The World Health Organization is developing a range of interventions, including technology supported interventions, to help address the mental health treatment gap, particularly in low and middle-income countries. One of these, Step-by-Step, is a guided, technology supported, intervention for depression. It provides psychoeducation and training in behavioural activation through an illustrated narrative with additional therapeutic techniques such as stress management (slow breathing), identifying strengths, positive self-talk, increasing social support and relapse prevention. Step-by-Step has been designed so that it can be adapted for use in settings with different cultural contexts and resource availability and to be meaningful in communities affected by adversity. This paper describes the process of developing Step-by-Step and highlights particular design features aimed at increasing feasibility of implementation in a wide variety of settings.
Background Despite progress in medical and skilled delivery care worldwide, neonatal and maternal mortality is still a major public health problem in resource-limited settings.Objective To determine whether psychosocial interventions (PSI) can reduce neonatal and maternal mortality in low-and middle-income countries, and which approaches are most promising.Methods Randomised controlled trials comparing a PSI with a control condition were identified through systematic searches in seven databases. Effects were pooled as risk ratios in random-effects meta-analyses. Risk of bias was assessed using the Cochrane risk of bias tool, and publication bias was estimated. Sensitivity analyses were conducted to investigate sources of heterogeneity.ResultsOf 22 eligible RCTs (20 cluster randomised trials), the outcomes of 21 were synthesized for the outcome of neonatal mortality and 14 for maternal mortality. PSIs effectively reduced the risk of neonatal mortality by about 15% (RR 0.85, 95% CI 0.78-0.94). The risk of maternal death was reduced by almost 21% (RR 0.79, 95% CI 0.68-0.93) with low levels of heterogeneity. There was low to medium risk of bias and no indication for substantial publication bias.Conclusions Results suggest that PSIs, mainly multi-method and group-based approaches, have the potential to substantially decrease the risk of maternal and neonatal death in low- and middle-income countries. The results of the latter outcome are marked by high heterogeneity and thus to be taken with caution.
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