Raymond Aborigo, PhD, right, briefs one of our community health nurses on our mental health/high blood pressure care plan.

Every May, as we recognize Mental Health Awareness month, the global implications of ignoring mental well-being continue to grow.  As early as 1953, the head of the World Health Organization declared that “without mental health there can be no physical health.” Vikram Patel, a psychiatrist who transformed global mental health by demonstrating that even lay people can provide effective therapy for depression and anxiety, said the same 15 years ago.

In the intervening decades, we have learned ever more about how depression and isolation make cardiovascular and other chronic disease worse—and, conversely, how those chronic illnesses can worsen mental health. The United States Surgeon General, for example, has declared that loneliness is therefore now a public health crisis.

But worldwide, due to a shortage of health workers, funding, and political will, we remain far from interrupting this vicious cycle.

Globally, depression is the leading cause of disability, whereas cardiovascular disease is the leading cause of death—so the two go hand in hand. Some four to six percent of the world lives with depression, and as many as 30 percent of adults live with high blood pressure and other heart diseases.

There is some good news, however: We know that simple behavior counseling can treat both diseases and others—not just one at a time, but together. For example, behavioral activation therapy for depression, pioneered by Dr. Patel and others, can also treat tobacco, alcohol, and other substance misuse—a major risk factor for heart and lung disease, cancer, and countless other chronic diseases. Conversely, motivational interviewing, another simple peer-counseling technique, can help those with chronic illness to stick to their medications, and enhance the impact of behavioral activation on depression.

In partnership with our colleagues at the Navrongo Health Research Centre in Ghana, we therefore developed and piloted a program—called COMBINE—in which community volunteers provide a single counseling intervention to persons living with depression or high blood pressure.

Combining behavioral activation and motivational interviewing, this home visit initiative offers strategies for improving mood, embracing healthy activities, and taking medication daily. Nurses and physician assistants support participants by providing primary care at clinics within walking distance. After 90 days, 93 percent of participants remained in the program, and 97 percent of them achieved control of their condition. In time, we aim to expand this program to include persons with other chronic conditions, like diabetes or asthma.

We hope to ensure that all persons with chronic disease have access to mental health counseling, regardless of depression or other mental health diagnosis—and that those living with mental illness can learn how physical exercise and other healthy actions can help improve mental health.

Despite the practical benefits of integrating mental health into chronic disease care, these care models remain underfunded and underused. Yet as more research shows how and why such programs work, we now have a playbook for how to change that. The road map includes using evidence-based treatments; reducing mental health stigma through community outreach; creating effective but simple measures to track patient progress; and recruiting respected community members to deliver care. Implementing these seemingly simple components requires ongoing efforts from national policymakers and local leaders.

The details will differ across communities, but the strategy grows clearer yearly even as the need for action expands in tandem. Mental health care is an ever-bigger part of health than we realized—but with timely action rooted in health research, that means it can also be a central tool in achieving primary care for all.

Evan Alvarez, MA, MS, is a Program Coordinator with the Arnhold Institute for Global Health and the Department for Global Health and Health System Design at the Icahn School of Medicine at Mount Sinai.

David Heller, MD, MPH, is an Assistant Professor at the Arnhold Institute for Global Health and the Department for Global Health and Health System Design and co-director of the Arnhold Institute’s global partnership in Ghana.

Imagine you’re a young person who left or was forced out of your family home due to factors such as abject poverty, violence and abuse, or family conflict. With limited education, a lack of an extended family to turn to, and minimal resources, you find yourself turning to the streets for survival.

This is often the case of young people who find themselves in street situations in Kenya. Once on the streets, young people’s vulnerability to acquiring HIV is elevated due to a lack of safe and adequate housing, violence, and limited opportunities for employment and income generation resulting in many young people, particularly adolescent girls and young women, relying on selling or exchanging sex for money, food, shelter, or other material resources. At the same time, street-connected young people’s ability to access and use health services is extremely restricted owing to their stigmatized identity, lack of health insurance, and other barriers to accessing care.

Evidence demonstrates that the burden of HIV among street-connected young people in Kenya is high. At the same time, these young people face several hurdles to accessing HIV testing and knowing their HIV status and being connected to and remaining engaged in HIV care.

Peer navigators are young people with lived experience on the streets, who are well known by the street community. Peer navigators, as the name suggests, help young people in street situations navigate and gain entry to the health system, by removing many of the barriers that prevent this stigmatized group from accessing care. The peer navigators work to engage street-connected young people in HIV testing and counseling, while providing HIV prevention information and other HIV-related support.

Evans is one of the founders of the adolescent peer mentor program at the MTRH-Rafiki Centre for Excellence in Adolescent Health at AMPATH.

Evans, a young man with experience living and working on the streets, is one of the founders of the adolescent peer mentor program at the MTRH-Rafiki Centre for Excellence in Adolescent Health at AMPATH. He did a three-year term as one of the first peer mentors (peer mentors are based at the clinic versus peer navigators who tend to work out in the community).

Now he is a staunch advocate for children, youth, and families in street situations in Eldoret. He is also an aspiring politician and a volunteer program manager at Inuka Pamoja, which is a community-based organization that provides financial and other support to children and adolescents to help them remain in school.  He sat down with Lonnie Embleton PhD, MPH, an Adolescent Health Advisor and Assistant Professor, Department of Global Health and Health Systems Design, to discuss his passion for getting street-connected young people into care, the psychological hardship and support needed for peers who deal with difficult circumstances, and his hopes for adolescents and young people in Kenya.

 What does the day in the life of a peer mentor or navigator look like?

Peer mentors act as a bridge between the clients who are coming to MTRH or AMPATH and their clinicians, and give them a voice; they act as a support system for young people with whom they have shared experiences.

There was once a young man who had a problem with taking medication; this had created viral resistance and he was on third-line antiretroviral therapy. He was chased away by family due to stigma, so I came in to help. I discussed his situation with stakeholders, a counseling team, and went to visit the home. The family members didn’t want to be with him, but the boy is now healthy, well, and in school. As a peer mentor, I was able to help link him to the right people; because I had a good rapport with him, I was able to create a trusted environment, and link him to the best professionals who can help him.

How has being a peer mentor changed your life?

Being a peer mentor impacted my life in a very big way. It was my first job, and with the salary I was given I could pay my bills. I gained a lot of experience in how to handle youth and received AMPATH training. The peer mentorship program helped me a lot, and I’m still using the lessons I learned now in life.

Can you tell us more about what you do now?

Currently, I am a volunteer program manager at Inuka Pamoja, and an active aspiring politician. I’m trying to get a breakthrough in life. I joined politics because for people to listen to you in Kenya, you have to be in politics. Then, you meet a lot of people who are connected, and have a bigger voice on how better to help young people in street situations. I wanted to introduce a bill to parliament to help children and youth in the slums and on the streets in Eldoret. I ask myself, how can we help the less fortunate people in the community?  Most are coming from Eldoret informal settlements—Langas, Kamukunji, Mali Nne, and Huruma.

What is one thing that you wish people knew about the role of youth peer mentors?

I really need people to understand that peer mentors are doing very tough work, and people should know that they go through psychological problems, dealing with clients with serious issues. They need and must be offered psychological support. Dealing with street children every day, I don’t go home okay. It can drain you—peer mentors need support and care to deal with what they see. Peer mentors are not paid enough, and are doing very important work.

What are some of the challenges young people face you work with?

Children, youth, and street families need care. For example, the two peer navigators that work at the Rafiki clinic and in the community hold medications for adolescents that live on the street to come and take every day. But often adolescents do not want to be seen at the Rafiki clinic because of stigma, so they do not take their meds. Many of the children and youth in street situations who are on medications have changed their drug regimen, often because of poor adherence and viral resistance. This is a huge issue in these communities. The location they go to take their HIV medicine is an issue because of stigma, and most of the street-connected young people on medication lack access to basic needs, which affects treatment adherence as well. For me, I didn’t take my drugs because I didn’t have food or somewhere to stay when I lived on the street. Then, the drugs interfered with my body. Something that is really important is mass testing in the streets–many people are still infecting others because they don’t know their status.

What motivated you as a peer mentor? What was your favorite thing about working as a peer mentor?

My initial motivation was poverty. I went to the Rafiki clinic to look for a job and earn a living. Looking back to the life I had when I was taking medication and living on the street, I had a very hard time with it. I got a lot of support, and I wanted to pass that support onto someone else. People with HIV can live when they take their medications. My life and experiences encouraged me and inspired me. My favorite part about working as a peer mentor was that I could learn something new every day! I was always learning new things, I got to interact with so many different people.

How would you describe yourself?

I’m a go-getter, and I love pushing things to move. I’m an honest and straightforward guy, and sometimes I get angry when things are not right.

What do you want the world to know about young people and young people in Kenya?

I want the world to know that adolescents are a part of the population that people forget about, a lot. Something more needs to be done about adolescent care in Kenya, because we are not doing much for them, and it’s a critical age.

If you had three wishes, what would they be?

My current wish is about children, youth, and families in street situations who are on medication: I hope the HIV prevalence among them can reduce. I wish that people in street situations who are on HIV medication and who cannot afford a meal, can be given a meal a day and given their medication. I wish for them to have the opportunity to enroll in training and financial literacy classes.

Lonnie Embleton, PhD, MPH, is an Adolescent Health Advisor and Assistant Professor, Department of Global Health and Health System Design.

Ava Boal is an Associate Researcher.

Peers play a critical role in supporting young people living with HIV as they navigate the HIV care continuum. Peer mentors, educators, or navigators, are young people of a similar age with shared lived experiences, such as being HIV positive, pregnant during adolescence, and/or being street-connected. Oftentimes the age gap, stigma, or embarrassment prevents adolescents from communicating their needs and concerns with health care providers. Adolescents can communicate candidly and honestly with a peer navigator, who can then help the adolescent get the care and services they need.

The MTRH-Rafiki Centre for Excellence in Adolescent Health, has four peer mentors dedicated to adolescents living with HIV, and two peer navigators dedicated to engaging street-connected young people in HIV prevention and care. Together, these peers work with more than 800 adolescents in the clinic, as well as in the community to conduct home visits to find clients who have missed an appointment. Not only do the peer mentors and navigators improve patient care and drug adherence, but they also create a sense of camaraderie among adolescents attending the clinic and provide a friendly face and safe environment for patients to voice what is going on in their lives without fear of judgment.

Rodney, a peer mentor who has worked at the Rafiki Centre.

In the first of our monthly Peer Spotlight Series, Lonnie Embleton, PhD, MPH, Assistant Professor and Adolescent Health Advisor at the Arnhold Institute for Global Health at Mount Sinai, interviews Rodney, a peer mentor who has worked at the Rafiki Centre for two years. They discuss the role of peer mentors in patient care, both physical and emotional, and the impact that being a peer mentor has had on Rodney’s life. Rodney also illustrates the challenges of being a peer mentor, and talks about what support he and his co-workers need. Peer mentors have an immense positive impact on their adolescent patients, but require support themselves; they are also young adults who have faced adverse experiences and are emotionally affected by the difficult subjects they encounter daily.

Can you tell me about what a peer mentor does and your role at Rafiki and AMPATH as a young person? 

As a peer mentor, I talk to clients and bond with them, and when they have an issue that they feel they can’t share with their care worker, they can share it with me. If they don’t want to see someone at the facility, they can make arrangements to see someone locally, and they’ll come for the visit. I can also act as a link between the adolescent client and their parent or caregiver, who they may fear.

Is it hard to talk to the parents? What do you do if this is the case?

Yes, sometimes the parents are very harsh. If so, we refer them to the psychologist, so the psychologist can talk them down.

How did you become a peer mentor?

I was also a patient at Rafiki, and when I became 24, I transitioned to the adult program. They said I might be a good example, so they took me in at Rafiki to become a peer mentor, and I liked the idea. I studied IT, but there are no jobs available, so I am doing the peer mentorship program. If I could get an IT job, I would take it. It is very hard for young people to find jobs, especially without connections or money. We have to go for casual jobs, which are very easy to find but tiresome; someone offers you a job that’s very hard, but pays very little.

What does it mean to be an adolescent/youth peer mentor in Kenya?

Being a peer mentor means I can help people. For example, we had a client, she had lost her home. She brews the local brew and would sell it during breakfast, so she had to skip medications. I helped advise her, and find her something else to do; like a shamba– plant, sell, and earn some money. Now she is doing well, and takes her medications.

Was it hard to become a peer mentor during the pandemic?

Yes, it was. Many people feared the hospital, and we lost many clients to follow-up; we had to visit them in their homes. It’s a challenge when you visit someone, these people [referring to health care providers/ administrators] are sure that if you take a matatu [public minibus], that you will alight at the client’s home. Instead, it is that you alight and then you will take a motorbike and go many kilometers into the village—it is hard to tell the organization and leadership that it is that far. It is sometimes difficult to express to the organization and leaders how hard the job is.

What does a day in the life of a peer mentor working with adolescents living with HIV look like?

When I get to Rafiki, I call clients who have an appointment (prior calling). Then I call those who missed their appointments (defaulter) and find out why they didn’t make it to the clinic and when they are available to reschedule. We also engage adolescents in indoor games like table tennis, although I am still learning how to play! Outside we play football; we have a team that trains from 4 to 6 pm. These activities help to remove the stigma. Rafiki is Rafiki to them, and everyone is friendly. It removes the “I am sick” status.

How has being a peer mentor changed your life?

It has changed my life, and I have lived a positive life. If I can encourage a positive life in the adolescents, and be an example of one, the adolescent will change as well. I gain experience day in and day out. Also, in calling the clients, I speak to parents sometimes; the experience has taught me how to communicate well with parents. I introduce myself: “I am Rodney from Rafiki, I am informing someone about their clinic appointment,” and the parent is thankful.

What is one thing that you wish people knew about the role of youth peer mentors?

They should know that the client trusts the peer mentor, and what peer mentors convey is directly from the client. That we play a very important role in the health care team.

What are some of the challenges young people you work with face? 

The adolescents I work with experience fear, stigma, and challenges with getting to the clinic, stress, and peer pressure. They live with their caregivers, and they fear bothering their caregivers for their meals and for help. Another challenge they face is distance to the clinic. When they arrive, they say, “I don’t have a fare to get here.” However, they can go to the social worker, and the social worker can help with their transport fees.

Also, drug and substance abuse occurs. It is very hard for adolescents to talk about it with anyone, but if we approach them in the right way then they do. Some of them drink alcohol, not because they like it, but to relieve their stress. Others drink or do drugs due to peer pressure. Today, I had a patient who was released from prison yesterday.

When in prison do patients experience a disruption of their drug regimen?

Yes, they are disrupted. When they get out, they have to start ART (antiretroviral therapy) again. They have to come into the clinic more, and do viral load testing.

What are some of the challenges of being a peer mentor?

The pay is little, and we need more support as peer mentors. We want to learn and gain more skills in the role as we try to find another job.

What motivates you as a peer mentor? What is your favorite part of working as a peer mentor?

I am motivated by seeing clients very happy as they leave the clinic, and clients doing well. They greet me and tell me I have helped them. My favorite part of working as a peer mentor is visiting someone in their home. I like adventure, and during home visits I get to go visit people in rural areas to find out how they are doing. When you go to their home, you can see if they have trouble out there, and you can say, “yes you really do” (maybe the roads are bad etc.)

Outside of being a peer mentor what else do you like to do for fun?

I like to cook. I cook ugali [corn meal] and chapati [flat bread].

What are words that best describe you? 

Laughing. Adventurous.

What do you want the world to know about young people and young people in Kenya?

That they have their own way to express their feelings. Young people are a very different group. They cannot express themselves like adults, and will only express their feelings to people they can trust. This is why peer mentors and navigators are so important.

If you had three wishes, what would they be?

A permanent job. A happy family. And have my own plot.

Lonnie Embleton, PhD, MPH, is an Adolescent Health Advisor and Assistant Professor, Department of Global Health and Health System Design.

Ava Boal is an Associate Researcher.

David Heller, MD, right, demonstrates blood pressure screening on Raymond Aborigo, PhD, for nursing students in Navrongo, Ghana.

Every year, the month of February is American Heart Month, a campaign to raise awareness of cardiovascular disease as the leading cause of death in the United States during a Valentine’s Day season associated with hearts and all things red. But this risk does not end in March or April—nor does it heed national borders. Diseases of the heart and blood vessels—which include not just heart attacks but also strokes— are the single leading cause of death worldwide. And the single leading risk factor for early death is high blood pressure.

The good news is that most heart disease is preventable. And even better news: You don’t need a physician to prevent heart disease. A few changes in behavior can greatly decrease risk of disease: A diet rich in fruits and vegetables, regular physical exercise, avoidance of tobacco, reduction of alcohol, and management of stress and depression. Research from around the world shows that nurses, pharmacists, and even volunteers can provide peer coaching and support to help persons at risk of heart disease to make these changes.

David Heller, MD

Unfortunately, this type of peer support is not available everywhere, either in the United States or the world. Raymond Aborigo, PhD, and I are researching care models to change that. Dr. Aborigo is Deputy Chief Health Research Officer at the Navrongo Health Research Centre (NHRC) in Ghana—a country with a massive and rising burden of heart disease, especially in recent years as diets and lifestyles have changed. With our teams at NHRC and Mount Sinai, we are exploring how best to train and equip Ghana’s health workers to treat and prevent the root causes of heart diseases through behavior change.

Ghana has a secret weapon: A nationwide rural health program that sends nurses and health volunteers door-to-door to counsel on healthy behaviors, offer basic health interventions like childhood vaccines, and link communities to essential medical care such as safe labor and delivery. This program, the Community-Based Health Planning and Services (CHPS) initiative, cut in half the number of children in Ghana dying before age 5.

Our research partnership trained the nurses of CHPS to provide door-to-door screening for two of the largest treatable risk factors for heart disease: high blood pressure and depression. We trained these nurses to treat these two conditions with medication at clinics within walking distance, and taught CHPS volunteers to visit patients at their homes weekly—offering advice on how to remember to take these medications, how to improve low mood, and other healthy habits like quitting tobacco and cutting back on salt. The team is supervised remotely by physician assistants and an on-call doctor, but nurses provide all clinical care.

In our pilot work to date, 93 percent of persons diagnosed completed our 90-day program, and 97 percent of them achieved the goal of normal blood pressure or improved depression score. We now want to scale up this program from four clinics to 20—and to adjust our care model to be as effective and easy to use for both CHPS staff members and patients alike. And because these healthy habits—including taking your medicines daily—can treat and prevent many other common chronic diseases such as diabetes and asthma, we hope to expand the model to bring comprehensive basic primary care to the people of northern Ghana and beyond.

Keeping a healthy heart is not just a one-month affair, and chronic health conditions like heart attacks cause 74 percent of all deaths worldwide. We hope to build a care model to help all people worldwide to access medications and support to prevent and control conditions like heart disease.

David Heller, MD, is an Assistant Professor at the Arnhold Institute for Global Health and the Department for Global Health and Health System Design at the Icahn School of Medicine at Mount Sinai and a practicing general internist.

Author Rose House, MD, MS, seated left, with the first class of EM Fellows in Nepal in 2014. She now works with Roshana Shrestha, MD, seated to her right, training the next generation of health care providers at Dhulikhel Hospital–Kathmandu University Hospital.

Impact. We all want to have an impact, an effect or influence on the people we meet, programs we create, or work we do. My residency program director, the late Carey Chisholm, MD, often talked of impact in the context of academic medicine: an opportunity to multiply our impact to provide excellent emergency care to many more patients and families by training the next generation of physicians.

This is the beauty of academic medicine and our academic partnership through AMPATH Nepal. Almost 10 years ago, I had the privilege of training the first class of emergency medicine fellows here in Nepal. Now those fellows are emergency medicine physicians, training the next generation of health care leaders. Roshana Shrestha, MD, is a graduate of that first class of emergency medicine fellows, a physician I would gladly have care for me or my family. I get to work alongside her in the emergency department (ED) at Dhulikhel Hospital-Kathmandu University Hospital, where she is a Professor of General Practice and Emergency Medicine. Now I get to watch Roshana teach.

Dr. House teaching alongside Dr. Shrestha and learning together during pediatric simulations.

Almost every week in the ED at Dhulikhel Hospital-Kathmandu University Hospital, Roshana and colleagues conduct in situ simulation as a part of resident training. This type of simulation takes place in the clinical setting in the ED to provide a realistic scenario for learning and practicing patient care.

We use an interdisciplinary approach to improve our teamwork, build communication skills, apply knowledge, and practice clinical skills. This is a fun and safe learning experience for the residents.

As we conduct these sessions, I admire the way Roshana and our other colleagues interact with the team—their patience, support, and teaching that fosters critical thinking. I also see the way the learners engage and respond, with deep respect, growing knowledge and skills, and a desire to learn more. I am also learning—learning how to be a better teacher, how to be a better clinician, and how to be a better team member.

Through AMPATH, we have the opportunity to do this across institutions—across continents— multiplying our impact, growing in diversity, and expanding our understanding of global healthcare needs. I get to see the next generation of physicians across our partnerships—thoughtful, committed, and talented physicians, equipped to care for our communities and train the next generation.

Rose House, MD, MS, an Associate Professor of Emergency Medicine and Pediatrics, has served as Nepal Partnership Director since September 2022. She works alongside Nepal colleagues to develop and support our global health partnership between Mount Sinai, Kathmandu University School of Medicine, and Dhulikhel Hospital in Nepal. She also provides education and clinical care in emergency medicine and pediatric emergency medicine. Before joining Mount Sinai, she worked at Indiana University School of Medicine, where she began her global health career in the AMPATH Kenya program. She then transitioned to global health work in Nepal where she supported emergency medicine training and bilateral exchange opportunities. She earned her MD at the Indiana University School of Medicine in 2005.