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Community-based mental health and well-being interventions for older adults in low- and middle-income countries: a systematic review and meta-analysis

BMC Geriatrics volume 22, Article number: 773 (2022) Cite this article

Abstract

Background

Mental health support is often scarce in low- and middle-income countries (LMIC), with mental health stigmatised. Older adults are some of the most vulnerable members of society and may require specific types of mental health support. The aim of this mixed-methods systematic review and meta-analysis was to explore the types, components, and efficacy of psychosocial community-based mental health interventions for older adults (aged 60 + years) residing in LMIC.

Methods

Six databases were searched in August 2021. Studies published since 2000 were included if they collected primary quantitative or qualitative data on community-based interventions for improving mental health for older adults residing in LMICs, focusing on improving mental health and well-being outcomes. Full texts were screened by two researchers.

Results

From 24,378 citations identified, 40 studies met eligibility criteria. Across 12 countries, interventions were categorised into those focusing on (1) Established forms of psychological therapy; (2) Exercise; (3) Education; (4) Social engagement; (5) Multi-component. Most interventions were effective in reducing levels of depression, anxiety, and improving well-being, including reminiscence therapy, different types of socialising, and breathing and laughter exercises. Some interventions reported no benefits and those that did at times failed to report continued benefits at follow-up. Given the variations in intervention type and delivery, cultures, and outcome measures used, underpinning factors of intervention success or failure were difficult to establish.

Conclusions

Psychosocial interventions for older adults in LMIC need to be adapted to local contexts depending on culture and population needs. Existing interventions and their components can be used as a foundation to produce adapted and multi-component interventions, to tackle growing and inadequate mental health care provision in LMIC.

Trial registration

The review protocol was registered on PROSPERO [CRD42021271404].

Peer Review reports

Background

Appropriate mental health care is often limited in low- and middle-income countries (LMIC) [1]. This is mostly the result of limited availability of mental health care services, or associated stigma in different cultures, with families preferring to care for their relative themselves as opposed to openly sharing a mental health problem in their community [2, 3]. Further barriers include resource and administrative barriers, information and knowledge barriers, and policy barriers [4].

Older adults living in LMICs can be particularly affected by poor mental health. Older adults in these countries are often amongst the poorest members of society, without pensions or alternative consistent income, thus relying on younger family members for basic necessities and housing [5, 6]. Research indicates the need for more diverse approaches to support older adults beyond heavy reliance on family as a support system, which can create vulnerabilities for older adults [5]. This is particularly important given that older adults are the fastest growing population group globally and thus adequate support systems need to be in place [6].

This can leave many mental health issues unaddressed, and highlights the need for providing different types of mental health support from those provided solely by health care providers. Stigma is often a significant barrier to accessing care for mental health needs [2]. One way of addressing this barrier can be by providing support outside of dedicated health services which is integrated into the local community and local contexts. There is a growing evidence base on such psychosocial, community-based interventions in various different countries, delivering support to older adults via established forms of intervention such as Cognitive Behavioural Therapy [7, 8] or educational interventions [9, 10].

Whilst there is a clear need to address the mental health of older adults in LMICs, and a growing evidence base exploring the effects of different psychosocial interventions, there is no systematic review of the evidence to date. Instead, systematic reviews have focused on children or working-age adults with specific conditions [11, 12], or digital interventions for mental health in the adult population [13]. An umbrella review by Barbui et al. (2020) [14] reported on the effects of psychosocial interventions on various mental health outcomes in adults living in LMICs, providing overall support for the efficacy of non-pharmacological interventions. However, neither their review, nor the others we identified have specifically focused on older adults – a particularly vulnerable population group which has been affected to a great extent by the COVID-19 pandemic both in terms of their physical and mental health [15].

The aim of this mixed-method systematic review and meta-analysis was to explore the types, components, and efficacy of psychosocial community-based mental health interventions for older adults residing in LMIC. The meta-analysis specifically aimed to look at the most common type of mental health outcome, which is depression. With no existing review conducted on this topic to date, findings from this review can help identify best practices of effective global mental health interventions and their components, to develop and adapt them for older adults in different settings and contexts.

Methods

This mixed-method systematic review and meta-analysis was conducted adhering to the guidelines outlined by the PRISMA checklist. A prospective protocol was registered on PROSPERO [CRD42021271404]. Two unpaid carers were involved in interpreting the findings.

Study selection

Studies were eligible for inclusion if the intervention being evaluated was designed to improve the mental health and/or wellbeing of older adults aged 60 + years living in a low- and middle-income country as defined by World Bank at the time the review was conducted. The mental health promotion intervention considered in this review included but not limited to studies addressing levels and diagnoses of depression, anxiety, loneliness, social isolation, quality of life, social functioning, and mental well-being. For the purposes of this review, mental health and well-being interventions were defined as any psychosocial intervention that aims to improve the mental health or modify factors that are responsible for poor mental health. The intervention should focus on the prevention, promotion, and treatment of mental health and well-being. These included non-pharmacological, psychotherapy, and psychosocial interventions, but excluded pharmacological interventions. The quantitative outcomes considered in this review were indicators of negative mental health such as depression, anxiety, psychological distress, suicidal behaviour and positive mental health such as resilience, emotional wellbeing, and quality of life. Similarly, the qualitative outcomes considered in this review were facilitators, barriers and factors affecting the effectiveness of mental health interventions for older adults residing in LMICs.

For assessing the effectiveness of interventions and their core components, we included randomized controlled trials, cluster randomized controlled trials, and quasi-experimental study designs. For assessing the facilitators and barriers of interventions, we included qualitative study designs such as ethnography, phenomenological approaches, grounded theory studies and qualitative process evaluations.

Studies were excluded if they were: not published in a peer-reviewed journal; did not include data on older people aged 60 + years separately from others; published before 2000; published in languages other than English and Spanish; focused on physiological/pharmacological interventions or complementary/alternative medicinal procedures (e.g., acupressure or acupuncture); were not conducted in the community; were not conducted in an LMIC.

Searches and search strategy

We searched the following databases from January 2000 to the 5th of August 2021: Pubmed, CINAHL, Embase, PsycINFO, Scopus, and Web of Science. The detailed search strategy can be found in Additional file 1: Appendix 1.

Screening and selection

Titles and abstracts retrieved from the database searches were imported to EndNote and duplicate records were removed. At Stage 1, a study author (NS) assessed the remaining records against inclusion criteria by checking the title and abstract. A 10% random sample of papers were checked for appropriate inclusion/exclusion by another author (CG). At Stage 2, full text articles were sought for studies that were deemed suitable at Stage 1 and assessed against the inclusion criteria by NS and CG independently. Any discrepancy in the judgement between the authors were sorted by discussion. Reference list of included studies and similar review articles identified during screening were also screened to identify further studies for inclusion.

Quality assessments

The quality of included studies was rated by a study author (NS) for quantitative studies, and by a different study author for qualitative studies (CG). The Quality Assessment Tool for Quantitative Studies [16] was used to assess the quality of quantitative studies. The studies were rated overall strong when the study had no weak ratings for any domains, including study design, confounders, blinding, data collection methods, withdrawal and dropouts, intervention integrity and analysis appropriate to the question. Similarly, the studies were rated overall moderate with only one weak rating for the eight domains and weak rating when study had two or more weak ratings for two or more domains, or the study had a weak rating for the study design domain.

To assess the qualitative studies the Critical Appraisals Skills Programme (CASP) [17] tool was used. Quality assessments did not influence study selection but was used in guiding the discussion of findings and drawing conclusions.

Data extraction

Data were extracted using excel sheets designed to extract data from quantitative and qualitative studies separately. The data extracted from quantitative studies included study design, country undertaken, aims, studied outcomes, sample size, participant characteristics, and intervention characteristics. Means, standard deviations and sample sizes were extracted for the intervention and control groups. Similarly, for qualitative studies study objective, guiding framework, data collection and analysis methods and key themes were extracted.

Synthesis

This systematic review pooled the effect of different categories of psychosocial intervention on depression in older adults in a pairwise meta-analysis, with adequate data for other outcomes not available. One researcher extracted the data, which was discussed with all research team members. Studies were pooled under the following categories: Psychological therapy interventions (subcategories: Cognitive behaviour therapy, Reminiscence therapy and Other forms of therapy), Exercise interventions, Educational interventions, Social engagement interventions, and Multi-component interventions. Only randomised control trials (RCT), cluster randomised control trials (cRCT), and quasi experimental controlled designs were considered for estimating a pooled effect estimate. Post-intervention means and standard deviation for the longest follow up were used in calculating the pooled effect size using the generic inverse-variance method [18]. The studies were heterogenous in terms of intervention components and outcomes measurement, and therefore random‐effects model was used to calculate pooled effect sizes [19]. The pooled effect size in the meta-analyses was reported as standardised mean difference (SMD), as different instruments were used to assess depressive symptoms in the included studies. Three cluster‐RCTs in the meta-analysis that did not account for clustering in their results were adjusted, assuming a large intra‐cluster correlation coefficient of 0.10 [20]. For two studies that included two arms of the same study [21, 22] in the same meta-analysis, the number of participants in the control group was halved to avoid double counting [23]. The extent of heterogeneity was assessed using the I2 statistic with observed value 0%–40% judged likely not important; 30%–60% moderate heterogeneity; 50%–90% substantial heterogeneity; and 75%–100% judged considerable heterogeneity [24]. All statistical analysis were conducted using STATA (StataCorp LLC, USA).

Findings from qualitative studies were narratively synthesised for each respective intervention type.

Public involvement

Two unpaid carers from the UK were involved in interpreting the findings and in the dissemination. One was a former carer for her mother with dementia, and one was a current carer for her elderly mother with mental health issues. Both unpaid carers attended team meetings and read through the manuscript drafts. Both carers agreed with the interpretation of the findings, and thus ensured their real-life relevance to those with lived experiences.

Results

Overview of included studies

The searches yielded 24,378 citations, with 15,514 hits after duplicates and non-English records were removed. After Stage 1 screening, 95 articles were identified for full text screening. After Stage 2 screening, 40 studies from 46 papers met the inclusion criteria (see Table 1 and Fig. 1) and were included in this review. The studies were conducted in Bangladesh (n = 1), Brazil (n = 2), China (n = 9), Dominican Republic (n = 1), India (n = 4), Indonesia (n = 3), Iran (n = 6), Malaysia (n = 2), Mexico (n = 1), Philippines (n = 2), Thailand (n = 5) and Turkey (n = 4). The interrater agreement for Stage 1 and Stage 2 are 99.3% and 83.7%, respectively. Out of the 40 included studies, 16 were randomized controlled studies [8, 21, 22, 25,26,27,28,29,30,31,32,33,34,35,36,37], three cluster randomised control studies [38,39,40], 12 quasi experimental controlled studies [9, 10, 41,42,43,44,45,46,47,48,49,50] and five pre-test post-test studies [7, 51,52,53,54]. Three studies [55,56,57] were RCTs with an embedded qualitative study for the evaluation of intervention implementation. However, for one study, only the result of the qualitative part was available [56]. The final included study was a quasi-experimental controlled study with an embedded qualitative study for the evaluation of intervention implementation [58].

Table 1 Characteristics of included studies
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Fig. 1
figure 1

PRISMA Flowchart diagram of study selection

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The interventions were predominantly delivered by health or social care professionals (n = 11) [8, 9, 26, 30, 34, 40, 46,47,48,49,50, 53], trained lay volunteers (n = 5) [39, 54, 56, 57, 60] and research team members with a lack of qualification description [10, 21, 22, 25, 29, 31, 33, 35,36,37,38, 41, 45]. In the Carandang et al. [43] study, the intervention involved the older adults themselves participating in a volunteer activity (assist in behaviour change and engaging with community) whereas Borbon-Castro et al. [42] involved Higher Education students in physical activity and sport discipline. In the remaining studies, there were no information about who delivered the intervention [7, 27, 28, 32, 44, 51, 52, 58].

Twenty-six studies [7, 8, 10, 21, 22, 25, 26, 28, 29, 32,33,34,35, 38,39,40, 42, 43, 46,47,48,49, 51, 53, 55, 57] reported depression as an outcome variable. Other outcomes included anxiety [53], post-traumatic stress disorder [8], happiness [9, 34], life satisfaction [26], quality of life [41], stress [51], mental health status [49], loneliness [36], resilience [43] and social support [9].

Quality of assessed studies

Figures 2 and 3 provide an overview of the summary ratings for each risk of bias item. Of the quantitative studies, overall, six studies were rated strong [8, 25, 38, 39, 46, 55], 16 studies [9, 21, 22, 28, 30,31,32, 34,35,36,37, 40, 42, 47, 50, 57] were rated moderate, and 17 studies [7, 10, 26, 27, 29, 33, 41, 43,44,45, 48, 49, 51,52,53,54, 58] rated weak. Twenty studies reported similarity in comparison groups at baseline and were rated strong for confounders domain. Data collection methods, withdrawal and dropouts and intervention integrity were reported appropriately in most of the studies and were therefore rated strong for these domains. Regarding the four qualitative studies (see Table 2), ethics were missing for some, and limited learning was suggested.

Fig. 2
figure 2

Component ratings about each component of quality assessment tool presented as percentages across all included studies

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Fig. 3
figure 3

Study quality rating of each component of each study

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Table 2 Risk of bias ratings for qualitative studies using the Critical Appraisal Skills Programme (CASP) for Qualitative Studies
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Groupings of interventions

We categorised the 40 included studies into the following categories (and sub-categories) (see Table 1): (1) Therapy interventions (Sub-categories: Established forms of short-term therapy, Other forms of therapy); (2) Exercise interventions (Sub-categories: Muscle strengthening, Relaxation exercise); (3) Educational interventions; (4) Social engagement interventions; (5) Multi-component. Some interventions could be fitted under two categories, with some interventions also being multi-component. Figure 4 shows the Forrest plot of studies including data on outcomes of levels of depressive symptomatology.

Fig. 4
figure 4

Forrest Plot of studies including data on outcomes of levels of depressive symptomatology. Legend. Two comparisons from RCTs [Ansai and Reblatto (2015) and Moares et al. (2020)] with three treatment arms have been included under the category exercise interventions. The number of participants in the control group in these comparisons has been halved so as to avoid double counting. Black boxes represent the effect estimates (standardised mean difference), and the horizontal bars are for the 95% confidence intervals (CIs). The diamond is for the pooled effect estimate and 95% CI and the dotted vertical line centered on the diamond has been added to assist visual interpretation

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Psychological therapy interventions

Established forms of therapy

Eleven studies evaluated the effectiveness of established forms of therapy interventions, including cognitive behavioural therapy [8, 34, 46, 57] and reminiscence therapy [7, 30, 36, 40, 47, 48, 58]. Cognitive behaviour therapy (CBT) was delivered by trained therapist [8, 34], trained health care workers [57] and a team comprising of trained healthcare workers and trained volunteers [46]. In one study [8], the focus of CBT was trauma due to recent earthquake, in another study the CBT was tailored to local context such as encouraging to visit the temple regularly [57]. Two studies focused on the behavioural activation component of CBT [34, 46], where participants were encouraged to engage in activities that they enjoyed. The participants themselves selected and planned their activities for the duration of intervention.

Similarly, reminiscence therapy aimed to restore beliefs and acquire coping skills among older adults by recalling past events and memories. All studies implemented reminiscence therapy in groups and one study based reminiscence therapy on traditional festivals [36]. Some studies combined reminiscence therapy with other interventions like exercise [36] and psychoeducation [47]. Two studies were rated strong, six studies moderate, and three studies weak.

Xie et al. [34] reported reductions in anxiety scores following behaviour activation. However, another study [46] reported reduction in anxiety scores at 3-month follow-up statistically significant improvement was not sustained at 6-months follow-up. Similarly, CBT did not have a significant effect on anxiety scores [57]. The studies reported reduction in PTSD scores [8], improvement in happiness scores [34], reduction in stress and loneliness [30, 36], improvement in resilience score [36] and mixed results for life satisfaction [48, 58] and quality of life scores [8, 57] with one study showing improvement and others showing no significant effect.

The pooled estimate of three studies [40, 47, 48] showed a moderate to large reduction in depression scores in older adults following reminiscence therapy (SMD -0.94, 95% CI -1.53 to -0.35, I2 = 79.1%) with considerable heterogeneity. Of the remaining studies, one study [7] reported depression as an outcome. This study also reported a significant reduction in depression scores in older adults following reminiscence therapy. The pooled analysis of four studies assessing cognitive behaviour therapy showed a nonsignificant reduction in depression scores following intervention (SMD -0.96, 95% CI -1.61 to 0.31, I2 = 85.4%) with considerable heterogeneity.

Qualitative findings showed that older adults experienced reminiscence therapy to add a new perspective to their past experiences, strengthened their social connectedness and provided psychological support [58]. In another study [57, 59], facilitators to delivering a CBT intervention by village doctors included previous knowledge of mental health issues, policy alliance, instruction manuals and traning in CBT techniques. Busy schedules and lack of comptency in delivering the intervention were reported to be barriers.

Other forms of therapy

Seven studies evaluated the effectiveness of other forms of therapy interventions, including music therapy [51], progressive muscle relaxation [29], problem solving therapy [55], psychosocial care [52], laughter therapy [28, 33], and peer counselling [43].

Problem solving therapy was delivered by trained lay counsellors in depression in later life [55, 61]. Participants in the study received instructions for management of their chronic conditions, encouraged to access health care services and assist in obtaining available resources [55]. Similarly, peer counselling was delivered by volunteers trained to interact with older adults, identify their problems and encourage them to adopt healthy lifestyle [43]. Laughter therapy was delivered as an integrated intervention of laughter exercise, breathing exercise and physical exercise [28, 33]. One study was rated strong, one moderate and five studies weak.

Studies reported improvement in life satisfaction [33], improvement in quality of life [52], resilience [43], social support [43] and mixed results for loneliness with one study showing improvement in loneliness score [52] and other study showing no effect [43]. The pooled estimate of five studies [28, 29, 33, 43, 55] showed a small to moderate reduction in depression scores in older adults following other forms of therapy (SMD -0.48, 95% CI -0.72 to -0.24, I2 = 31.6%) with likely no important heterogeneity. Only one study [52] reported depression as an outcome, but demonstrated no significant reduction in depression at post intervention follow up.

Qualitative findings from one study [55, 61] reported that older adults enjoyed the intervention as it provided them with the opportunity to share their feelings, which helped coping with loneliness and isolation.

Exercise interventions

Eleven studies evaluated the effectiveness of exercise interventions. These included aerobic exercises [21, 22, 32, 33, 42], muscle strengthening exercise [21, 22, 26, 35, 41, 42, 53] and yoga [31]. Aerobic exercises included exercise on stationary bikes [21, 22] or treadmills [22], walking [32, 42], jogging [53] and stretching [53]. Similarly, muscle strengthening exercise included weightlifting [21, 22], resistance training [21, 42], self-loading [42], physical fitness training [26] Chinese gymnastics and ballroom dancing [35]. Only one study [53] used a virtual medium and video recording to deliver the exercise intervention to older adults. Seven studies were rated as moderate, and four studies as weak. Studies reported improvement in quality of life [41], no effect on anxiety [53] and mixed results for life satisfaction scores with one study reporting improvement [26] but the other study reported no effect [33].

Six studies [21, 22, 26, 33, 35, 42] reported data that could be pooled in a meta-analysis. The pooled estimate of six studies showed a moderate to large reduction in depression scores in older adults following exercise intervention (SMD -0.96, 95% CI -1.49 to -0.44, I2 = 74.9%) with substantial heterogeneity. Out of the remaining studies three studies that reported depression as an outcome [32, 41, 53], two studies [32, 41] reported significant reduction in depression scores following the exercise intervention. However, one study [53] reported non-significant effect of exercise intervention on depression scores.

Educational interventions

Three studies evaluated the effectiveness of educational interventions, including educational training sessions [9, 49] and health promotion programs [10]. Studies used various techniques to provide skills and knowledge to older adults such as lectures/presentation [9, 49], printed material [9, 49], training [10, 49], self-study [49], and discussion [9, 49]. These interventions covered a range of topics including basic knowledge about mental health, exercise, healthy diet, sleep hygiene and emotion regulation [9, 10, 49]. One study was rated moderate, and two studies were rated weak. Reported outcomes covered improvement in happiness [9], social support [9], mental health status [49] and quality of life [10] scores. Pooled analysis of two studies [10, 49] showed a non-significant reduction of depression scores following education interventions (SMD -0.57, 95% CI -2.31 to 1.17, I2 = 98.1%) with considerable heterogeneity.

Social engagement interventions

Six studies evaluated the effectiveness of social engagement interventions, including intergenerational programmes [27, 38, 39], community-based day care [44], home visits by trained local volunteers [54] and social engagement groups [43]. Intergenerational programmes engaged older adults with younger generations in activities to facilitate physical activity and social connectedness among older adults [27, 38, 39]. Similar objectives were also incorporated in a community-based day care intervention that offered activities such as leisure exercise, counselling, medical services, and lunch [44]. Two studies were rated strong, and four studies were rated weak.

The studies reported improvement in quality of life [27, 39, 44], loneliness [43], resilience [43], social support [43] but no effect on life satisfaction scores [54]. The pooled estimate of three studies [38, 39, 43] showed a moderate to large reduction in depression scores in older adults following social engagement interventions (SMD -1.42, 95% CI -2.43 to -0.42, I2 = 85.4%) with substantial heterogeneity.

Multicomponent interventions

Seven studies evaluated the effectiveness of multicomponent interventions, involving for example peer counselling plus social engagement groups [43], intergenerational programs plus aerobic exercise [27], exercise combined with dietary counselling and social engagement [45]. One study was rated strong, two studies moderate, three studies weak, and one study was assessed only for a qualitative section. The studies reported improvement in life satisfaction [25], quality of life [27, 37, 45] anxiety [50] resilience [43], social support [43] but no improvement in loneliness [43] scores.

The pooled estimate of two studies [25, 43] showed a moderate to large reduction in depression scores in older adults following multicomponent intervention (SMD -1.25, 95% CI -1.78 to -0.71, I2 = 71.2%) with substantial heterogeneity. Findings from the qualitative section of a single study [56] reported health care providers approved the multidisciplinary team-based approach comprising village doctors, ageing workers, and psychiatrists for providing integrated health care including promotion of mental health. The intervention was also favoured by health care providers as it could be easily integrated into their existing practices.

Discussion

This is the first systematic review and meta-analysis to explore the different types, components, and effects of community-based psychosocial interventions for older adults living in LMICs. With older adults one of the fastest growing population groups globally [6], adequate support needs to be in place not only for their physical health, but also for their mental health and well-being. Across 12 different countries, five types of interventions with varied degrees of effectiveness emerged, including established forms of therapies such as reminiscence therapy, exercise interventions, educational interventions, those focusing on social engagement, as well as multi-component interventions. There was substantial heterogeneity in all the pooled effect estimates except for other forms of therapy. However, we could not investigate the heterogeneity with subgroup or meta regression due to small number of studies in each meta-analysis. The other forms of therapy resulted in small to moderate reduction in depression scores (SMD -0.48, 95% CI -0.72 to -0.24) in older adults. In an era of an ongoing pandemic, affecting people’s mental health across the globe [65], these different types of interventions may provide some ways to alleviate older adults’ poor mental health, if adequately tailored to their needs.

The included studies illustrate not only different types and components of interventions, but also different approaches to their delivery. Interventions were provided one-on-one or in group settings, with older adults meeting in different settings to receive the intervention, including the Office for Senior Citizens Affairs [43], at their homes [38], or welfare centres [28]. The way in which an intervention is delivered can affect the level of adherence or enrolment with some preferring group settings and the additional social aspect and others individual engagement. The provider of the intervention also varied, ranging from different types of professionals to volunteers. These variations in intervention mechanisms (type, components, delivery) make it difficult to directly compare interventions. Moreover, the varied contextual factors (cultural, geographical, and population) create further barriers for direct comparison. However, as shown, there are some types of interventions which can be categorised despite these differences, providing an overview of existing psychosocial interventions for older adults in LMICs, and highlighting different approaches in conducting these interventions.

Overall, the majority of interventions were found to be initially effective, with 14 studies being RCTs, although these effects were not always maintained at follow-up, however more rapid recovery is important to people with problems and their close associates. Where improvements in mental health or quality of life or reductions in loneliness were found, some differences were statistically significant, but not all. With depression being the most commonly reported outcome measure, exercise and social engagement indicated greater reductions in depressive symptoms in treatment groups [22, 43] as opposed to established forms of therapies or education for example [10, 46]. However, this conclusion is tempered given the varied tools used to measure depressive symptoms. These outcomes were not able to be assessed via the same quantitative approach in our meta-analysis however due to limitations among reported outcomes and inconsistent use of established outcome measures. Considering the population participating in these interventions are older adults residing in a variety of LMIC, it is unsurprising to find varied outcome measures, with some tools being culturally adapted and validated in some countries but not others. This reflects the imperative that such interventions need to be adapted to the cultural and population contexts, and may require different outcome measures or forms of evaluations than standardised tools to fully capture the effects of receiving an educational or exercise intervention for example. Whilst this increases local study validity and reliability, it does limit the potential for detailed quantitative cross-country comparisons.

Whilst some interventions were delivered one-on-one and others in group settings, improved well-being and mental health are linked to socialising with others [66] so that even one-on-one interventions consider widening and strengthening a person’s social circle. Interventions specifically focusing on social engagement reported reductions in loneliness and improvements in social support, quality of life, and resilience. One of the two most effective interventions in reducing depression, based on the meta-analysis, was a study on social engagement by Aekwarangkoon et al. [38]. Considering the relationship between loneliness and social isolation and poor mental health [67], which is of particular concern in many older adults who are living alone given its frequency and links to cognitive deteriorations [68], social engagement-focused interventions appear to be an important way of supporting older adults’ mental health and well-being. An additional benefit of these types of interventions is that they outlast the intervention delivery time, by enabling social networks which can be drawn upon and integrated into a person’s everyday life subsequently. This is particularly pertinent to these geographical and cultural contexts as mental health support in general is sparse and difficult to access, if not prohibited by stigma [69], so that easily achievable changes to people’s daily lives which do not specifically label attendees with mental health may be more suitable. In contrast, time-limited interventions such as CBT and reminiscence therapy may have a time-restricted impact, so that future research should follow up participants of social interventions for longer and establish the potential long-term integration and influence of the initial intervention into their daily lives.

Limitations

Concerning the limitations of included studies, many reported only limited methodological details about the interventions and population contexts, making it more difficult to compare findings. This is reflected in the low-quality ratings. Moreover, studies used different outcomes and outcome measures, further enhancing the complexity of comparing intervention results.

Concerning the review and meta-analysis, there are some limitations to consider. Whilst studies emerged from 12 LMIC and from across different geographical regions, and overall included a large number of reported interventions, findings indicate how different older adult populations have been supported by interventions for mental health and well-being in different contexts without being widely representative of all LMIC. Even with countries that reported an intervention, there are variations within countries, so that an intervention reported from the North of India for example may not be as relevant, acceptable and/or effective if it had been conducted in the South. This is not surprising as cultural, socio-economic, and other differences may be considerable across large populations in different areas. It is a deficit of such research to make assumptions that coalesce very different communities within a summarised country commentary [70], and suggests that interventions need to be adapted to localised contexts. Based on these variations in types of interventions and contexts, we were only able to conduct a meta-analysis on depression and no other outcome measures such as anxiety or quality of life. For multi-centre interventions to be comparable, the same outcome measures, linguistically and culturally adapted to the localised population, need to be employed to make more valid comparisons between intervention effects.

Conclusions

Psychosocial interventions for older adults living in LMIC are highly varied and have different levels of efficacy. Interventions may provide specific elements which can be adapted, depending on the different needs and local contexts of the relevant populations. These different intervention types and their components can form the foundation and provide a menu for the development or adaptation of different psychosocial community-based interventions supporting underserved older adult populations in LMIC. In the ongoing pandemic and increased mental health problems in the general population and older adults, including in LMIC [65], developing and implementing sustainable and effective psychosocial interventions to support good mental health are ever more important. To ensure improved comparability across interventions, there is a need for multi-country and -setting comparisons using the same outcome measures, as well as longer follow-up times beyond the lifespans of interventions.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

LMIC:

Lower- and middle-income countries

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Acknowledgements

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Funding

The support of the Economic and Social Research Council (ESRC) is gratefully acknowledged. This project is co-financed with funds from the PATRIMONIO AUTÓNOMO FONDO NACIONAL DE FINANCIAMIENTO PARA LA CIENCIA, LA TECNOLOGÍA Y LA INNOVACIÓN FRANCISCO JOSÉ DE CALDAS of the Ministry of Science, Technology and Innovation of Colombia (Contract 867–2020 / Project Code 115–884 -80644). This is also independent research funded by the National Institute for Health Research Applied Research Collaboration North West Coast (ARC NWC). The views expressed in this publication are those of the author(s) and not necessarily those of the National Institute for Health Research or the Department of Health and Social Care.

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Authors and Affiliations

  1. Department of Primary Care & Mental Health, University of Liverpool, Liverpool, UK

    Clarissa Giebel & Mark Gabbay

  2. NIHR ARC NWC, Liverpool, UK

    Clarissa Giebel, Ginger Liu, Dawn Allen & Mark Gabbay

  3. NHMRC Clinical Trials Center, University of Sydney, Sydney, Australia

    Nipun Shrestha

  4. Centre for Applied Dementia Studies, Bradford University, Bradford, UK

    Siobhan Reilly

  5. School of Psychology, Queen’s University Belfast, Belfast, UK

    Ross G. White

  6. National Faculty of Public Health, Universidad de Antioquia, Medellín, Colombia

    Maria Isabel Zuluaga & Gabriel Saldarriaga

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Contributions

CG, MG, IMZ, SR, GS, DA, GL, and RW conceptualised the systematic review. CG led and oversaw the review, rating citations at Stage 1 and Stage 2 of the inclusion stages, quality rating the qualitative studies, and drafting the overall manuscript. NS conducted the searches, rating citations at Stage 1 and 2 of the inclusion stages, extracted data, quality rated quantitative studies, and conducted the meta-analysis. All authors, MG, IMZ, SR, DA, GL, GS, RW, and NS, approved the final manuscript drafted by CG.

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Correspondence to Clarissa Giebel.

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Giebel, C., Shrestha, N., Reilly, S. et al. Community-based mental health and well-being interventions for older adults in low- and middle-income countries: a systematic review and meta-analysis. BMC Geriatr 22, 773 (2022). https://doi.org/10.1186/s12877-022-03453-1

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BMC Geriatrics

ISSN: 1471-2318

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