Understandings of depression among community members and primary healthcare attendees in rural Ethiopia: A qualitative study

Strengthening primary health care in Ethiopia: A scoping review of successes, challenges, and pathways towards universal health coverage using the WHO monitoring framework

INTRODUCTION

The ultimate goal of primary health care (PHC), as a whole-of-government and whole-of-society approach, is to achieve the highest level of health by bringing health services closer to the users. This entails that PHC should be viewed as the all-inclusive strategy to achieve universal health coverage (UHC) of the sustainable development goals (SDG). Ethiopia has been implementing PHC since the Alma-Ata Declaration. The World Health Organization (WHO) has recently released a PHC Monitoring Framework to support the monitoring of progress in PHC implementation. However, an evidence gap highlights the need for studies investigating PHC progress towards UHC using this progress monitoring framework. This study aims to evaluate Ethiopia's PHC system using the WHO PHC monitoring framework and identify successes and challenges towards UHC and health security.

METHOD

This scoping review was conducted and structured based on Arksey and O'Malley's methodological framework. We searched five databases (PubMed, Scopus, Embase, Web of Science, CINAHL) and hand-searched for relevant articles. We used the WHO PHC monitoring conceptual framework to summarise findings qualitatively. We reported our findings using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) framework.

RESULTS

We included a total of 110 papers - 56 cross-sectional/national surveys, 19 qualitative studies, 16 mixed-method studies, five fiscal/cost/formative or project model analyses, three ecological/ethnographic studies, three longitudinal/quasi-experimental studies, and two each of implementation/participatory research, cohort studies, and case studies. The Ethiopian PHC system has achieved encouraging success in improving healthcare access and coverage, driven by growing political and leadership commitments through implementing a national health extension package (HEP), service integration and multisectoral approaches to achieve UHC. However, Ethiopia's efforts to achieve UHC have faced many challenges, including inadequate service integration, lack of resources and budgets, uneven distribution of health workers and infrastructure, gaps in priority setting, service innovation, stakeholder engagement and funding PHC research. These are affecting access to affordable care and hindering the progress towards UHC.

CONCLUSION

Ethiopia's PHC system has achieved significant progress in expanding infrastructure and improving access to health services towards UHC. However, challenges remain, particularly in underserved rural areas, with inequitable access, weak governance, and limited integration of essential services. Hence, by improving resource allocation, addressing rural inequities, systemic and infrastructural challenges and fostering stronger governance and service integration, Ethiopia can further improve and build on the successes of the PHC system, making it more resilient and better equipped to meet the health needs of its population.

A pilot cluster-controlled trial of interventions to improve detection of depression in primary healthcare in Ethiopia

BACKGROUND

The low recognition of depression in primary healthcare (PHC) remains a major obstacle to rendering adequate care for people with depression globally. This study aimed to evaluate the feasibility and potential benefit of a contextually developed multicomponent and multilevel intervention to improve the identification of depression in PHC.

METHODS

A pilot, four-arm, parallel-group, cluster, non-randomised controlled trial was conducted in a predominantly rural district in Ethiopia. The active interventions were allocated to three PHC facilities: (1) a core multicomponent intervention focusing on providers-a manualised training package along with system intervention (mobile application, posters, quality improvement and supervision) (Level-I/Arm I), (2) Level-I intervention plus a 4-item screening questionnaire administered by triage nurses (Level-II/Arm II), (3) Level-II intervention plus service user awareness raising (Level-III/Arm III). In the control facility, standard integrated mental healthcare (care by providers trained in the standard WHO mhGAP intervention guide) was available. The outcomes were the identification of depression and the feasibility and acceptability of implementation by PHC clinicians. Quantitative and qualitative data were collected post-intervention. Descriptive analysis and thematic analysis were used to analyse the data.

RESULTS

A total of 21 providers (14 clinicians and 7 triage nurses) and 1659 adult outpatients participated in the study. Overall, 116 outpatients (7.0%) received a diagnosis of depression by PHC clinicians. Detection of depression was significantly better in the active intervention arms combined: 8.3% (n = 115/1380) vs. 0.4% (n = 1/279) in the control arm. Level-II and Level-III intervention arms had significantly higher rates of detection (10.1% Level II, 9.2% Level III) compared with Level I (5.2%); however, there was no significant difference between Level-II and Level-III. The interventions demonstrated very good acceptability, feasibility and appropriateness although screening, which was included in the Level II and Level III intervention arms, had relatively lower acceptability and an overall low positive predictive value.

CONCLUSIONS

The tested interventions hold good promise of enhancing the identification of depression in PHC, with excellent feasibility and acceptability parameters. Although screening has good potential, implementation in routine care requires further optimisation and evaluation.

TRIAL REGISTRATION

Trial ID: PACTR202206723109626. Registration date: 21 June 2022. Retrospectively registered.

Experience and perceptions of mental ill-health in people with epilepsy in rural Ethiopia: A qualitative study

INTRODUCTION

Understanding the lived experience of mental health and illness in people with epilepsy has been little investigated in Africa and yet is essential to inform person-centered care. The aim of this study was to explore the experiences mental ill-health in the contexts of the lives of people with epilepsy in rural Ethiopia.

METHODS

A phenomenological approach was employed using in-depth individual interviews with PWE. Participants were selected purposely. The setting was Gurage Zone in south-central Ethiopia, where efforts had been made to expand access to mental health and epilepsy care through integration in primary health care. Thematic analysis was used.

RESULT

Twenty-two participant were interviewed (8 women, 14 men). The following themes were identified: expression of ill-health; the essence of emotions; the emotional burden of epilepsy and aspirations and mitigating impacts. Participants reported multiple bodily (e.g., fatigue) and emotional (e.g., irritability, sadness) experiences that were tied up with their experience of epilepsy and not separable into physical vs. mental health. Occupation and social life difficulties were interconnected with emotional and bodily sickness. Emotions were considered inherently concerning, with emotional imbalance spoken of as a cause or trigger for seizures. These emotional burdens resulted in difficulties fulfilling occupational and social life obligations, in turn exacerbating the epilepsy-related stigma experienced by others. Participants sought to mitigate these interconnected psychosocial impacts through finding spiritual meaning in, or acceptance of, their experiences, drawing on family care and, for some, emotional support from health professionals.

CONCLUSIONS

People living with epilepsy in this rural Ethiopian setting experience various emotional, financial, occupational and interpersonal problems that are crucially interwoven with one another and with the experience of epilepsy. A people-centered approach to support the recovery of people with epilepsy requires consideration of mental health alongside physical health, as well as interventions outside the health system to address poverty and stigma.

Adapting brief problem-solving therapy for pregnant women experiencing depressive symptoms and intimate partner violence in rural Ethiopia

OBJECTIVE

To adapt an evidence-based psychological intervention for pregnant women experiencing depressive symptoms and intimate partner violence (IPV) in rural Ethiopia.

METHOD

We conducted a desk review of contextual factors in Sodo, Ethiopia, followed by qualitative interviews with 16 pregnant women and 12 antenatal care (ANC) providers. We engaged stakeholders through participatory theory of change (ToC) workshops, to select the intervention and articulate a programme theory. We used "ADAPT" guidance to adapt the intervention to the context, before mapping potential harms in a "dark logic model".

RESULTS

Brief problem-solving therapy developed for South Africa was the most contextually relevant model. We adapted the delivery format (participants prioritised confidentiality and brevity) and training and supervision (addressing IPV). Consensus long-term outcomes in our ToC were ANC providers skilled in detecting and responding to emotional difficulties and IPV, women receiving appropriate support, and emotional difficulties improving. Our dark logic model highlighted the risk of more severe IPV and mental health symptoms not being referred appropriately.

CONCLUSION

Although intervention adaptation is recommended, the process is rarely reported in depth. We comprehensively describe how contextual considerations, stakeholder engagement, programme theory, and adaptation can tailor psychological interventions for the target population in a low-income, rural setting.

Depression and Global Mental Health in the Global South: A Critical Analysis of Policy and Discourse

Over the past two decades, depression has become a prominent global public health concern, especially in low- and middle-income countries (LMICs). The World Health Organization (WHO) and the Movement for Global Mental Health have developed international guidelines to improve mental health services globally, prioritizing LMICs. These efforts hold promise for advancing care and treatment for depression and other mental, neurological, and substance abuse disorders in LMICs. The intervention guides, such as the WHO's mhGAP-Intervention Guides, are evidence-based tools and guidelines to help detect, diagnose, and manage the most common mental disorders. Using the Global South as an empirical site, this article draws on Foucauldian critical discourse and document analysis methods to explore how these international intervention guides operate as part of knowledge-power processes that inscribe and materialize in the world in some forms rather than others. It is proposed that these international guidelines shape the global discourse about depression through their (re)production of biopolitical assumptions and impacts, governmentality, and "conditions of possibility." The article uses empirical data to show nuance, complexity, and multi-dimensionality where binary thinking sometimes dominates, and to make links across arguments for and against global mental health. The article concludes by identifying several resistive discourses and suggesting reconceptualizing the treatment gap for common mental disorders.

Developing interventions to improve detection of depression in primary healthcare settings in rural Ethiopia

BACKGROUND

The poor detection of depression in primary healthcare (PHC) in low- and middle-income countries continues to threaten the plan to scale up mental healthcare coverage.

AIMS

To describe the process followed to develop an intervention package to improve detection of depression in PHC settings in rural Ethiopia.

METHOD

The study was conducted in Sodo, a rural district in south Ethiopia. The Medical Research Council's framework for the development of complex interventions was followed. Qualitative interviews, observations of provider-patient communication, intervention development workshops and pre-testing of the screening component of the intervention were conducted to develop the intervention.

RESULTS

A multicomponent intervention package was developed, which included (a) manual-based training of PHC workers for 10 days, adapted from the World Health Organization's Mental Health Gap Action Programme Intervention Guide, with emphasis on depression, locally identified depressive symptoms, communication skills, training by people with lived experience and active learning methods; (b) screening for culturally salient manifestations of depression, using a four-item tool; (c) raising awareness among people attending out-patient clinics about depression, using information leaflets and health education; and (d) system-level interventions, such as supportive supervision, use of posters at health facilities and a decision support mobile app.

CONCLUSIONS

This contextualised, multicomponent intervention package may lead to meaningful impact on the detection of depression in PHC in rural Ethiopia and similar settings. The intervention will be pilot tested for feasibility, acceptability and effectiveness before its wider implementation.