches. We will collect unit costs from the RCTs and national administrative databases. We will also calculate incremental cost-effectiveness ratios (ICERs) and display 95% confidence intervals (CI) from non-parametric bootstrapping (1000 replicates). We will calculate the incremental cost-effectiveness rate, as well as a deterministic and probabilistic sensitivity analysis. Finally, we will draw a Cost-Effectiveness Acceptability Curve (CEAC) to compare a range of possible cost-effectiveness limits. RESULTS The economic evaluation project had its project charter in June 2018 and is expected to be completed in September 2021. The final results will be available in the second half of 2021. CONCLUSIONS We expect to assess if CONEMO plus enhanced usual care is a cost-effective strategy to improve depressive symptoms in this population compared to usual enhanced care. This study will assist health managers in allocating additional resources for mental health initiatives and will inform policymakers. It also provides a basis for further research on how this emerging technology and enhanced usual care can improve mental health and well-being in low-income settings. CLINICALTRIAL ClinicalTrials.gov - Brazil NCT02846662 and Peru NCT03026426

Background: Task-shifting and eHealth have been proposed as ways of approaching the mental health treatment gap in low and middle-income countries (LMIC). The Latin America Treatment & Innovation Network in Mental Health (LATIN-MH) developed CONEMO (Emotional Control), a behavioral intervention used to treat depressive symptoms in a sample of patients with diabetes and hypertension in Sao Paulo, Brazil. The intervention uses task shifting and is delivered via a smartphone app. The effectiveness of this intervention was tested in two randomized trials in these countries. Aim: This paper aims to present the protocol for a study that will explore perceived barriers and facilitators to implementing this intervention to help future scale-up. Methods: We will conduct qualitative research with users of the CONEMO intervention and health professionals who participated directly and indirectly in the trial in Brazil. We will use semi-structured interviews, and we will adopt the Consolidated Framework for Implementation Research (CFIR) for data analysis. Discussion: Task-shifting and eHealth are potentially important tools to help decrease the mental health treatment gap in Latin America. This study will increase our understanding of the factors which may facilitate or hinder the implementation of mobile behavioral mental health interventions, using task-shifting, within LMICs. Findings could be used in future design and planning to facilitate successful implementation and treatment. Registration in Clinical Trials (www.clinical.trials.gov) NCT028406662