Dr Erica Breuer

Dr Erica Breuer

Conjoint Lecturer

School of Medicine and Public Health

Career Summary

Biography

Dr Erica Breuer is a public health researcher. She has various research interests including the development and evaluation mental health services in low and middle income countries as well as developing  and evaluating theories of change for health and social care programmes. From 2008-2018 she worked initially with and then for the Department of Psychiatry and Mental Health at the University of Cape Town, South Africa. She worked on studies evaluating measurement tools for mental illness, intervention studies of community based mental health services and epidemiological studies of mental illness in South Africa, Ethiopia, India, Nepal, Uganda and Kenya including the PRIME programme (www.prime.uct.ac.za). She also contributed to the development, teaching and supervision of the MPhil in Public Mental Health from 2011-2018 at the University of Cape Town 

In September 2018 she was appointed a Conjoint Lecturer at UoN and in that capacity has contributed to teaching and learning through guest lectures and the Joint Medical Programme Global Health Pathway planning committee. She has worked as a consulting researcher on mental health programmes and as the Theory of Change lead for Strengthening Responses for Dementia in Low and Middle Countries (http://www.lse.ac.uk/cpec/research/projects/dementia/stride). 

In March 2020 she joined Prof Liz Sullivan’s group as a Post-doctoral Research Fellow and is working on research related to women in contact with the justice system.


Qualifications

  • Doctor of Philosophy, University of Cape Town - South Africa
  • Bachelor of Applied Science (Physiotherapy), University of Newcastle
  • Master of Public Health, University of Cape Town - South Africa

Keywords

  • Evaluation
  • Global Mental Health
  • Public Health

Languages

  • English (Mother)
  • German (Fluent)

Fields of Research

Code Description Percentage
111799 Public Health and Health Services not elsewhere classified 80
111714 Mental Health 20

Professional Experience

UON Appointment

Title Organisation / Department
Postdoctoral Research Fellow University of Newcastle
Office of the PVC Health and Medicine
Australia

Academic appointment

Dates Title Organisation / Department
1/4/2018 - 31/3/2020 Consulting researcher

Consulted on various research projects including the Programme for Improving Mental Healthcare and leading the Theory of Change Work package for Strengthening Responses to dementia in developing countries (STRiDE). 

Self-employed
Australia
1/9/2011 - 31/3/2018 Research and project manager: Programme for Improving Mental Healthcare

Managed the Programme for Improving Mental Health Care, an international research programme consortium investigating the development, implementation, evaluation of district level mental healthcare plans in Ethiopia, India, Nepal, South Africa and Uganda.

Contributed to various research projects within the research programme. 

University of Cape Town
Psychiatry and Mental Health
South Africa
19/9/2018 - 31/3/2020 Conjoint Lecturer Faculty of Health and Medicine, The University of Newcastle
School of Medicine and Public Health
Australia

Professional appointment

Dates Title Organisation / Department
1/2/2010 - 31/8/2011 Research Assistant and Human Resources and Financial Compliance Manager

Contributed to research on HIV and mental health in sub-Saharan Africa, developed human resources and financial compliance protocols for the Kidzpositive Family Fund.

Kidzpositive Family Fund
South Africa
Edit

Publications

For publications that are currently unpublished or in-press, details are shown in italics.


Journal article (29 outputs)

Year Citation Altmetrics Link
2020 Kokota D, Lund C, Ahrens J, Breuer E, Gilfillan S, 'Evaluation of mhGAP training for primary healthcare workers in Mulanje, Malawi: a quasi-experimental and time series study', INTERNATIONAL JOURNAL OF MENTAL HEALTH SYSTEMS, 14 (2020)
DOI 10.1186/s13033-020-0337-0
2020 Luitel NP, Breuer E, Adhikari A, Kohrt BA, Lund C, Komproe IH, Jordans MJD, 'Process evaluation of a district mental healthcare plan in Nepal: a mixed-methods case study.', BJPsych Open, 6 e77 (2020)
DOI 10.1192/bjo.2020.60
2020 Chisholm D, Garman E, Breuer E, Fekadu A, Hanlon C, Jordans M, et al., 'Health service costs and their association with functional impairment among adults receiving integrated mental health care in five low- and middle-income countries: the PRIME cohort study', Health policy and planning, 35 567-576 (2020)

© World Health Organization 2020. All rights reserved. The World Health Organization has granted the Publisher permission for the reproduction of this article. This study examines... [more]

© World Health Organization 2020. All rights reserved. The World Health Organization has granted the Publisher permission for the reproduction of this article. This study examines the level and distribution of service costs-and their association with functional impairment at baseline and over time-for persons with mental disorder receiving integrated primary mental health care. The study was conducted over a 12-month follow-up period in five low- and middle-income countries participating in the Programme for Improving Mental health carE study (Ethiopia, India, Nepal, South Africa and Uganda). Data were drawn from a multi-country intervention cohort study, made up of adults identified by primary care providers as having alcohol use disorders, depression, psychosis and, in the three low-income countries, epilepsy. Health service, travel and time costs, including any out-of-pocket (OOP) expenditures by households, were calculated (in US dollars for the year 2015) and assessed at baseline as well as prospectively using linear regression for their association with functional impairment. Cohort samples were characterized by low levels of educational attainment (Ethiopia and Uganda) and/or high levels of unemployment (Nepal, South Africa and Uganda). Total health service costs per case for the 3 months preceding baseline assessment averaged more than US$20 in South Africa, $10 in Nepal and US$3-7 in Ethiopia, India and Uganda; OOP expenditures ranged from $2 per case in India to $16 in Ethiopia. Higher service costs and OOP expenditure were found to be associated with greater functional impairment in all five sites, but differences only reached statistical significance in Ethiopia and India for service costs and India and Uganda for OOP expenditure. At the 12-month assessment, following initiation of treatment, service costs and OOP expenditure were found to be lower in Ethiopia, South Africa and Uganda, but higher in India and Nepal. There was a pattern of greater reduction in service costs and OOP spending for those whose functional status had improved in all five sites, but this was only statistically significant in Nepal.

DOI 10.1093/heapol/czz182
2019 Shidhaye R, Murhar V, Muke S, Shrivastava R, Khan A, Singh A, Breuer E, 'Delivering a complex mental health intervention in low-resource settings: lessons from the implementation of the PRIME mental healthcare plan in primary care in Sehore district, Madhya Pradesh, India', BJPSYCH OPEN, 5 (2019) [C1]
DOI 10.1192/bjo.2019.53
Citations Scopus - 1Web of Science - 1
2019 Breuer E, Hanlon C, Bhana A, Chisholm D, De Silva M, Fekadu A, et al., 'Partnerships in a Global Mental Health Research Programme the Example of PRIME', Global Social Welfare, 6 159-175 (2019)

© 2018, The Author(s). Collaborative research partnerships are necessary to answer key questions in global mental health, to share expertise, access funding and influence policy. ... [more]

© 2018, The Author(s). Collaborative research partnerships are necessary to answer key questions in global mental health, to share expertise, access funding and influence policy. However, partnerships between low- and middle-income countries (LMIC) and high-income countries have often been inequitable with the provision of technical knowledge flowing unilaterally from high to lower income countries. We present the experience of the Programme for Improving Mental Health Care (PRIME), a LMIC-led partnership which provides research evidence for the development, implementation and scaling up of integrated district mental healthcare plans in Ethiopia, India, Nepal, South Africa and Uganda. We use Tuckman¿s first four stages of forming, storming, norming and performing to reflect on the history, formation and challenges of the PRIME Consortium. We show how this resulted in successful partnerships in relation to management, research, research uptake and capacity building and reflect on the key lessons for future partnerships.

DOI 10.1007/s40609-018-0128-6
Citations Scopus - 2
2019 Myers B, Breuer E, Lund C, Williams PP, van der Westhuizen C, Brooke-Sumner C, et al., 'Assessing capability for implementing mental health counselling within primary care facilities in a middle-income country: A feasibility study', JOURNAL OF PSYCHIATRIC AND MENTAL HEALTH NURSING, 26 163-174 (2019)
DOI 10.1111/jpm.12519
2018 Lund C, Brooke-Sumner C, Baingana F, Baron EC, Breuer E, Chandra P, et al., 'Social determinants of mental disorders and the Sustainable Development Goals: a systematic review of reviews', The Lancet Psychiatry, 5 357-369 (2018)

© 2018 Elsevier Ltd Mental health has been included in the UN Sustainable Development Goals. However, uncertainty exists about the extent to which the major social determinants of... [more]

© 2018 Elsevier Ltd Mental health has been included in the UN Sustainable Development Goals. However, uncertainty exists about the extent to which the major social determinants of mental disorders are addressed by these goals. The aim of this study was to develop a conceptual framework for the social determinants of mental disorders that is aligned with the Sustainable Development Goals, to use this framework to systematically review evidence regarding these social determinants, and to identify potential mechanisms and targets for interventions. We did a systematic review of reviews using a conceptual framework comprising demographic, economic, neighbourhood, environmental events, and social and culture domains. We included 289 articles in the final Review. This study sheds new light on how the Sustainable Development Goals are relevant for addressing the social determinants of mental disorders, and how these goals could be optimised to prevent mental disorders.

DOI 10.1016/S2215-0366(18)30060-9
Citations Scopus - 59Web of Science - 56
2018 Gilissen J, Pivodic L, Gastmans C, Vander Stichele R, Deliens L, Breuer E, Van Den Block L, 'How to achieve the desired outcomes of advance care planning in nursing homes: A theory of change', BMC Geriatrics, 18 (2018)

© 2018 The Author(s). Background: Advance care planning (ACP) has been identified as particularly relevant for nursing home residents, but it remains unclear how or under what cir... [more]

© 2018 The Author(s). Background: Advance care planning (ACP) has been identified as particularly relevant for nursing home residents, but it remains unclear how or under what circumstances ACP works and can best be implemented in such settings. We aimed to develop a theory that outlines the hypothetical causal pathway of ACP in nursing homes, i.e. what changes are expected, by means of which processes and under what circumstances. Methods: The Theory of Change approach is a participatory method of programme design and evaluation whose underlying intention is to improve understanding of how and why a programme works. It results in a Theory of Change map that visually represents how, why and under what circumstances ACP is expected to work in nursing home settings in Belgium. Using this approach, we integrated the results of two workshops with stakeholders (n = 27) with the results of a contextual analysis and a systematic literature review. Results: We identified two long-term outcomes that ACP can achieve: to improve the correspondence between residents wishes and the care/treatment they receive and to make sure residents and their family feel involved in planning their future care and are confident their care will be according to their wishes. Besides willingness on the part of nursing home management to implement ACP and act accordingly, other necessary preconditions are identified and put in chronological order. These preconditions serve as precursors to, or requirements for, accomplishing successful ACP. Nine original key intervention components with specific rationales are identified at several levels (resident/family, staff or nursing home) to target the preconditions: selection of a trainer, ensuring engagement by management, training ACP reference persons, in-service education for healthcare staff, information for staff, general practitioners, residents and their family, ACP conversations and documentation, regular reflection sessions, multidisciplinary meetings, and formal monitoring. Conclusions: The Theory of Change map presented here illustrates a theory of how ACP is expected to work in order to achieve its desired long-term outcomes while highlighting organisational factors that potentially facilitate the implementation and sustainability of ACP. We provide the first comprehensive rationale of how ACP is expected to work in nursing homes, something that has been called for repeatedly.

DOI 10.1186/s12877-018-0723-5
Citations Scopus - 17Web of Science - 14
2018 Breuer E, Subba P, Luitel N, Jordans M, De Silva M, Marchal B, Lund C, 'Using qualitative comparative analysis and theory of change to unravel the effects of a mental health intervention on service utilisation in Nepal', BMJ Global Health, 3 (2018)

© Author(s) (or their employer(s)) 2018. Background The integration of mental health services into primary care is essential to improve the coverage of mental health services in l... [more]

© Author(s) (or their employer(s)) 2018. Background The integration of mental health services into primary care is essential to improve the coverage of mental health services in low resource settings, but the evaluation of this remains challenging. We used a programme¿s Theory of Change (ToC) as a conceptual framework to determine what combination(s) of conditions at facility and community level influenced the mental health service utilisation as a result of a district mental healthcare plan (MHCP) implemented in Chitwan, Nepal. In addition, we show how qualitative comparative analysis can be used to provide an integrated analysis of data from a ToC. Methods We conducted a longitudinal case study of 10 health facilities where the MHCP was implemented. We collected data from all facilities at baseline (October to December 2013) and quarterly following the implementation of the intervention (March 2014 to November 2016). The data were analysed using pooled qualitative comparative analysis in fsQCA V.2.5. results The following conditions were necessary for high mental health service utilisation: presence of basic and advanced psychosocial care, evidence-based identification and treatment guidelines (WHO mhGAP), referral to tertiary services and the presence of trained female community health volunteers . Two additional combinations of conditions were also identified as sufficient for a high mental health service utilisation: high medication supply, trained facility staff and either the use of a community informant detection tool or having a larger proportion of the community attend community awareness activities. Conclusions Both supply-side interventions (formalised approaches to health worker detection and treatment, training of health workers, supervision) and demand-side interventions (community awareness and case finding) are important to integrate mental health in primary care. ToC can be used to provide an integrated analysis of data from a ToC, therefore helping to shed light on the black box of complex multilevel interventions.

DOI 10.1136/bmjgh-2018-001023
2018 Breuer E, De Silva M, Lund C, 'Theory of change for complex mental health interventions: 10 lessons from the programme for improving mental healthcare', GLOBAL MENTAL HEALTH, 5 (2018)
DOI 10.1017/gmh.2018.13
Citations Web of Science - 1
2017 Sorsdahl K, Stein DJ, Naledi T, Breuer E, Myers B, 'Problematic alcohol and other substance use among patients presenting to emergency services in South Africa: Who is ready for change?', South African Medical Journal, 107 352-353 (2017)

© 2017, South African Medical Association. All rights reserved. Background. Studies that identify factors associated with intervention uptake are urgently needed in poorly resourc... [more]

© 2017, South African Medical Association. All rights reserved. Background. Studies that identify factors associated with intervention uptake are urgently needed in poorly resourced healthcare systems. This is important, as knowing who is likely to engage may lead to intervention targeting, which is an efficient use of scarce health resources. Objective. To identify patient characteristics that predict the acceptance of a brief intervention for substance use delivered in emergency departments (EDs). Methods. Patients presenting to three EDs were screened for substance use using the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST). All patients identified as at risk for substance use problems were offered a brief psychotherapy intervention focused on substance user education. Data were collected on patients¿ age, sex, presenting condition (injury/no injury), type of substance used, and severity of substance use. Logistic regression analysis was used to identify variables that predicted acceptance of the offer of a brief intervention. Results. Being between the ages of 25 and 39 years increased the likelihood of accepting an offer of help compared with 18 - 24-year-olds. Polysubstance users were less likely to accept an offer of help than patients with problematic alcohol use only, while patients with higher ASSIST scores were more likely to accept an offer of help than those with lower scores. Conclusions. Findings suggest that more work is needed to understand the mechanisms underlying treatment acceptance. Brief interventions delivered in ED services in countries such as South Africa should target alcohol users with higher ASSIST scores in order to ensure the efficient use of scarce health resources.

DOI 10.7196/SAMJ.2017.v107i4.10791
Citations Scopus - 3Web of Science - 1
2016 Petersen I, Fairall L, Bhana A, Kathree T, Selohilwe O, Brooke-Sumner C, et al., 'Integrating mental health into chronic care in South Africa: The development of a district mental healthcare plan', British Journal of Psychiatry, 208 s29-s39 (2016)

© The Royal College of Psychiatrists 2016. Background In South Africa, the escalating prevalence of chronic illness and its high comorbidity with mental disorders bring to the for... [more]

© The Royal College of Psychiatrists 2016. Background In South Africa, the escalating prevalence of chronic illness and its high comorbidity with mental disorders bring to the fore the need for integrating mental health into chronic care at district level. Aims To develop a district mental healthcare plan (MHCP) in South Africa that integrates mental healthcare for depression, alcohol use disorders and schizophrenia into chronic care. Method Mixed methods using a situation analysis, qualitative key informant interviews, theory of change workshops and piloting of the plan in one health facility informed the development of the MHCP. Results Collaborative care packages for the three conditions were developed to enable integration at the organisational, facility and community levels, supported by a human resource mix and implementation tools. Potential barriers to the feasibility of implementation at scale were identified. Conclusions The plan leverages resources and systems availed by the emerging chronic care service delivery platform for the integration of mental health. This strengthens the potential for future scale up.

DOI 10.1192/bjp.bp.114.153726
Citations Scopus - 36Web of Science - 32
2016 Breuer E, De Silva MJ, Shidaye R, Petersen I, Nakku J, Jordans MJD, et al., 'Planning and evaluating mental health services in low-and middle-income countries using theory of change', British Journal of Psychiatry, 208 s55-s62 (2016)

© The Royal College of Psychiatrists 2016. Background There is little practical guidance on how contextually relevant mental healthcare plans (MHCPs) can be developed in lowresour... [more]

© The Royal College of Psychiatrists 2016. Background There is little practical guidance on how contextually relevant mental healthcare plans (MHCPs) can be developed in lowresource settings. Aims To describe how theory of change (ToC) was used to plan the development and evaluation of MHCPs as part of the PRogramme for Improving Mental health carE (PRIME). Method ToC development occurred in three stages: (a) development of a cross-country ToC by 15 PRIME consortium members; (b) development of country-specific ToCs in 13 workshops with a median of 15 (interquartile range 13-22) stakeholders per workshop; and (c) review and refinement of the crosscountry ToC by 18 PRIME consortium members. Results One cross-country and five district ToCs were developed that outlined the steps required to improve outcomes for people with mental disorders in PRIME districts. Conclusions ToC is a valuable participatory method that can be used to develop MHCPs and plan their evaluation.

DOI 10.1192/bjp.bp.114.153841
Citations Scopus - 29Web of Science - 29
2016 De Silva MJ, Rathod SD, Hanlon C, Breuer E, Chisholm D, Fekadu A, et al., 'Evaluation of district mental healthcare plans: The PRIME consortium methodology', British Journal of Psychiatry, 208 s63-s70 (2016)

© The Royal College of Psychiatrists 2016. Background Few studies have evaluated the implementation and impact of real-world mental health programmes delivered at scale in low-res... [more]

© The Royal College of Psychiatrists 2016. Background Few studies have evaluated the implementation and impact of real-world mental health programmes delivered at scale in low-resource settings. Aims To describe the cross-country research methods used to evaluate district-level mental healthcare plans (MHCPs) in Ethiopia, India, Nepal, South Africa and Uganda. Method Multidisciplinary methods conducted at community, health facility and district levels, embedded within a theory of change. Results The following designs are employed to evaluate the MHCPs: (a) repeat community-based cross-sectional surveys to measure change in population-level contact coverage; (b) repeat facility-based surveys to assess change in detection of disorders; (c) disorder-specific cohorts to assess the effect on patient outcomes; and (d) multilevel case studies to evaluate the process of implementation. Conclusions To evaluate whether and how a health-system-level intervention is effective, multidisciplinary research methods are required at different population levels. Although challenging, such methods may be replicated across diverse settings.

DOI 10.1192/bjp.bp.114.153858
Citations Scopus - 40Web of Science - 37
2016 Fekadu A, Hanlon C, Medhin G, Alem A, Selamu M, Giorgis TW, et al., 'Development of a scalable mental healthcare plan for a rural district in Ethiopia', British Journal of Psychiatry, 208 s4-s12 (2016)

© The Royal College of Psychiatrists 2016. Background Developing evidence for the implementation and scaling up of mental healthcare in low-and middle-income countries (LMIC) like... [more]

© The Royal College of Psychiatrists 2016. Background Developing evidence for the implementation and scaling up of mental healthcare in low-and middle-income countries (LMIC) like Ethiopia is an urgent priority. Aims To outline a mental healthcare plan (MHCP), as a scalable template for the implementation of mental healthcare in rural Ethiopia. Method A mixed methods approach was used to develop the MHCP for the three levels of the district health system (community, health facility and healthcare organisation). Results The community packages were community case detection, community reintegration and community inclusion. The facility packages included capacity building, decision support and staff well-being. Organisational packages were programme management, supervision and sustainability. Conclusions The MHCP focused on improving demand and access at the community level, inclusive care at the facility level and sustainability at the organisation level. The MHCP represented an essential framework for the provision of integrated care and may be a useful template for similar LMIC.

DOI 10.1192/bjp.bp.114.153676
Citations Scopus - 44Web of Science - 38
2016 Baron EC, Hanlon C, Mall S, Honikman S, Breuer E, Kathree T, et al., 'Maternal mental health in primary care in five low- and middle-income countries: A situational analysis', BMC Health Services Research, 16 (2016)

© 2016 Baron et al. Background: The integration of maternal mental health into primary health care has been advocated to reduce the mental health treatment gap in low- and middle-... [more]

© 2016 Baron et al. Background: The integration of maternal mental health into primary health care has been advocated to reduce the mental health treatment gap in low- and middle-income countries (LMICs). This study reports findings of a cross-country situation analysis on maternal mental health and services available in five LMICs, to inform the development of integrated maternal mental health services integrated into primary health care. Methods: The situation analysis was conducted in five districts in Ethiopia, India, Nepal, South Africa and Uganda, as part of the Programme for Improving Mental Health Care (PRIME). The analysis reports secondary data on the prevalence and impact of priority maternal mental disorders (perinatal depression, alcohol use disorders during pregnancy and puerperal psychosis), existing policies, plans and services for maternal mental health, and other relevant contextual factors, such as explanatory models for mental illness. Results: Limited data were available at the district level, although generalizable data from other sites was identified in most cases. Community and facility-based prevalences ranged widely across PRIME countries for perinatal depression (3-50 %) and alcohol consumption during pregnancy (5-51 %). Maternal mental health was included in mental health policies in South Africa, India and Ethiopia, and a mental health care plan was in the process of being implemented in South Africa. No district reported dedicated maternal mental health services, but referrals to specialised care in psychiatric units or general hospitals were possible. No information was available on coverage for maternal mental health care. Challenges to the provision of maternal mental health care included; limited evidence on feasible detection and treatment strategies for maternal mental disorders, lack of mental health specialists in the public health sector, lack of prescribing guidelines for pregnant and breastfeeding women, and stigmatising attitudes among primary health care staff and the community. Conclusions: It is difficult to anticipate demand for mental health care at district level in the five countries, given the lack of evidence on the prevalence and treatment coverage of women with maternal mental disorders. Limited evidence on effective psychosocial interventions was also noted, and must be addressed for mental health programmes, such as PRIME, to implement feasible and effective services.

DOI 10.1186/s12913-016-1291-z
Citations Scopus - 28Web of Science - 27
2016 Fekadu A, Medhin G, Selamu M, Shiferaw T, Hailemariam M, Rathod SD, et al., 'Non-fatal suicidal behaviour in rural Ethiopia: A cross-sectional facility- and population-based study', BMC Psychiatry, 16 (2016)

© 2016 Fekadu et al. Background: Injury related to self-harm is one of the leading causes of global disease burden. As a formative work for a programme to implement comprehensive ... [more]

© 2016 Fekadu et al. Background: Injury related to self-harm is one of the leading causes of global disease burden. As a formative work for a programme to implement comprehensive mental healthcare in a rural district in Ethiopia, we determined the 12-month prevalence of non-fatal suicidal behaviour as well as factors associated with this behaviour to understand the potential burden of the behaviour in the district. Method: Population-based (n=1485) and facility-based (n=1014) cross-sectional surveys of adults, using standardised, interview-based measures for suicidality (items on suicide from the Composite International Diagnostic Interview), depressive symptoms (the Patient Health Questionnaire) and alcohol use disorders (Alcohol Use Disorder Investigation Test; AUDIT). Results: The overall 12-month prevalence of non-fatal suicidal behaviour, consisting of suicidal ideation, plan and attempt, was 7.9% (95% Confidence Interval (CI)=6.8% to 8.9%). The prevalence was significantly higher in the facility sample (10.3%) compared with the community sample (6.3%). The 12-month prevalence of suicide attempt was 4.4% (95% CI=3.6% to 5.3%), non-significantly higher among the facility sample (5.4%) compared with the community sample (3.8%). Over half of those with suicidal ideation (56.4%) transitioned from suicidal ideation to suicide attempt. Younger age, harmful use of alcohol and higher depression scores were associated significantly with increased non-fatal suicidal behaviours. The only factor associated with transition from suicidal ideation to suicide attempt was high depression score. Only 10.5% of the sample with suicidal ideation had received any treatment for their suicidal behaviour: 10.8% of the community sample and 10.2% of the facility sample. Although help seeking increased with progression from ideation to attempt, there was no statistically significant difference between the groups. Conclusion: Non-fatal suicidal behaviour is an important public health problem in this rural district. A more in-depth understanding of the context of the occurrence of the behaviour, improving access to care and targeting depression and alcohol use disorder are important next steps. The role of other psychosocial factors should also be explored to assist the provision of holistic care.

DOI 10.1186/s12888-016-0784-y
Citations Scopus - 15Web of Science - 12
2016 Breuer E, Lee L, De Silva M, Lund C, 'Using theory of change to design and evaluate public health interventions: A systematic review', Implementation Science, 11 (2016)

© 2016 Breuer et al. Background: Despite the increasing popularity of the theory of change (ToC) approach, little is known about the extent to which ToC has been used in the desig... [more]

© 2016 Breuer et al. Background: Despite the increasing popularity of the theory of change (ToC) approach, little is known about the extent to which ToC has been used in the design and evaluation of public health interventions. This review aims to determine how ToCs have been developed and used in the development and evaluation of public health interventions globally. Methods: We searched for papers reporting the use of "theory of change" in the development or evaluation of public health interventions in databases of peer-reviewed journal articles such as Scopus, Pubmed, PsychInfo, grey literature databases, Google and websites of development funders. We included papers of any date, language or study design. Both abstracts and full text papers were double screened. Data were extracted and narratively and quantitatively summarised. Results: A total of 62 papers were included in the review. Forty-nine (79 %) described the development of ToC, 18 (29 %) described the use of ToC in the development of the intervention and 49 (79 %) described the use of ToC in the evaluation of the intervention. Although a large number of papers were included in the review, their descriptions of the ToC development and use in intervention design and evaluation lacked detail. Conclusions: The use of the ToC approach is widespread in the public health literature. Clear reporting of the ToC process and outputs is important to strengthen the body of literature on practical application of ToC in order to develop our understanding of the benefits and advantages of using ToC. We also propose a checklist for reporting on the use of ToC to ensure transparent reporting and recommend that our checklist is used and refined by authors reporting the ToC approach.

DOI 10.1186/s13012-016-0422-6
Citations Scopus - 57Web of Science - 50
2016 Rathod SD, De Silva MJ, Ssebunnya J, Breuer E, Murhar V, Luitel NP, et al., 'Treatment contact coverage for probable depressive and probable alcohol use disorders in four low- and middle-income country districts: The prime cross-sectional community surveys', PLoS ONE, 11 (2016)

© 2016 Rathod et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and repr... [more]

© 2016 Rathod et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Context: A robust evidence base is now emerging that indicates that treatment for depression and alcohol use disorders (AUD) delivered in low and middle-income countries (LMIC) can be effective. However, the coverage of services for these conditions in most LMIC settings remains unknown. Objective: To describe the methods of a repeat cross-sectional survey to determine changes in treatment contact coverage for probable depression and for probable AUD in four LMIC districts, and to present the baseline findings regarding treatment contact coverage. Methods: Population-based cross-sectional surveys with structured questionnaires, which included validated screening tools to identify probable cases.We defined contact coverage as being the proportion of cases who sought professional help in the past 12 months. Setting: Sodo District, Ethiopia; Sehore District, India; Chitwan District, Nepal; and Kamuli District, Uganda Participants: 8036 adults residing in these districts between May 2013 and May 2014 Main Outcome Measures: Treatment contact coverage was defined as having sought care from a specialist, generalist, or other health care provider for symptoms related to depression or AUD. Results: The proportion of adults who screened positive for depression over the past 12 months ranged from 11.2% in Nepal to 29.7% in India and treatment contact coverage over the past 12 months ranged between 8.1% in Nepal to 23.5% in India. In Ethiopia, lifetime contact coverage for probable depression was 23.7%. The proportion of adults who screened positive for AUD over the past 12 months ranged from 1.7% in Uganda to 13.9% in Ethiopia and treatment contact coverage over the past 12 months ranged from 2.8% in India to 5.1% in Nepal. In Ethiopia, lifetime contact coverage for probable AUD was 13.1%. Conclusions: Our findings are consistent with and contribute to the limited evidence base which indicates low treatment contact coverage for depression and for AUD in LMIC. The planned follow up surveys will be used to estimate the change in contact coverage coinciding with the implementation of district-level mental health care plans.

DOI 10.1371/journal.pone.0162038
Citations Scopus - 23Web of Science - 22
2015 Hanlon C, Medhin G, Selamu M, Breuer E, Worku B, Hailemariam M, et al., 'Validity of brief screening questionnaires to detect depression in primary care in Ethiopia', Journal of Affective Disorders, 186 32-39 (2015)

© 2015 Elsevier B.V. All rights reserved. Background: Brief depression screening questionnaires may increase detection of depression in primary care settings but there have been f... [more]

© 2015 Elsevier B.V. All rights reserved. Background: Brief depression screening questionnaires may increase detection of depression in primary care settings but there have been few validation studies carried out in typical populations in low-income countries. Methods: Cultural validation of the Patient Health Questionnaire (PHQ-9/PHQ-2), the 20-item Self-Reporting Questionnaire (SRQ-20) and the Kessler scales (K6/K10) was carried out in 306 adults consecutively attending primary care facilities in small towns in Ethiopia. To assess criterion validity, the gold standard assessment for presence of Major Depressive Disorder (MDD) was made by Ethiopian psychiatric nurses using the Mini International Neuropsychiatric Interview. Results: The prevalence of gold standard MDD was 5.9%, with irritability more common than depressed mood or anhedonia. The area under the receiver operating characteristic curve indicated good performance of the PHQ-9, SRQ-20, K6 and K10 (0.83-0.85) but only fair for the PHQ-2 (0.78). No cut-off score had acceptable sensitivity combined with adequate positive predictive value. All screening questionnaires were associated with disability and the PHQ-9 and SRQ-20 were associated with higher health service contacts, indicating convergent validity. Construct validity of all scales was indicated by unidimensionality on exploratory factor analysis. Limitations: Test-retest reliability was not assessed. Conclusions: Brief depression screening questionnaires were found to be valid in primary care in this low-income country. However, these questionnaires do not have immediate applicability in routine clinical settings. Further studies should evaluate utility of indicated screening embedded within health system changes that support MDD detection. Investigation of irritability as a core depression symptom is warranted.

DOI 10.1016/j.jad.2015.07.015
Citations Scopus - 56Web of Science - 59
2015 Hailemariam M, Fekadu A, Selamu M, Alem A, Medhin G, Giorgis TW, et al., 'Developing a mental health care plan in a low resource setting: The theory of change approach', BMC Health Services Research, 15 (2015)

© 2015 Hailemariam et al. Background: Scaling up mental healthcare through integration into primary care remains the main strategy to address the extensive unmet mental health nee... [more]

© 2015 Hailemariam et al. Background: Scaling up mental healthcare through integration into primary care remains the main strategy to address the extensive unmet mental health need in low-income countries. For integrated care to achieve its goal, a clear understanding of the organisational processes that can promote and hinder the integration and delivery of mental health care is essential. Theory of Change (ToC), a method employed in the planning, implementation and evaluation of complex community initiatives, is an innovative approach that has the potential to assist in the development of a comprehensive mental health care plan (MHCP), which can inform the delivery of integrated care. We used the ToC approach to develop a MHCP in a rural district in Ethiopia. The work was part of a cross-country study, the Programme for Improving Mental Health Care (PRIME) which focuses on developing evidence on the integration of mental health in to primary care. Methods: An iterative ToC development process was undertaken involving multiple workshops with stakeholders from diverse backgrounds that included representatives from the community, faith and traditional healers, community associations, non-governmental organisations, Zonal, Regional and Federal level government offices, higher education institutions, social work and mental health specialists (psychiatrists and psychiatric nurses). The objective of this study is to report the process of implementing the ToC approach in developing mental health care plan. Results: A total of 46 persons participated in four ToC workshops. Four critical path dimensions were identified: community, health facility, administrative and higher level care organisation. The ToC participants were actively engaged in the process and the ToC encouraged strong commitment among participants. Key opportunities and barriers to implementation and how to overcome these were suggested. During the workshops, a map incorporating the key agreed outcomes and outcome indicators was developed and finalized later. Conclusions: The ToC approach was found to be an important component in the development of the MHCP and to encourage broad political support for the integration of mental health services into primary care. The method may have broader applicability in planning complex health interventions in low resource settings.

DOI 10.1186/s12913-015-1097-4
Citations Scopus - 11Web of Science - 9
2014 Breuer E, Stoloff K, Myer L, Seedat S, Stein DJ, Joska JA, 'The Validity of the substance abuse and mental illness symptom screener (SAMISS) in people living with HIV/AIDS in primary HIV care in cape town, South Africa', AIDS and Behavior, 18 1133-1141 (2014)

Given the high prevalence of HIV in South Africa and co-morbid mental disorders in people living with HIV/AIDs (PLWHA) we sought to validate a brief screening tool in primary HIV ... [more]

Given the high prevalence of HIV in South Africa and co-morbid mental disorders in people living with HIV/AIDs (PLWHA) we sought to validate a brief screening tool in primary HIV care. Methods: 366 PLWHA were recruited prior to combination anti-retroviral treatment (CART) initiation from two primary health HIV clinics. A mental health nurse administered a sociodemographic questionnaire and the Mini Neuropsychiatric Interview (MINI) and a lay counsellor administered the Substance and Mental Illness Symptom Screener (SAMISS). Results: Using the MINI, 17 % of participants were identified with either depression, anxiety disorders or adjustment disorder and 18 % with substance or alcohol abuse/dependence. The sensitivity and specificity of the SAMISS was 94 % (95 % CI: 88-98 %) and 58 % (95 % CI: 52-65 %) respectively, with the alcohol component (sensitivity: 94 %; specificity: 85 %) performing better than the mental illness component of the SAMISS (sensitivity: 97 %; specificity: 60 %). The specificity of the tool improved when the cut-off for the mental illness component was increased. Conclusion: The SAMISS may provide a useful first tier screening tool for common mental disorders in primary care for PLWHA. © Springer Science+Business Media New York 2014.

DOI 10.1007/s10461-014-0698-y
Citations Scopus - 14Web of Science - 15
2014 Fekadu A, Medhin G, Selamu M, Hailemariam M, Alem A, Giorgis TW, et al., 'Population level mental distress in rural Ethiopia', BMC Psychiatry, 14 (2014)

Background: As part of a situational analysis for a research programme on the integration of mental health care into primary care (Programme for Improving Mental Health Care-PRIME... [more]

Background: As part of a situational analysis for a research programme on the integration of mental health care into primary care (Programme for Improving Mental Health Care-PRIME), we conducted a baseline study aimed at determining the broad indicators of the population level of psychosocial distress in a predominantly rural community in Ethiopia.Methods: The study was a population-based cross-sectional survey of 1497 adults selected through a multi-stage random sampling process. Population level psychosocial distress was evaluated by estimating the magnitude of common mental disorder symptoms (CMD; depressive, anxiety and somatic symptoms reaching the level of probable clinical significance), harmful use of alcohol, suicidality and psychosocial stressors experienced by the population.Results: The one-month prevalence of CMD at the mild, moderate and severe threshold levels was 13.8%, 9.0% and 5.1% respectively. The respective one-month prevalence of any suicidal ideation, persistent suicidal ideation and suicide attempt was 13.5%, 3.8% and 1.8%. Hazardous use of alcohol was identified in 22.4%, significantly higher among men (33.4%) compared to women (11.3%). Stressful life events were widespread, with 41.4% reporting at least one threatening life event in the preceding six months. A similar proportion reported poor social support (40.8%). Stressful life events, increasing age, marital loss and hazardous use of alcohol were associated with CMD while stressful life events, marital loss and lower educational status, and CMD were associated with suicidality. CMD was the strongest factor associated with suicidality [e.g., OR (95% CI) for severe CMD = 60.91 (28.01, 132.48)] and the strength of association increased with increase in the severity of the CMD.Conclusion: Indicators of psychosocial distress are prevalent in this rural community. Contrary to former assumptions in the literature, social support systems seem relatively weak and stressful life events common. Interventions geared towards modifying general risk factors and broader strategies to promote mental wellbeing are required. © 2014 Fekadu et al.; licensee BioMed Central Ltd.

DOI 10.1186/1471-244X-14-194
Citations Scopus - 44Web of Science - 42
2014 Breuer E, De Silva MJ, Fekadu A, Luitel NP, Murhar V, Nakku J, et al., 'Using workshops to develop theories of change in five low and middle income countries: Lessons from the programme for improving mental health care (PRIME)', International Journal of Mental Health Systems, 8 (2014)

Background: The Theory of Change (ToC) approach has been used to develop and evaluate complex health initiatives in a participatory way in high income countries. Little is known a... [more]

Background: The Theory of Change (ToC) approach has been used to develop and evaluate complex health initiatives in a participatory way in high income countries. Little is known about its use to develop mental health care plans in low and middle income countries where mental health services remain inadequate.Aims: ToC workshops were held as part of formative phase of the Programme for Improving Mental Health Care (PRIME) in order 1) to develop a structured logical and evidence-based ToC map as a basis for a mental health care plan in each district; (2) to contextualise the plans; and (3) to obtain stakeholder buy-in in Ethiopia, India, Nepal, South Africa and Uganda. This study describes the structure and facilitator's experiences of ToC workshops.Methods: The facilitators of the ToC workshops were interviewed and the interviews were recorded, transcribed and analysed together with process documentation from the workshops using a framework analysis approach.Results: Thirteen workshops were held in the five PRIME countries at different levels of the health system. The ToC workshops achieved their stated goals with the contributions of different stakeholders. District health planners, mental health specialists, and researchers contributed the most to the development of the ToC while service providers provided detailed contextual information. Buy-in was achieved from all stakeholders but valued more from those in control of resources.Conclusions: ToC workshops are a useful approach for developing ToCs as a basis for mental health care plans because they facilitate logical, evidence based and contextualised plans, while promoting stakeholder buy in. Because of the existing hierarchies within some health systems, strategies such as limiting the types of participants and stratifying the workshops can be used to ensure productive workshops. © 2014 Breuer et al.; licensee BioMed Central Ltd.

DOI 10.1186/1752-4458-8-15
Citations Scopus - 27Web of Science - 31
2014 Hanlon C, Luitel NP, Kathree T, Murhar V, Shrivasta S, Medhin G, et al., 'Challenges and opportunities for implementing integrated mental health care: A district level situation analysis from five low- and middle-income countries', PLoS ONE, 9 (2014)

Background: Little is known about how to tailor implementation of mental health services in low- and middle-income countries (LMICs) to the diverse settings encountered within and... [more]

Background: Little is known about how to tailor implementation of mental health services in low- and middle-income countries (LMICs) to the diverse settings encountered within and between countries. In this paper we compare the baseline context, challenges and opportunities in districts in five LMICs (Ethiopia, India, Nepal, South Africa and Uganda) participating in the PRogramme for Improving Mental health carE (PRIME). The purpose was to inform development and implementation of a comprehensive district plan to integrate mental health into primary care. Methods: A situation analysis tool was developed for the study, drawing on existing tools and expert consensus. Cross-sectional information obtained was largely in the public domain in all five districts. Results: The PRIME study districts face substantial contextual and health system challenges many of which are common across sites. Reliable information on existing treatment coverage for mental disorders was unavailable. Particularly in the low-income countries, many health service organisational requirements for mental health care were absent, including specialist mental health professionals to support the service and reliable supplies of medication. Across all sites, community mental health literacy was low and there were no models of multi-sectoral working or collaborations with traditional or religious healers. Nonetheless health system opportunities were apparent. In each district there was potential to apply existing models of care for tuberculosis and HIV or non-communicable disorders, which have established mechanisms for detection of drop-out from care, outreach and adherence support. The extensive networks of community-based health workers and volunteers in most districts provide further opportunities to expand mental health care. Conclusions: The low level of baseline health system preparedness across sites underlines that interventions at the levels of health care organisation, health facility and community will all be essential for sustainable delivery of quality mental health care integrated into primary care. © 2014 Hanlon et al.

DOI 10.1371/journal.pone.0088437
Citations Scopus - 130Web of Science - 123
2014 De Silva MJ, Breuer E, Lee L, Asher L, Chowdhary N, Lund C, Patel V, 'Theory of Change: A theory-driven approach to enhance the Medical Research Council's framework for complex interventions', Trials, 15 (2014)

© 2014 De Silva et al.; licensee BioMed Central Ltd. Background: The Medical Research Councils' framework for complex interventions has been criticized for not including theo... [more]

© 2014 De Silva et al.; licensee BioMed Central Ltd. Background: The Medical Research Councils' framework for complex interventions has been criticized for not including theory-driven approaches to evaluation. Although the framework does include broad guidance on the use of theory, it contains little practical guidance for implementers and there have been calls to develop a more comprehensive approach. A prospective, theory-driven process of intervention design and evaluation is required to develop complex healthcare interventions which are more likely to be effective, sustainable and scalable.Methods: We propose a theory-driven approach to the design and evaluation of complex interventions by adapting and integrating a programmatic design and evaluation tool, Theory of Change (ToC), into the MRC framework for complex interventions. We provide a guide to what ToC is, how to construct one, and how to integrate its use into research projects seeking to design, implement and evaluate complex interventions using the MRC framework. We test this approach by using ToC within two randomized controlled trials and one non-randomized evaluation of complex interventions. Results: Our application of ToC in three research projects has shown that ToC can strengthen key stages of the MRC framework. It can aid the development of interventions by providing a framework for enhanced stakeholder engagement and by explicitly designing an intervention that is embedded in the local context. For the feasibility and piloting stage, ToC enables the systematic identification of knowledge gaps to generate research questions that strengthen intervention design. ToC may improve the evaluation of interventions by providing a comprehensive set of indicators to evaluate all stages of the causal pathway through which an intervention achieves impact, combining evaluations of intervention effectiveness with detailed process evaluations into one theoretical framework. Conclusions: Incorporating a ToC approach into the MRC framework holds promise for improving the design and evaluation of complex interventions, thereby increasing the likelihood that the intervention will be ultimately effective, sustainable and scalable. We urge researchers developing and evaluating complex interventions to consider using this approach, to evaluate its usefulness and to build an evidence base to further refine the methodology. Trial registration: Clinical trials.gov: NCT02160249.

DOI 10.1186/1745-6215-15-267
Citations Scopus - 143Web of Science - 133
2013 Lund C, Waruguru M, Kingori J, Kippen-Wood S, Breuer E, Mannarathd S, Raja S, 'Outcomes of the mental health and development model in rural Kenya: A 2-year prospective cohort intervention study', International Health, 5 43-50 (2013)

Background: The aim of this study was to evaluate outcomes for participants in BasicNeeds' Mental Health and Development programme in rural Kenya. Methods: All new entrants t... [more]

Background: The aim of this study was to evaluate outcomes for participants in BasicNeeds' Mental Health and Development programme in rural Kenya. Methods: All new entrants to the programme in the Meru South and Nyeri North districts were enrolled in the study over a 3-month period (n=203). Assessments of mental health, functioning, economic status and quality of life were conducted at baseline and at 1-year and 2-year follow up, using a single group cohort design. Results: Over the 2 years there were significant improvements in scores on the General Health Questionnaire (21.5 [95% CI: 20.2-22.8] to 6 [95% CI: 4.8-7.2] < 0.01), Global Assessment of Functioning scale (78 [95% CI: 75.5-80.3] to 94 [95% CI: 90.7-97.3] < 0.01), summed WHO Quality of Life-Brief scale (39.5 [95% CI: 38.6-40.4] to 57.2 [95% CI: 56.2-58.3] < 0.01) and the proportion who were engaged in either income generation or productive work (45.3-64.0%, < 0.01). Conclusions: The mental health and development model shows improvements in mental health, functioning, income generation and quality of life among people living with severe mental illness in rural Kenya. The findings demonstrate the feasibility and benefits of integrating mental health and poverty alleviation components in mental health care in Africa. © Royal Society of Tropical Medicine and Hygiene 2013. All rights reserved.

DOI 10.1093/inthealth/ihs037
Citations Scopus - 28Web of Science - 25
2012 Breuer E, Stoloff K, Myer L, Seedat S, Stein DJ, Joska J, 'Reliability of the Lay Adherence Counsellor Administered Substance Abuse and Mental Illness Symptoms Screener (SAMISS) and the International HIV Dementia Scale (IHDS) in a Primary care HIV Clinic in Cape Town, South Africa', AIDS AND BEHAVIOR, 16 1464-1471 (2012)
DOI 10.1007/s10461-011-0067-z
Citations Scopus - 15Web of Science - 13
2011 Breuer E, Myer L, Struthers H, Joska JA, 'HIV/AIDS and mental health research in sub-Saharan Africa: a systematic review', AJAR-AFRICAN JOURNAL OF AIDS RESEARCH, 10 101-122 (2011)
DOI 10.2989/16085906.2011.593373
Citations Scopus - 58Web of Science - 54
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Research Supervision

Number of supervisions

Completed3
Current0

Past Supervision

Year Level of Study Research Title Program Supervisor Type
2019 Masters The profile and management of beneficiaries of a novel integrated mental health managed care programme for the South African Police Services medical aid scheme Public Health Not Elswr Classi, University of Cape Town Principal Supervisor
2017 Masters Formative Study on the Adaptation of Mental Health Promotion Programs for Perinatal Depression in West Chitwan Public Health Not Elswr Classi, University of Cape Town Principal Supervisor
2015 Masters Prevalence of moderate and high risk substance use and service needs among psychiatric inpatients at Zomba Mental hospital in Malawi Public Health Not Elswr Classi, University of Cape Town Principal Supervisor
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Dr Erica Breuer

Positions

Conjoint Lecturer
School of Medicine and Public Health
Faculty of Health and Medicine

Postdoctoral Research Fellow
Office of the PVC Health and Medicine
Faculty of Health and Medicine

Contact Details

Email erica.breuer@newcastle.edu.au
Phone (02) 4055 3480

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Location Callaghan
University Drive
Callaghan, NSW 2308
Australia
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