In low- and middle-income countries, fewer than 1 in 10 people with mental health conditions are estimated to be accurately diagnosed in primary care. This is despite more than 90 countries providing mental health training for primary healthcare workers in the past two decades. The lack of accurate diagnoses is a major bottleneck to reducing the global mental health treatment gap. In this commentary, we argue that current research practices are insufficient to generate the evidence needed to improve diagnostic accuracy. Research studies commonly determine accurate diagnosis by relying on self-report tools such as the Patient Health Questionnaire-9. This is problematic because self-report tools often overestimate prevalence, primarily due to their high rates of false positives. Moreover, nearly all studies on detection focus solely on depression, not taking into account the spectrum of conditions on which primary healthcare workers are being trained. Single condition self-report tools fail to discriminate among different types of mental health conditions, leading to a heterogeneous group of conditions masked under a single scale. As an alternative path forward, we propose improving research on diagnostic accuracy to better evaluate the reach of mental health service delivery in primary care. We recommend evaluating multiple conditions, statistically adjusting prevalence estimates generated from self-report tools, and consistently using structured clinical interviews as a gold standard. We propose clinically meaningful detection as ‘good-enough’ diagnoses incorporating multiple conditions accounting for context, health system and types of interventions available. Clinically meaningful identification can be operationalized differently across settings based on what level of diagnostic specificity is needed to select from available treatments. Rethinking research strategies to evaluate accuracy of diagnosis is vital to improve training, supervision and delivery of mental health services around the world.

The urgency to tackle climate change has placed sustainable development at the centre of recent trade related debates. An emerging consensus is that trade should be considered and can be used as means to achieve sustainable development goals. As the circumstances are changing, one issue to be addressed is how to adjust trade negotiations which used to be the main approach to pursuing market opening and liberalization with the support of the theory of comparative advantage. In this context, this paper examines trade negotiations on environmental services by focusing on developing countries' participation. Environmental services and related trade play a critical role in achieving environmental and sustainable development goals. Nevertheless, developing countries' participation in environmental services trade negotiations has been limited. By analysing the reasons behind such limited participation and assessing some new approaches, this paper attempts to explore how environmental services trade negotiations could be adapted to better engage developing countries and serve Sustainable Development Goals.

The paper investigates the gender-driven disparities in total factor productivity (TFP) between women-owned enterprises (WOEs) and male-owned enterprises (MOEs) across 30 developing countries. Utilizing firm-level data from the World Bank Enterprise Surveys, the study addresses biases in previous gender literature by employing a semi-parametric technique to more accurately measure TFP. The results reveal a significant TFP gap, with WOEs being 5.5% to 6.7% less productive than MOEs, even after controlling for key firm characteristics like age, innovation, human capital, and ownership status. The study attributes this productivity disparity primarily to financial obstacles faced by WOEs, which hinder their ability to innovate and capitalize on opportunities. The lack of access to credit leads to a misallocation of capital, excluding equally efficient women entrepreneurs from financial resources that could stimulate productivity. Contrary to some assumptions, the study finds no evidence that WOEs underperform in sectors with high financial dependence, suggesting that WOEs are not inherently inefficient in their use of capital. Our findings provide causal evidence as we control for selectivity bias in the TFP-WOEs nexus by identifying exogenously the factors that affect financial constraints and innovation.

Wearable technology and daily diaries offer insights into everyday behaviors that can further health research and treatment globally. However, the use of these methodologies outside of high-income settings has been limited. We conducted two pilot studies that enrolled 60 young women in the urban slums of Kampala, Uganda to understand design considerations associated with using wearable technology and daily diaries in this context. Each participant in the pilot studies was asked to wear a wearable activity tracker and complete daily diary questionnaires for 5 days. Based on our experiences, we identified several lessons that may be beneficial to others interested in implementing wearable technology and daily self-reports in their research and interventions, particularly when working in low-resource contexts. We discuss the importance of designing solutions tailored to the available resources, building validation for the most critical measures, investing in data management efforts and providing transparent and culturally accessible information to participants. Examples from our study are provided. These lessons may reduce the barriers and improve data quality for future researchers and practitioners interested in using these data collection methods globally.

Given the rate of advancement in predictive psychiatry, there is a threat that it outpaces public and professional willingness for use in clinical care and public health. Prediction tools in psychiatry estimate the risk of future development of mental health conditions. Prediction tools used with young populations have the potential to reduce the worldwide burden of depression. However, little is known globally about adolescents’ and other stakeholders’ attitudes toward use of depression prediction tools. To address this, key informant interviews and focus group discussions were conducted in Brazil, Nepal, Nigeria and the United Kingdom with 23 adolescents, 45 parents, 47 teachers, 48 health-care practitioners and 78 other stakeholders (total sample = 241) to assess attitudes toward using a depression prediction risk calculator based on the Identifying Depression Early in Adolescence Risk Score. Three attributes were identified for an acceptable depression prediction tool: it should be understandable, confidential and actionable. Understandability includes depression literacy and differentiating between having a condition versus risk of a condition. Confidentiality concerns are disclosing risk and impeding educational and occupational opportunities. Prediction results must also be actionable through prevention services for high-risk adolescents. Six recommendations are provided to guide research on attitudes and preparedness for implementing prediction tools.

Hypertension and depression are increasingly common noncommunicable diseases in Ghana and worldwide, yet both are poorly controlled. We sought to understand how healthcare workers in rural Ghana conceptualize the interaction between hypertension and depression, and how care for these two conditions might best be integrated. We conducted a qualitative descriptive study involving in-depth interviews with 34 healthcare workers in the Kassena-Nankana districts of the Upper East Region of Ghana. We used conventional content analysis to systematically review interview transcripts, code the data content and analyze codes for salient themes. Respondents detailed three discrete conceptual models. Most emphasized depression as causing hypertension: through both emotional distress and unhealthy behavior. Others posited a bidirectional relationship, where cardiovascular morbidity worsened mood, or described a single set of underlying causes for both conditions. Nearly all proposed health interventions targeted their favored root cause of these disorders. In this representative rural Ghanaian community, healthcare workers widely agreed that cardiovascular disease and mental illness are physiologically linked and warrant an integrated care response, but held diverse views regarding precisely how and why. There was widespread support for a single primary care intervention to treat both conditions through counseling and medication.

Non-specialist mental health interventions serve as a potential solution to reduce the mental healthcare gap in low- and middle-income countries, such as Sri Lanka. However, contextual factors often influence their effective implementation, reflecting a research-to-practice gap. This study, using a qualitative, participatory approach with local mental health workers (n = 9) and potential service users (n = 11), identifies anticipated barriers and facilitators to implementing these interventions while also exploring alternative strategies for reducing the mental healthcare gap in this context. Perceived barriers include concerns about effectiveness, acceptance and feasibility in the implementation of non-specialist mental health interventions (theme 1). The participants’ overall perception that these interventions are a beneficial strategy for reducing the mental healthcare gap was identified as a facilitating factor for implementation (theme 2). Further facilitators relate to important non-specialist characteristics (theme 3), including desirable traits and occupational backgrounds that may aid in increasing the acceptance of this cadre. Other suggestions relate to facilitating the reach, intervention acceptance and feasibility (theme 4). This study offers valuable insights to enhance the implementation process of non-specialist mental health interventions in low-and middle-income countries such as Sri Lanka.

Compared to the global average, the exit rate of old-aged Iranian labourers is significantly higher than that of middle-aged, raising the hypothesis that social security generosity pulls older workers into early retirement. We used a unique individual dataset of Iran’s Social Security Organization (ISSO), including 267, 000 newly retired in 2016 and 2018, to assess the impact of ISSO’s pension policies on employees’ retirement age. In a counterfactual evaluation design, this study first estimated the implicit tax on work continuation and then applied the Heckman two-stage selection model. The findings show that ISSO’s retirement rules determining the age of exit and benefit eligibilities significantly increase the retirement probability and simultaneously decline the retirement age. Moreover, the implicit tax on work continuation, which reflects ISSO’s benefit formula, has a significant positive effect on retirement probability. The replacement rate also has a significant negative impact on retirement age. The retirement probability in hazardous jobs is higher than in normal ones, while exemptions significantly fall the outflow age of hazardous job holders. To maintain the scheme’s sustainability, reforms have to target an increase in the statutory retirement age, a reduction in the accrual rate, the calculation of reference salary for more extended periods, and the decline of the exemption coefficient for hazardous jobs.

Economic sanctions have inflicted various economic difficulties on Iranian families. The extent to which these sanctions-induced calamities have affected Iranian older adults’ material well-being remains unknown. Meanwhile, inadequate institutional support for the disadvantaged older population may worsen their precarious economic well-being. We use household-level surveys and quantile regression analysis to explore changes in Iranian older persons’ material well-being during the sanctions era. We also examine whether Iran’s pension system has alleviated the adverse effects of economic sanctions. Our investigation indicates that older adults’ material well-being decreases during sanctions. However, those without pension coverage are economically more vulnerable compared with pensioners. Among the non-pensioners, low-income and low-consumption ones are susceptible to relatively more considerable material well-being losses. To protect these vulnerable groups, policymakers should implement appropriate policy interventions, such as expansions in non-contributory anti-poverty schemes.

In low-resource settings, valid mental health screening tools for non-specialists can be used to identify patients with psychiatric disorders in need of critical mental health care. The Mental Wellness Tool-13 (mwTool-13) is a 13-item screener for identifying adults at risk for common mental disorders (CMDs) alcohol-use disorders (AUDs), substance-use disorders (SUD), severe mental disorders (SMDs), and suicide risk (SR). The mwTool-13 is administered in two steps, specifically, only those who endorse any of the initial three questions receive the remaining ten questions. We evaluated the performance of mwTool-13 in South Africa against a diagnostic gold standard. We recruited a targeted, gender-balanced sample of adults, aged ≥18 years at primary and tertiary healthcare facilities in Eastern Cape Province. Of the 1885 participants, the prevalence of CMD, AUD, SMD, SR, and SUD was 24.4%, 9.5%, 8.1%, 6.0%, and 1.6%, respectively. The mwTool-13 yielded high sensitivities for CMD, SMD, and SR, but sub-optimal sensitivities for AUD and SUD (56.7% and 64.5%, respectively). Including a single AUD question in the initial question set improved the tool’s performance in identifying AUD and SUD (sensitivity > 70%), while maintaining brevity, face-validity, and simplicity in the South African setting.

There is a growing recognition of the benefits of collaborating with people with lived experience (PWLE) of mental health conditions in mental health research and implementation of services. Such collaboration has been effective in reducing mental health stigma and improving the quality of mental health care. Here, we describe using PhotoVoice as a collaborative method in which PWLE use visual narratives to tell their recovery stories for promoting social contact, debunking myths and reducing stigma. First, we outline the framework of this collaboration, drawing on theories from medical anthropology and social psychology and focusing on reducing mental health stigma among primary healthcare workers. Then, we describe the process using our learnings from implementing PhotoVoice in Nepal, Ethiopia and Uganda. We highlight collaboration in five key steps with associated considerations: (1) identifying PWLE for collaboration; (2) training in photography, distress management and presentation skills; (3) developing a photographic recovery story; (4) training healthcare workers using the PhotoVoice narratives; and (5) ongoing support of mental health systems strengthening in collaboration with PWLE. Then, we critically reflect on the process, highlighting the benefits and challenges to the participants and researchers, thereby paving the way for expanding collaborations with PWLE using the PhotoVoice method.