Feasibility and effectiveness of nurses and clinical officers in implementing the WHO mhGAP intervention guide: Pilot study in Makueni County, Kenya

The international league against epilepsy primary healthcare educational curriculum: Assessment of educational needs

OBJECTIVE

To assess the need for an epilepsy educational curriculum for primary healthcare providers formulated by the International League Against Epilepsy (ILAE) and the importance attributed to its competencies by epilepsy specialists and primary care providers and across country-income settings.

METHODS

The ILAE primary care epilepsy curriculum was translated to five languages. A structured questionnaire assessing the importance of its 26 curricular competencies was posted online and publicized widely to an international community. Respondents included epilepsy specialists, primary care providers, and others from three World Bank country-income categories. Responses from different groups were compared with univariate and ordinal logistic regression analyses.

RESULTS

Of 785 respondents, 60% noted that a primary care epilepsy curriculum did not exist or they were unaware of one in their country. Median ranks of importance for all competencies were high (very important to extremely important) in the entire sample and across different groups. Fewer primary care providers than specialists rated the following competencies as extremely important: definition of epilepsy (p = .03), recognition of seizure mimics (p = .02), interpretation of test results for epilepsy care (p = .001), identification of drug-resistant epilepsy (0.005) and management of psychiatric comorbidities (0.05). Likewise, fewer respondents from LMICs in comparison to UMICs rated 15 competencies as extremely important.

SIGNIFICANCE

The survey underscores the unmet need for an epilepsy curriculum in primary care and the relevance of its competencies across different vocational and socioeconomic settings. Differences across vocational and country income groups indicate that educational packages should be developed and adapted to needs in different settings.

A profound absence of counseling interventions for suicide prevention among youth in Africa: A call to action based on an empty scoping review

OBJECTIVE

One-third of all global suicide deaths occur among adolescents and young adults, making suicide the second leading cause of death among young people. Nearly 80% of suicide deaths occur in low- and middle-income countries, and many African nations have higher rates of suicide than global averages. However, interventions are scarce. We conducted a scoping review of counseling interventions for suicide prevention among youth in Africa.

METHOD

We performed structured searches of the Medline, Embase, PyscINFO, African Index Medicus, Global Heath Database, and Proquest Dissertations and Theses Global databases. Studies were eligible for inclusion if they described a counseling intervention conducted in Africa, focused on participants under age 22, and included a suicide-related outcome.

RESULTS

After removal of duplicates, 1808 titles and abstracts were screened and 10 studies were identified for full-text review. Of these, six included adult participants and did not disaggregate results for youth, two did not describe an intervention, and two did not include a relevant outcome. Thus, no studies were eligible for inclusion.

CONCLUSIONS

This empty review highlights the striking absence of published research on a life-threatening public health challenge, representing a distinct call to action for improved efforts in adolescent suicide prevention in Africa.

Depression and Intimate Partner Violence (IPV) in mothers 6 weeks to 12 months post-delivery in a rural setting in Kenya

Using a cohort of 544 postpartum mothers, 6 weeks to 12 months post-delivery in the largely rural Makueni County in Kenya, we aimed to determine: (1) the prevalence of postpartum depression (PPD) and the prevalence of each of the four domains of intimate partner violence (IPV), that is physical violence, sexual violence, emotional violence, and controlling behavior; (2) the co-occurrence of PPD and IPV; (3) risk factors and associations between sociodemographic variables and IPV, PPD and IPV and PPD co-occurring. We concurrently administered a researcher-designed sociodemographic ad hoc questionnaire, the WHO Intimate Partner Violence questionnaire and the Mini-International Neuropsychiatric Interview for adults (MINI Plus) for DSM-IV/ICD10 depression. The prevalence of PPD was 14.5%; Emotional violence 80.3%; Controlling behavior 74.4% (a form of emotional violence); Physical violence 40.3%; Sexual violence 28.9%. We found the following overlaps: 39% of participants reported both physical and emotional violence; 39% had both sexual and emotional violence; 15% experienced physical and sexual violence; and 15% of participants reported physical, sexual, and emotional violence. Postpartum depression was associated with physical violence during pregnancy, self-employed status, history of mood disorders and medical problems in the child. Further, we report associations between various types of IPV and history of depression, physical violence during pregnancy, low education level, marital status, and current depression diagnosis. IPV and PPD were highly prevalent in our population of postpartum mothers. Various types of IPV were significantly associated with various sociodemographic indicators while only sexual violence was significantly associated with PPD. Based on our results, we provide suggestions for potential interventions in the Kenyan setting.

A scoping review of counseling interventions for suicide prevention in Africa: Few studies address this life-saving aspect of mental health treatment

BACKGROUND

Nearly 800,000 people die by suicide each year, with 77 % occurring in low- and middle-income countries. Suicide is underestimated in many African settings due to challenges in data collection, stigma, and policies that promote silence; nonetheless, rates of suicide in Africa are consistently higher than global averages.

METHODS

We conducted a scoping review of counseling interventions assessing suicide outcomes among adults in Africa using MEDLINE, Embase, PsycINFO, African Index Medicus, CABI Global Health, and Proquest databases. Study screening and data extraction was informed by the JBI Manual for Evidence Synthesis.

RESULTS

Of 2438 abstracts reviewed, 33 studies met criteria for full-text review and 13 were included in the analysis. Interventions served several populations, including people living with HIV, out of school youth, university students, and women undergoing obstetric fistula repair. There was a near-equal split in individual versus group counseling modalities and the use of professional versus lay counselors. The majority of interventions had primary outcomes focused on other mental health or social variables with a secondary focus on suicide. Mechanisms of change for suicide prevention were poorly articulated.

LIMITATIONS

The review was limited to English-language studies conducted after 2001 and excluded qualitative studies and those with fewer than 10 participants.

CONCLUSIONS

There is a clear paucity of research in this area, particularly in the lack of randomized clinical trials and studies with suicide prevention as their primary outcome. Researchers should seek to develop or adapt evidence-based, culturally-resonant interventions to reduce the burden of suicide on the African continent.

Integration and Evaluation of a Community-Level Dementia Screening Program in Kenya (DEM-SKY): A Protocol

BACKGROUND

In Kenya, many people are currently living with dementia without a formal diagnosis or support; often attributing symptoms to normal aging or as a consequence of past behaviors. Dementia screening is not commonplace within Kenya. Improving the supply (or opportunity) of dementia screening within the region may promote uptake, thus leading to more people to seek a formal diagnosis and subsequently receive support within the Kenyan healthcare system. Community Healthcare Workers (CHWs) have successfully demonstrated their value in delivering health interventions within Kenya and have strong links within local communities.

OBJECTIVE

To integrate and evaluate a community-level dementia screening program among older adults in rural Kenya.

METHODS

Through leveraging this resource, we will deliver dementia screening to older adults (≥60 years) within Makueni County, Kenya over a 6-month period. Here, we present a protocol for the process evaluation of a dementia screening program in Kenya - DEM-SKY. The process evaluation seeks to understand the adoption, implementation, continuation, and implementation determinants, using quantitative and qualitative measures.

CONCLUSIONS

Gaining perspectives of different participants involved in the program (i.e., older adults, CHWs, hospital staff, and trainers), will ensure that we understand the reason for successful (or unsuccessful) delivery of DEM-SKY.

Feasibility and preliminary efficacy of training health workers in detecting Priority Mental Health Conditions among adolescents in rural South India

INTRODUCTION

Half of all mental disorders start during adolescence, before 14 years. In India, the current prevalence of mental disorders in 13-17 years age group was 7.3%. Many gaps persist in the mental healthcare delivery through the national mental health program, the low psychiatrist population ratio being one of them. Community health workers can play an essential role in providing mental healthcare in such resource-constrained settings. The World Health Organization mental health gap action program (WHO mhGAP) is a widely studied mental health tool that health workers can use to identify mental disorders. The study's aim was to test the preliminary efficacy of training healthcare workers (HCWs) in identifying mental health conditions among adolescents using modified WHO mhGAP modules.

METHODS

The feasibility study was carried out in two Primary Health Centers (PHCs) in rural Bengaluru. Study had two components: (1) training of HCWs on adolescent mental health and (2) detection of selected priority mental health conditions among adolescents by trained HCWs. HCWs were trained in five adolescent mental health conditions using a training manual and modified WHO mhGAP modules that excluded emergency presentations and management sections. Pre- and post-training assessments were carried out. A sample of 272 adolescents attending PHCs were assessed for any mental health condition by HCWs using mhGAP modules. A sub-sample of adolescents and all adolescents identified by HCWs with a mental health condition was interviewed by the investigator to validate the diagnosis. Qualitative interviews were carried out with participating HCWs to understand the acceptability of the intervention, acceptability, and barriers to training in identifying mental health conditions among adolescents RESULTS: A total of 23 HCWs underwent training. There was a significant increase in the mental health knowledge scores of HCWs post-training compared to baseline (p value <0.001). Out of 272 adolescents, 18 (6.8%) were detected to have any mental health condition by HCWs as per the modified WHO mhGAP modules. A sample of 72 adolescents consisting of all adolescents identified with a mental health condition by HCWs and a random sample of adolescents without any diagnosis were validated by the research investigator (AS). There was a good agreement between diagnosis by health workers and the research investigator with a Cohen's Kappa of 0.88. Four themes emerged from the qualitative analysis.

CONCLUSIONS

Training was effective in improving the knowledge of HCWs. There was a good agreement between trained HCWs and the investigator in detecting adolescent mental health conditions using modified mhGAP modules. The modified WHO mhGAP can thus be used by trained non-specialist HCWs to screen for adolescent mental health conditions in primary health centers.

Mental health task-sharing in South Africa - a role for clinical associates?

BACKGROUND

South Africa (SA) lacks the specialised workforce needed to provide mental health services particularly in the public sector and in rural areas. Mid-level medical workers offer a potential option for mental health task-sharing in countries where they exist, including SA. The objectives of the study were to explore the roles that SA's mid-level medical worker cadre (clinical associates) could play in mental health service delivery, and to explore views on advanced training in mental health for this cadre.

METHODS

This was an explorative, qualitative study involving key informants linked to the three clinical associate training programmes in SA. A total of 19 in-depth interviews were conducted with university-based academic staff, facility-based trainers, and student representatives. The interviews were audio-recorded and professionally transcribed. Thematic analysis was conducted with the aid of Atlas.ti software. Themes and subthemes were identified.

RESULTS

The first theme identified was 'there is a place for them at the table'. Participants felt that there was a definite role for clinical associates in mental health service provision. The levels of care thought most appropriate were primary health care facilities and district hospitals. The most frequently identified role for clinical associates was in providing immediate care and stabilising mental health patients presenting in emergency settings. Other potential settings included inpatient wards, outpatients' departments, and in communities (e.g. home visits). The second theme identified was 'earning a seat at the table'. There was virtually unanimous support for additional training and in particular a postgraduate clinical specialisation in mental health. Participants felt a clinical specialisation in mental health would strengthen the health system by addressing workforce shortages as well as access and equity issues. They also held the view it would strengthen the profession by creating a career path and providing more employment opportunities for clinical associates.

CONCLUSIONS

There was broad support for a role for clinical associates in mental health service delivery in SA as well as for the establishing a clinical specialisation in mental health for clinical associates. Clinical associates with advanced training in mental health could potentially play an important role in rural settings to alleviate the shortage of specialist mental health practitioners.

Impact of Mental Health First Aid Training Courses on Patients’ Mental Health

Background

With the prevalence of mental issues worldwide, more and more people are suffering from psychological torture. Mental Health Gap Action Program (mhGAP) has been introduced to improve the life quality of humans.

Objectives

To explore and synthesize evidence of participants' experience of mental health first aid (MHFA) training course.

Method

Peer-reviewed qualitative evidence was systematically reviewed and thematically synthesized. Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medical Literature Analysis and Retrieval System Online (MEDLINE), Psychological Information (PsycINFO), PubMed, Psych ARTICLES, Web of Science, Joanna Briggs Institute (JBI), and National Institute for Health and Care Excellence (NICE) databases were searched for the inception of the present study. The study's quality was appraised using the Critical Appraisal Checklist for Qualitative Research of Joanna Briggs Institute (JBI) appraisal tool. All the participants who have attended the MHFA training course (excluding instructors) setting were included.

Results

Six papers published between 2005 and 2019 were included for thematic synthesis. The review indicated that MHFA had been a positive experience for participants.

Conclusions

MHFA courses can provide participants with professional knowledge of mental health counseling and improve their knowledge, practice, and attitudes towards their patients. Professional MHFA training courses should therefore be popularized and promoted among other populations.

Socio-demographic, economic and mental health problems were risk factors for suicidal ideation among Kenyan students aged 15 plus

BACKGROUND

About a third of youth with suicidal ideation develop suicidal plans and about 60% of youth with suicidal plans make suicidal attempts. This study aimed to study different types of suicidal ideation and the risk factors in Kenyan youth.

METHODS

We studied a total of 9742 high school, college and university students using following self-administered instruments: - a researcher design socio-demographic questionnaire, Psychiatric Diagnostic Screening Questionnaire (PDSQ) to document psychiatric disorders and various types of suicidal ideas in previous two weeks, Washington Early Recognition Center Affectivity and Psychosis tool to assess stress, affectivity and psychosis, Wealth index questionnaire to document economic indicators based on household items for the families of the students. We used descriptive statistics, univariate analysis, bivariate logistic regression analysis and variables with a p-value of less than <.05 were entered into generalized linear models using logit links to identify independent predictors.

RESULTS

The overall prevalence of different types of suicidal ideation was (22.6%), major depression was found in 20.0%, affectivity, psychosis and stress was found in 10.4%, 8.7% and 26.0% respectively. Female gender, major depression, stress, affectivity and psychosis and being in high school were significant (p < 0.05) predictors of suicidal ideation.

LIMITATIONS

This was a cross sectional study that focused only on suicidal ideas and associated economic factors and mental health disorders. It did not study suicidal behavior.

CONCLUSION

Future studies are needed to study the progression from suicidal ideas to suicidal attempts and the factors associated with that progression.

Individual and community experiences and the use of language in understanding diabetes and depression in rural Kenya

As the prevalence of long-term conditions continues to rise it becomes increasingly important to identify ways to mitigate their effects, including the psychological impact. In rural Kenya identifying people with diabetes or mental health problems is challenging due to the stigma and negative experiences within community settings.Four broad themes were identified; (1) misconceptions and stigma: the use of language, (2) treatment and medications, (3) community beliefs and alternative treatment pathways, (4) the role of informal and formal care.Our study demonstrated the detrimental effect of the use of stigmatising language and misconceptions surrounding diabetes and depression at both the individual and community levels. Inequalities in health care access were observed and a lack of resources in rural communities was evident. Improvements in support for health care workers at the community level as well as acknowledging the importance of informal care could help improve the psychological and emotional impact of diabetes and depression.

Efficacy and cost-effectiveness of task-shared care for people with severe mental disorders in Ethiopia (TaSCS): a single-blind, randomised, controlled, phase 3 non-inferiority trial

BACKGROUND

There have been no trials of task-shared care (TSC) using WHO's mental health Gap Action Programme for people with severe mental disorders (psychosis or affective disorder) in low-income or middle-income countries. We aimed to evaluate the efficacy and cost-effectiveness of TSC compared with enhanced specialist mental health care in rural Ethiopia.

METHODS

In this single-blind, phase 3, randomised, controlled, non-inferiority trial, participants had a confirmed diagnosis of a severe mental disorder, recruited from either the community or a local outpatient psychiatric clinic. The intervention was TSC, delivered by supervised, non-physician primary health care workers trained in the mental health Gap Action Programme and working with community health workers. The active comparison group was outpatient psychiatric nurse care augmented with community lay workers (PSY). Our primary endpoint was whether TSC would be non-inferior to PSY at 12 months for the primary outcome of clinical symptom severity using the Brief Psychiatric Rating Scale, Expanded version (BPRS-E; non-inferiority margin of 6 points). Randomisation was stratified by health facility using random permuted blocks. Independent clinicians allocated groups using sealed envelopes with concealment and outcome assessors and investigators were masked. We analysed the primary outcome in the modified intention-to-treat group and safety in the per-protocol group. This trial is registered with ClinicalTrials.gov, number NCT02308956.

FINDINGS

We recruited participants between March 13, 2015 and May 21, 2016. We randomly assigned 329 participants (111 female and 218 male) who were aged 25-72 years and were predominantly of Gurage (198 [60%]), Silte (58 [18%]), and Mareko (53 [16%]) ethnicity. Five participants were found to be ineligible after randomisation, giving a modified intention-to-treat sample of 324. Of these, 12-month assessments were completed in 155 (98%) of 158 in the TSC group and in 158 (95%) of 166 in the PSY group. For the primary outcome, there was no evidence of inferiority of TSC compared with PSY. The mean BPRS-E score was 27·7 (SD 4·7) for TSC and 27·8 (SD 4·6) for PSY, with an adjusted mean difference of 0·06 (90% CI -0·80 to 0·89). Per-protocol analyses (n=291) were similar. There were 47 serious adverse events (18 in the TSC group, 29 in the PSY group), affecting 28 participants. These included 17 episodes of perpetrated violence and seven episodes of violent victimisation leading to injury, ten suicide attempts, six hospital admissions for physical health conditions, four psychiatric admissions, and three deaths (one in the TSC group, two in the PSY group). The incremental cost-effectiveness ratio for TSC indicated lower cost of -US$299·82 (95% CI -454·95 to -144·69) per unit increase in BPRS-E scores from a health care sector perspective at 12 months.

INTERPRETATION

WHO's mental health Gap Action Programme for people with severe mental disorders is as cost-effective as existing specialist models of care and can be implemented effectively and safely by supervised non-specialists in resource-poor settings.

FUNDING

US National Institute of Mental Health.

Feasibility study on the mhGAP-IG as a tool to enhance parental awareness of symptoms of mental disorders in lower primary (6-10 year old) school-going children: Towards inclusive child mental health services in a Kenyan setting

AIMS

(1) To determine the feasibility of involving parents as key partners in school mental health activities; (2) to determine whether educating parents on mental health treatment Gap Intervention Guideline (mhGAP-IG) section on children leads to enhanced parent perception of mental health symptoms in their children; and (3) to determine context appropriate social demographic predictors of the parental awareness following the psychoeducation using the mhGAP-IG children version.

METHODS

Consenting parents completed the Child Behaviour Checklist (CBCL) and the Brief Problem Monitor for Parents (BPM-P) about their children at baseline and at 6 months post-baseline respectively. Immediately after post-baseline, they received psychoeducation on the importance of mental well-being in children and how to recognize symptoms of mental disorders, using the mhGAP-IG section on children. This psychoeducation was the intervention between baseline and 6 months post-baseline. We analysed means of mental disorder symptoms and prevalence of the various mental syndromes/problems on the CBCL/BPM-P scores to determine the statistical significance of the changes between baseline and 6 months.

RESULTS

Overall, there was significant increase (P < 0.05) in the symptoms mean scores and prevalence of syndromes/problems between baseline and 6 months post-psychoeducation. However, there were some differences between urban and rural settings and in some parents and children socio-demographics and gender that should be considered in individual cases.

CONCLUSION

It is feasible to include parents in school mental health programmes as key stakeholders. The mhGAP-IG section on children is a good tool for psychoeducation. However, there are predictors of outcomes that need further research.

Improving work and employment opportunities for women with psychosocial disabilities: an action research protocol

In Kenya, employment rates for persons with disabilities are very low and those with psychosocial disabilities have even more dismal rates of employment. This situation has negative impact on the individual’s recovery, quality of life, mental and physical health. The systemic exclusion of persons with psychosocial disabilities in work and employment disproportionately affects women. The aim of this study is to test the feasibility of disability inclusion training to improve work and employment opportunities for women with psychosocial disabilities in Tana River County, Kenya. The study will adopt a mixed methods research design using action research approach. A sample of women with psychosocial disabilities will be trained using a researcher designed disability inclusion training manual, while employers and other stakeholders will be trained on inclusive employment. Trainings will be tailored to suit different employers and for different types of psychosocial disabilities. Interactive learning and linking sessions involving the two groups and process evaluations will be conducted at different time points to measure the impact of the intervention. Findings from this pilot study will inform future research on work and employability programs for rural women with psychosocial disabilities. The study protocol was approved by Maseno University Ethics Review Committee (MUERC/00851/20). Findings from this study will be disseminated through conference presentations and scientific publications in peer reviewed journals.

Using the WHO-AIMS to inform development of mental health systems: the case study of Makueni County, Kenya

BACKGROUND

In order to develop a context appropriate in mental health system, there is a need to document relevant existing resources and practices with a view of identifying existing gaps, challenges and opportunities at baseline for purposes of future monitoring and evaluation of emerging systems. The World Health Organization Assessments Instrument for Mental Health Systems (WHO-AIMS) was developed as a suitable tool for this purpose. Our overall objective of this study, around which research questions and specific aims were formulated, was to establish a baseline on mental health system as at the time of the study, at Makueni County in Kenya, using the WHO-AIMS.

METHODS

To achieve our overall objective, answer our research questions and achieve specific aims, we conducted a mixed methods approach in which we did an audit of DHIS records and county official records, and conducted qualitative interviews with the various officers to establish the fidelity of the data according to their views. The records data was processed via the prescribed WHO-Aims 2.2 excel spreadsheet while the qualitative data was analyzed thematically. This was guided by the six domains stipulated in the WHO AIMS.

RESULTS

We found that at the time point of the study, there were no operational governance, policy or administrative structures specific to mental health, despite recognition by the County Government of the importance of mental health. The identified interviewees and policy makers were cooperative and participatory in identifying the gaps, barriers and potential solutions to those barriers. The main barriers and gaps were human and financial resources and low prioritization of mental health in comparison to physical conditions. The solutions lay in bridging of the gaps and addressing the barriers.

CONCLUSION

There is a need to address the identified gaps and barriers and follow up on solutions suggested at the time of the study, if a functional mental health system is to be achieved at Makueni County.

Perceived impacts as narrated by service users and providers on practice, policy and mental health system following the implementation of the mhGAP-IG using the TEAM model in a rural setting in Makueni County, Kenya: a qualitative approach

Background

A team approach is key to reduction of the mental health treatment gap. It requires collaborative effort of all formal and informal community based service providers and the consumers of the services. Qualitative evaluations of such an approach add value to the quantitative evaluations.

Methods

A qualitative study was conducted among 205 participants. These were grouped into a total of 19 focus group discussions for community health workers (CHW), traditional healers (TH), faith healers (FH) and patients. For nurses and clinical officers we held 10 key informant interviews and three key informant discussions. We aimed to document personal perceptions as expressed in narratives on mental health following a community based application of the WHO mental health treatment Gap-intervention guideline (mhGAP-IG) using the TEAM model. We also aimed to document how the narratives corroborated key findings on the quantitative wing of the TEAM model.

Results

There were three categories of perceptions: (i) patient-related, (ii) health provider-related and, (iii) health system related. The patient related narratives were linked to improvement in their mental and physical health, increased mental health awareness, change in lifestyle and behavior, enhanced social functioning and an increase in family productivity. Health provider perceptions were related to job satisfaction, capacity building and increased interest in mental health training. Mental health system related narratives included effectiveness and efficiency in service delivery and increase in number of referrals at the primary health care facilities.

Conclusion

The TEAM is a feasible model for the implementation of the mhGAP-IG. It led to positive perceptions and narratives by service provides and service consumers. The qualitative findings corroborated the quantitative findings of TEAM.