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Cited by 27Mental Health Treatment and AccessHealth Policy Implementation ScienceDigital Mental Health Interventions

Primary-level and community worker interventions for the prevention of mental disorders and the promotion of well-being in low- and middle-income countries

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Purgato, Marianna, Prina, Eleonora, Ceccarelli, Caterina, Cadorin, Camilla, Abdulmalik, Jibril O, Amaddeo, Francesco, Arcari, Lyria, Churchill, Rachel +7 more·2023·Cochrane Database of Systematic Reviews
DOI 10.1002/14651858.cd014722.pub2PMC PMC10594594
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Abstract

BACKGROUND: There is a significant research gap in the field of universal, selective, and indicated prevention interventions for mental health promotion and the prevention of mental disorders. Barriers to closing the research gap include scarcity of skilled human resources, large inequities in resource distribution and utilization, and stigma. OBJECTIVES: To assess the effectiveness of delivery by primary workers of interventions for the promotion of mental health and universal prevention, and for the selective and indicated prevention of mental disorders or symptoms of mental illness in low- and middle-income countries (LMICs). To examine the impact of intervention delivery by primary workers on resource use and costs. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, CINAHL, Global Index Medicus, PsycInfo, WHO ICTRP, and ClinicalTrials.gov from inception to 29 November 2021. SELECTION CRITERIA: Randomized controlled trials (RCTs) of primary-level and/or community health worker interventions for promoting mental health and/or preventing mental disorders versus any control conditions in adults and children in LMICs. DATA COLLECTION AND ANALYSIS: Standardized mean differences (SMD) or mean differences (MD) were used for continuous outcomes, and risk ratios (RR) for dichotomous data, using a random-effects model. We analyzed data at 0 to 1, 1 to 6, and 7 to 24 months post-intervention. For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥ 0.80 large clinical effects. We evaluated the risk of bias (RoB) using Cochrane RoB2. MAIN RESULTS: Description of studies We identified 113 studies with 32,992 participants (97 RCTs, 19,570 participants in meta-analyses) for inclusion. Nineteen RCTs were conducted in low-income countries, 27 in low-middle-income countries, 2 in middle-income countries, 58 in upper-middle-income countries and 7 in mixed settings. Eighty-three RCTs included adults and 30 RCTs included children. Cadres of primary-level workers employed primary care health workers (38 studies), community workers (71 studies), both (2 studies), and not reported (2 studies). Interventions were universal prevention/promotion in 22 studies, selective in 36, and indicated prevention in 55 RCTs. Risk of bias The most common concerns over risk of bias were performance bias, attrition bias, and reporting bias. Intervention effects 'Probably', 'may', or 'uncertain' indicates 'moderate-', 'low-', or 'very low-'certainty evidence. *Certainty of the evidence (using GRADE) was assessed at 0 to 1 month post-intervention as specified in the review protocol. In the abstract, we did not report results for outcomes for which evidence was missing or very uncertain. Adults Promotion/universal prevention, compared to usual care: - probably slightly reduced anxiety symptoms (MD -0.14, 95% confidence interval (CI) -0.27 to -0.01; 1 trial, 158 participants) - may slightly reduce distress/PTSD symptoms (SMD -0.24, 95% CI -0.41 to -0.08; 4 trials, 722 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD -0.69, 95% CI -1.08 to -0.30; 4 trials, 223 participants) Indicated prevention, compared to usual care: - may reduce adverse events (1 trial, 547 participants) - probably slightly reduced functional impairment (SMD -0.12, 95% CI -0.39 to -0.15; 4 trials, 663 participants) Children Promotion/universal prevention, compared to usual care: - may improve the quality of life (SMD -0.25, 95% CI -0.39 to -0.11; 2 trials, 803 participants) - may reduce adverse events (1 trial, 694 participants) - may slightly reduce depressive symptoms (MD -3.04, 95% CI -6 to -0.08; 1 trial, 160 participants) - may slightly reduce anxiety symptoms (MD -2.27, 95% CI -3.13 to -1.41; 1 trial, 183 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD 0, 95% CI -0.16 to -0.15; 2 trials, 638 participants) - may slightly reduce anxiety symptoms (MD 4.50, 95% CI -12.05 to 21.05; 1 trial, 28 participants) - probably slightly reduced distress/PTSD symptoms (MD -2.14, 95% CI -3.77 to -0.51; 1 trial, 159 participants) Indicated prevention, compared to usual care: - decreased slightly functional impairment (SMD -0.29, 95% CI -0.47 to -0.10; 2 trials, 448 participants) - decreased slightly depressive symptoms (SMD -0.18, 95% CI -0.32 to -0.04; 4 trials, 771 participants) - may slightly reduce distress/PTSD symptoms (SMD 0.24, 95% CI -1.28 to 1.76; 2 trials, 448 participants). AUTHORS' CONCLUSIONS: The evidence indicated that prevention interventions delivered through primary workers - a form of task-shifting - may improve mental health outcomes. Certainty in the evidence was influenced by the risk of bias and by substantial levels of heterogeneity. A supportive network of infrastructure and research would enhance and reinforce this delivery modality across LMICs.

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  • Human RoB assessments in the source Cochrane review were performed independently by 2 reviewers using the RoB 2 tool, with discrepancies resolved through consensus discussion.

    “In accordance with standard Cochrane methodology, RoB assessments in the source review were performed independently by 2 reviewers using the RoB 2 tool, with discrepancies resolved through consensus discussion; full reviewer details are reported in the source review [19].”

    From Retrieve-Then-Verify for Evaluating Evidence Support and Hallucination in Large Language Model–Generated Medical Information: Empirical Study (2026) · cites this paper as [19]

    The Methods (Data collection and analysis) state that two review authors (EP and CC) independently assessed risk of bias using the Cochrane Risk of Bias 2 tool. They resolved disagreements by discussion or consultation with a third review author, so the claim's description of resolution solely through consensus discussion omits an alternative the source reports. (LLM, conf=0.85)

    Experimental — accuracy not yet measured

  • Reviewers were systematic review specialists with expertise in global mental health interventions.

    “Reviewers were systematic review specialists with expertise in global mental health interventions; their institutional affiliations and authorship details are listed in the source review [19].”

    From Retrieve-Then-Verify for Evaluating Evidence Support and Hallucination in Large Language Model–Generated Medical Information: Empirical Study (2026) · cites this paper as [19]

    The Methods > Data collection and analysis section identifies review authors conducting systematic screening, risk-of-bias assessment, and GRADE assessment for this review of mental-health interventions in low- and middle-income countries. This supports describing them as reviewers working in that field. The available copy does not show their institutional affiliations or establish that all were systematic review specialists; its end may be missing. (LLM, conf=0.78)

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Authors
Purgato, M., Prina, E., Ceccarelli, C., Cadorin, C., Abdulmalik, J. O., Amaddeo, F., Arcari, L., Churchill, R., Jordans, M. J., Lund, C., Papola, D., Uphoff, E., van Ginneken, N., Tol, W. A., & Barbui, C.
Affiliations
  • University of Verona (IT)
  • University of Ibadan (NG)
  • University of York (GB)
  • King's College London (GB)
  • University of Cape Town (ZA)
  • Department of Primary Care and Mental Health; University of Liverpool; Liverpool UK
  • University of Copenhagen (DK)
Corresponding author
Purgato, Marianna
ORCID
Venue
Cochrane Database of Systematic Reviews
Publisher
Wiley
Published
2023-10-24
Volume
2023
Issue
10
Pages
CD014722-CD014722
ISSN
  • 1361-6137 (ISSN-L)
  • 1465-1858
DOI
10.1002/14651858.cd014722.pub2
PMC
PMC10594594
OpenAlex
W4387893326
Cited by
27
References
67
Citations by year
2026: 5 · 2025: 5 · 2024: 11 · 2023: 3 · 2021: 3
FWCI
1.17
Type
journal article
Language
en
Open access
Licence
cc-by-nc
Locations
  • Cochrane Database of Systematic Reviews (publishedVersion)
  • PubMed Central (publishedVersion, cc-by-nc)
  • PubMed (publishedVersion)
Funders
  • Johns Hopkins University
  • Universidade de São Paulo
  • Instituto Colombiano de Bienestar Familiar
Topics
  • Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
  • Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
  • Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
Keywords
mental health promotion, mental disorder prevention, community health workers, universal prevention, selective prevention, indicated prevention, low- and middle-income countries, resource utilization (health care), cost-effectiveness, mental health professionals, mental health stigma, mental health service delivery, children and adolescents, adults, risk of bias, quality of evidence
MeSH terms
Adult, Anxiety, Mental Disorders, Child, Developing Countries, Health Promotion, Humans, Mental Health, Randomized Controlled Trials as Topic

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