The Management of Depressed Patients by the Tunisian General Practitioners: A Critical Trans-sectional Study

Highlighting successes and challenges of the mental health system in Tunisia: an overview of services, facilities, and human resources

BACKGROUND

Tunisia is a lower-middle-income country located in North Africa with strengths and challenges to its mental health system.

AIMS

We present an overview of available services, facilities, and human resources to offer mental health care in Tunisia.

METHODS

We conducted a cross-sectional study, where data for the year 2017 was collected between May 2018 and May 2019 by consulting stakeholders involved in the health field in Tunisia. We compare this information with data published in the WHO-AIMS report (2008), which presents mental health data in Tunisia for the year 2004.

RESULTS

Successes of the mental health system in Tunisia include an increase in the ratios of psychiatrists and psychologists, with these ratios being higher than those of other lower-middle-income countries; a flourishing child-psychiatry practice; and an increase in people being treated for mental health conditions. Challenges include psychiatrists being over-represented in large cities along the coastline and in the private sector, and most people receiving treatment in specialized mental health facilities.

CONCLUSIONS

The further operationalization of the National Strategy for Mental Health Promotion is envisioned, through the training of non-specialists in mental health care and incentives offered to psychiatrists to work in the country's interior and the public sector.

Building capacity in mental health care in low- and middle-income countries by training primary care physicians using the mhGAP: a randomized controlled trial

To address the rise in mental health conditions in Tunisia, a training based on the Mental Health Gap Action Programme (mhGAP) Intervention Guide (IG) was offered to primary care physicians (PCPs) working in the Greater Tunis area. Non-specialists (such as PCPs)' training is an internationally supported way to target untreated mental health symptoms. We aimed to evaluate the programme's impact on PCPs' mental health knowledge, attitudes, self-efficacy and self-reported practice, immediately following and 18 months after training. We conducted an exploratory trial with a combination of designs: a pretest-posttest control group design and a one-group pretest-posttest design were used to assess the training's short-term impact; and a repeated measures design was used to assess the training's long-term impact. The former relied on a delayed-intervention strategy: participants assigned to the control group (Group 2) received the training after the intervention group (Group 1). The intervention consisted of a weekly mhGAP-based training session (totalling 6 weeks), comprising lectures, discussions, role plays and a support session offered by trainers. Data were collected at baseline, following Group 1's training, following Group 2's training and 18 months after training. Descriptive, bivariate and ANOVA analyses were conducted. Overall, 112 PCPs were randomized to either Group 1 (n = 52) or Group 2 (n = 60). The training had a statistically significant short-term impact on mental health knowledge, attitudes and self-efficacy scores but not on self-reported practice. When comparing pre-training results and results 18 months after training, these changes were maintained. PCPs reported a decrease in referral rates to specialized services 18 months after training in comparison to pre-training. The mhGAP-based training might be useful to increase mental health knowledge and self-efficacy, and decrease reported referral rates and negative mental health attitudes among PCPs in Tunisia and other low- and middle-income countries. Future studies should examine relationships among these outcome variables.

"We find what we look for, and we look for what we know": factors interacting with a mental health training program to influence its expected outcomes in Tunisia

BACKGROUND

Primary care physicians (PCPs) working in mental health care in Tunisia often lack knowledge and skills needed to adequately address mental health-related issues. To address these lacunas, a training based on the Mental Health Gap Action Programme (mhGAP) Intervention Guide (IG) was offered to PCPs working in the Greater Tunis area between February and April 2016. While the mhGAP-IG has been used extensively in low- and middle-income countries (LMICs) to help build non-specialists' mental health capacity, little research has focused on how contextual factors interact with the implemented training program to influence its expected outcomes. This paper's objective is to fill that lack.

METHODS

We conducted a case study with a purposeful sample of 18 trained PCPs. Data was collected by semi-structured interviews between March and April 2016. Qualitative data was analyzed using thematic analysis.

RESULTS

Participants identified more barriers than facilitators when describing contextual factors influencing the mhGAP-based training's expected outcomes. Barriers were regrouped into five categories: structural factors (e.g., policies, social context, local workforce development, and physical aspects of the environment), organizational factors (e.g., logistical issues for the provision of care and collaboration within and across healthcare organizations), provider factors (e.g., previous mental health experience and personal characteristics), patient factors (e.g., beliefs about the health system and healthcare professionals, and motivation to seek care), and innovation factors (e.g., training characteristics). These contextual factors interacted with the implemented training to influence knowledge about pharmacological treatments and symptoms of mental illness, confidence in providing treatment, negative beliefs about certain mental health conditions, and the understanding of the role of PCPs in mental health care delivery. In addition, post-training, participants still felt uncomfortable with certain aspects of treatment and the management of some mental health conditions.

CONCLUSIONS

Findings highlight the complexity of implementing a mhGAP-based training given its interaction with contextual factors to influence the attainment of expected outcomes. Results may be used to tailor structural, organizational, provider, patient, and innovation factors prior to future implementations of the mhGAP-based training in Tunisia. Findings may also be used by decision-makers interested in implementing the mhGAP-IG training in other LMICs.