Exploring the impact of a complex intervention for women with depression in contexts of adversity: A pilot feasibility study of COURRAGE-plus in South Africa

Abstract

Background: Depression is a leading cause of disease burden worldwide but is often undertreated in low- and middle-income countries. Reasons behind the treatment gap vary, but many highlight a lack of interventions which speak to the socio-economic and structural realties that are associated to mental health problems in many settings, including South Africa. The COURRAGE-PLUS intervention responds to this gap, by combining a collective narrative therapy (9 weeks) intervention, with a social intervention promoting group-led practical action against structural determinants of poor mental health (4 weeks), for a total of 13 sessions. The overall aim is to promote mental health, while empowering communities to acknowledge, and respond in locally meaningful ways to social adversity linked to development of mental distress. Aim: To pilot and evaluate the effectiveness of a complex intervention – COURRAGE-PLUS on symptoms of depression as assessed by the Patient Health Questionnaire (PHQ-9) among a sample of women facing contexts of adversity in Gauteng, South Africa. Methods: PHQ-9 scores were assessed at baseline, post collective narrative therapy (midline), and post social intervention (endline). Median scores and corresponding interquartile ranges were computed for all time points. Differences in scores between time points were tested with a non-parametric Friedman test. The impact across symptom severities was compared descriptively to identify potential differences in impact across categories of symptom severity within our sample. Results: Participants’ ( n = 47) median depression score at baseline was 11 (IQR = 7) and reduced to 4 at midline (IQR = 7) to 0 at endline (IQR = 2.5). The Friedman test showed a statistically significant difference between depression scores across time points, [Formula: see text](2) = 49.29, p < .001. Median depression scores were reduced to 0 or 1 Post-Intervention across all four severity groups. Conclusions: COURRAGE-PLUS was highly effective at reducing symptoms of depression across the spectrum of severities in this sample of women facing adversity, in Gauteng, South Africa. Findings supports the need for larger trials to investigate collective narrative storytelling and social interventions as community-based interventions for populations experiencing adversity and mental distress.

A Refugee Rose of competencies and capabilities for mental healthcare of refugees

“…Such interventions necessarily must work at the complex intersections of multiple adversities, socioeconomic adversity, and isolation and victimisation. 47 , 48 Only through such innovations will we address the complexity of need among those facing historical and contemporary adversity while continuing to live in positions of marginalisation and exclusion. Unpacking the institutional and societal drivers of such intersectional inequalities, including discrimination and racism, have been exposed by the recent COVID0-19 pandemic, 49 , 50 showing that social and health systems reforms are needed.…”

Overlooked and unaddressed: A narrative review of mental health consequences of child marriages

“…Given the embeddedness of these women within community life, collective and participatory interventions could be valuable. For example, Collective narrative therapy, which has been shown to be effective in community-based settings [90] (Burgess et al, 2021) could also resonate with these populations, through their ability to centre collective action while restoring traumatic histories.…”

Does experiencing a traumatic life event increase the risk of intimate partner violence for young women? A cross-sectional analysis and structural equation model of data from theStepping Stones and Creating Futuresintervention in South Africa

“…For example, recent work has highlighted the ability for such interventions to reduce symptoms of poor mental health, as well as increase self-efficacy and collective agency, in response to the social-structural challenges that increase women’s risk of IPV (including food insecurity). 47 …”

“…It also points to a need for further research to investigate positive mental health supports (ie, engagement coping strategies, gender awareness, etc) that could be provided to women following experiences of non-partner rape that may help in reducing their risk of IPV. For example, recent work has highlighted the ability for such interventions to reduce symptoms of poor mental health, as well as increase self-efficacy and collective agency, in response to the social-structural challenges that increase women’s risk of IPV (including food insecurity) 47…”