"A constant struggle to receive mental health care": health care professionals' acquired experience of barriers to mental health care services in Rwanda

Exploring Nonspecialist Preparedness to Deliver an Evidence-Based, Family Strengthening Intervention in Rwanda: A Qualitative Study

Families in low- and middle-income countries (LMICs) face significant mental health and psychosocial care gaps. In recent years, researchers and practitioners have addressed these gaps by task-sharing evidence-based mental health and psychosocial support (MHPSS) interventions to nonspecialist community providers. Supervision and training approaches are intended to prepare nonspecialists to deliver evidence-based interventions with quality. However, there is still little research exploring nonspecialist experiences with training and supervision and how, if at all, their training and supervision experiences result in fidelity and competence in delivering the intervention. This qualitative study uses data from a cluster-randomized trial of a family strengthening and violence prevention program in Rwanda, known as Sugira Muryango. In semi-structured interviews, the nonspecialists provided examples of using skills such as rapport-building, empathy, and active listening to deliver Sugira Muryango effectively. Because nonspecialists were serving in their own communities, they found that it was easier to earn trust with friends and neighbors, and this facilitated effective delivery of Sugira Muryango. Nonspecialists discussed how training, monthly supervision, in-person monitoring visits, and the use of the manual and audio recorders equipped them to deliver Sugira Muryango with quality. Nonspecialists also provided examples of barriers to quality of delivery, including supervisor lack of availability, delayed compensation, and technology issues. Preparedness was consistent across gender; however, nonspecialists serving in a better-resourced district had previous experiences delivering evidence-based interventions and felt more prepared at the beginning of Sugira Muryango.

Morning Connections: How do you support hospital staff working remotely during a global pandemic without providing 'staff support'?

When lockdown was announced in the United Kingdom, kitchen tables transformed into offices overnight, as many National Health Service (NHS) workers adapted to new ways of working from home. To respond to the developing situation, we established a programme of weekly 'Connections' meetings where staff could be together, remotely. This article describes the evolution of our Morning Connections and Oncology Connections virtual meetings, including the content of sessions, how they were evaluated and whether they met their intention to support colleagues during a particularly challenging time, both personally and professionally, for NHS staff.

Prevalence of mental disorders, associated co-morbidities, health care knowledge and service utilization in Rwanda - towards a blueprint for promoting mental health care services in low- and middle-income countries?

Background

In order to respond to the dearth of mental health data in Rwanda where large-scale prevalence studies were not existing, Rwanda Mental Health Survey was conducted to measure the prevalence of mental disorders, associated co-morbidities and knowledge and utilization of mental health services nationwide within Rwanda.

Methods

This cross-sectional study was conducted between July and August 2018, among the general population, including survivors of the 1994 Genocide against the Tutsi. Participants (14–65 years) completed the Mini-International Neuropsychiatric Interview (Version 7.0.2), sociodemographic and epilepsy-related questionnaires. General population participants were selected first by random sampling of 240 clusters, followed by systematic sampling of 30 households per cluster. Genocide survivors within each cluster were identified using the 2007–2008 Genocide Survivors Census.

Results

Of 19,110 general survey participants, most were female (n = 11,233; 58.8%). Mental disorders were more prevalent among women (23.2%) than men (16.6%) (p < 0.05). The most prevalent mental disorders were major depressive episode (12.0%), panic disorder (8.1%) and post-traumatic stress disorder (PTSD) (3.6%). Overall, 61.7% had awareness of mental health services while only 5.3% reported to have used existing services. Of the 1271 genocide survivors interviewed, 74.7% (n = 949) were female; prevalence of any mental disorder was 53.3% for women and 48.8% for men. Most prevalent disorders were major depressive episode (35.0%), PTSD (27.9%) and panic disorder (26.8%). Among genocide survivors, 76.2% were aware of availability of mental health services, with 14.1% reported having used mental health services.

Conclusions

Despite high prevalence of mental disorders among the general population and genocide survivors, utilization of available mental health services was low. A comprehensive approach to mental health is needed for prevention of mental illness and to promote mental healthcare services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14165-x.

Kongera Kwiyubaka (rebuilding ourselves again): Culturally responsive and contextually relevant collective healing in post-genocide Rwanda

Drawing on the local experiences, knowledge, and wisdom of Rwandan youth can make them agents of healing from the genocide against the Tutsi in ways that are culturally appropriate, relevant, and meaningful. This qualitative study aimed to develop an emerging framework for intervening with youth that is centered in the experiences and cultural context of the Rwandan youth post-genocide. Drawing on Grounded Action research of post-genocide community-led healing practices with a group of 23 high school students, results indicated that "psychological healing" in post-genocide Rwanda may require different approaches than the dominant Western healing models. For research participants, "healing" meant "kongera kwiyubaka" (building ourselves again after the genocide), requiring "kwigira" (self-reliance) and "gusasa inzobe" (openness to share what is in their hearts). This study recommends that scholars, policy makers, and funders reimagine existing models of healing in post-genocide Rwanda and support local initiatives drawing on wisdom from lived experiences.

Provision and use of physical rehabilitation services for adults with disabilities in Rwanda: A descriptive study

Background

Physical rehabilitation interventions address functional deficits caused by impairments that affect someone’s performance. Whilst rehabilitation is important, it is assumed that these services are either minimal or nonexistent in low-resource settings. Our data expand on the data from the Situation Assessment of Rehabilitation in the Republic of Rwanda report to describe rehabilitation services and who access them at public and semiprivate facilities (primarily funded by the private sector).

Objectives

This article describes the use of the outpatient physical rehabilitation services across nine health facilities, the characteristics of adults attending these health facilities and some of the facilitators and barriers they encounter when attending rehabilitation.

Method

Data were collected between September and December 2018 from the heads of departments and adult patients attending outpatient rehabilitation services funded by the government, international nongovernmental organisations or faith-based organisations.

Results

Two hundred and thirteen adults were recruited from nine facilities. There is a sixfold difference in the number of rehabilitation personnel between public and semiprivate hospitals in these facilities’ catchment areas. However, most participants were recruited at public facilities (186 [87%]), primarily with physical disorders. Patients reported that family support (94%) was the most crucial facilitator for attending rehabilitation, whilst transportation cost (96%) was a significant barrier.

Conclusion

Rehabilitation service availability for Rwandan adults with disabilities is limited. Whilst family support helps patients attend rehabilitation, transportation costs remain a significant barrier to people attending rehabilitation. Strategies to address these issues include developing triage protocols, training community health workers and families.

Contribution

Data on rehabilitation service provision in Rwanda and most African countries are either non-existent or very limited. These data contain important information regarding the services provided and the people who used them across different health facilities (public versus private) and urban versus rural settings). To improve rehabilitation service provision, we first need to understand the current situation. These data are an important step to better understanding rehabilitation in Rwanda.

Barriers to Treatment as a Hindrance to Health and Wellbeing of Individuals with Mental Illnesses in Africa: a Systematic Review

African countries continue to neglect the effects of mental illness on their communities. Identifying barriers to treatment and developing mitigation strategies is essential to address the burden of mental illness within Africa. We searched PubMed, Medline, PSYCHInfo, ERIC, Cochrane Library, ClinicalTrials.gov, and reference lists through June 2020. Studies addressed barriers to mental illness treatment affecting patients and/or their care team. Data was extracted using a standardized data collection form. Three independent, blinded reviewers extrapolated qualitative and quantitative data. Themes were summarized qualitatively. Thirteen studies reflecting urban and rural settings qualified for review. Participants were 17 to 58 years old. Males accounted for 49.9% of the study population. Barriers were categorized as attitudinal, economic, physical, political, and infrastructural. Attitudinal barriers were most prevalent; infrastructural barriers were least discussed. Policy and infrastructural implementations would mitigate interconnected barriers and improve health and wellbeing within Africa.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s11469-021-00726-5.

Competencies for Nurses Regarding Psychosocial Care of Patients With Cancer in Africa: An Imperative for Action

Psychosocial care is considered an important component of quality cancer care. Individuals treated for cancer can experience biologic or physical, emotional, spiritual, and practical consequences (eg, financial), which have an impact on their quality of living. With the establishment of cancer centers in Africa, there is growing advocacy regarding the need for psychosocial care, given the level of unmet supportive care needs and high emotional distress reported for patients. Nurses are in an ideal position to provide psychosocial care to patients with cancer and their families but must possess relevant knowledge and skills to do so. Across Africa, nurses are challenged in gaining the necessary education for psychosocial cancer care as programs vary in the amount of psychosocial content offered. This perspective article presents competencies regarding psychosocial care for nurses caring for patients with cancer in Africa. The competencies were adapted by expert consensus from existing evidenced-based competencies for oncology nurses. They are offered as a potential basis for educational program planning and curriculum development for cancer nursing in Africa. Recommendations are offered regarding use of these competencies by nursing and cancer program leaders to enhance the quality of care for African patients with cancer and their family members. The strategies emphasize building capacity of nurses to engage in effective delivery of psychosocial care for individuals with cancer and their family members.

Co-creation and Evaluation of Nationwide Remote Training Service for Mental Health Education of Community Health Workers in Rwanda

Objective: Johnson & Johnson Global Public Health and the Ministry of Health of Rwanda strengthened the mental health awareness by providing an innovative, low-cost, easily accessible, and scalable remote training service (RTS) on mental health for Community Health Workers (CHWs).

Methods: The RTS consisted of eight training modules shared via simple feature phones over a 4-week period. Quiz questions and baseline/endline assessments were included to assess the feasibility and acceptability of the training platform, the knowledge and self-confidence gained by the CHWs, and prospects for the sustainability of the platform.

Results: Ninety-three percent of the CHWs completed at least four of the eight training modules, and 42% of the CHWs improved with a higher end score. The training content was considered interesting, easy to understand, and helpful to intervene appropriately to refer patients with signs of mental illness to a hospital and to provide community and family education on mental health topics.

Conclusion: The RTS is feasible and acceptable for the delivery of mental health training on a large scale and contributed to strengthening the capacity in delivering mental health care at community level.

The role of mental health symptomology and quality of life in predicting referrals to special child and adolescent mental health services

BACKGROUND

Children and adolescents' mental health problems have been largely assessed with conventional symptom scales, for example, Strengths and Difficulties Questionnaire (SDQ) given that it is one of the mostly widely used measures in specialist Child and Adolescent Mental Health Services (CAMHS). However, this emphasis on symptom scales might have missed some important features of the mental health challenges that children and young people experience including day to day functioning and life satisfaction aspect (i.e. qualify of life).

METHOD

The study examined longitudinal association between a young person's self-perceptions of quality of life and mental health difficulties and referral to specialist CAMHS service using a population cohort study (Targeted Mental Health in Schools service data) nested within a large-scale linkage between school (National Pupil Data base) and child mental health service administrative data (South London and Maudsley NHS Foundation Trust children and adolescent mental health services health records). Cox proportional hazard regression to estimate crude and adjusted hazard ratios (HRs) for the association between participant psychopathology, and incidence of CAMHS referral.

RESULTS

Pupils experiencing more behavioural difficulties, had an increased incidence of CAMHS referral (adjusted hazard ratio 1.1, 95% confidence interval 1.0-1.2). However, pupils who reported higher health related quality of life had a lower incidence of CAMHS referral over the follow-up period (adjusted hazard hario 0.94, 95% confidence interval 0.9-0.98).

CONCLUSION

Children and young people's perception of their quality of life should be considered at the stages of a clinical needs assessment.

Key Barriers to the Provision and Utilization of Mental Health Services in Low-and Middle-Income Countries: A Scope Study

Inadequate attention has been given to the provision of mental health (MH) services especially in low-and middle-income countries (LMICs). This study was aimed to identify key barriers to provide and utilize MH services in LMICs. A comprehensive search on7 important online databases was conducted for key barriers to the provision and utilization MH services in LMICs from Jan 2000 to Nov 2019. Five-step Arksey and O'Malley guideline was used for scope study. The extracted data were synthesized using a qualitative content analysis and thematic network. Three main themes identified as barriers to the provision of MH services in LMICs, namely resource and administrative barriers, information and knowledge barriers, as well as policy and legislation barriers. Also attitudinal barriers, structural barriers, knowledge barriers, and treatment-related barriers were four main themes emerged regarding the challenges of utilization of MH services. Equitable access to MH services in LMICs is influenced by many barriers in both provision and utilization sides. In order to alleviate these problems, health systems could adopt some strategies including integration of MH into the general health policy, improvement of public MH awareness, developing anti-stigma programs, reallocation of health resources toward high-priority MH needs, developing community-based insurance, as well as integration of MH services into all levels of health-care systems. The success of intervention strategies depends on the weight of these barriers in different socio-economic contexts.

Exploring Barriers to Mental Health Services Utilization at Kabutare District Hospital of Rwanda: Perspectives From Patients

Barriers to mental health interventions globally remain a health concern; however, these are more prominent in low- and middle-income countries (LMICs). The barriers to accessibility include stigmatization, financial strain, acceptability, poor awareness, and sociocultural and religious influences. Exploring the barriers to the utilization of mental health services might contribute to mitigating them. Hence, this research aims to investigate these barriers to mental health service utilization in depth at the Kabutare District Hospital of the Southern Province of Rwanda. The qualitative approach was adopted with a cross-sectional study design. The participants were patients with mental illnesses seeking mental health services at the hospital. Ten interviews were conducted in the local language, recorded, and transcribed verbatim and translated by the researchers. Thematic analysis was applied to analyze the data collected. The results revealed that the most common barriers are fear of stigmatization, lack of awareness of mental health services, sociocultural scarcity, scarcity of financial support, and lack of geographical accessibility, which limit the patients to utilize mental health services. Furthermore, it was revealed that rural gossip networks and social visibility within the communities compounded the stigma and social exclusion for patients with mental health conditions. Stigmatization should be reduced among the community members for increasing their empathy. Then, the awareness of mental disorders needs to be improved. Further research in Rwanda on the factors associated with low compliance to mental health services with greater focus on the community level is recommended.

A qualitative study of healthcare professionals' perceptions of men and women's mental healthcare seeking in Rwanda

This study aimed to explore health care professionals (HCP') perceptions about mental-health-seeking behaviours in men and women and its social and gender implications in Rwanda. Six focus group discussions including 43 HCPs working at mental health facilities and district hospitals in Rwanda were conducted. Data were analysed using qualitative content analysis. The emerging theme "Traditional gender role patterns and stigma are displayed in mental health care seeking, adherence to treatment and family effects" illustrated how HCPs perceived gender differences and outcomes in mental healthcare seeking. The theme was based on three categories: "Gender differences in health care seeking patterns," "Gender roles and stigma affect adherence to counselling and treatment," and "Gender roles exert an influence on family support" and related subcategories, with which each described various aspects contributing to the result. According to HCPs who regularly encountered people with mental health problems, neither men nor women with mental health problems could adequately benefit from the available mental health services because of the strong influence stigma and prevailing traditional gender roles had on men's and women's mental-healthcare-seeking behaviour. There is an urgent need for comprehensive societal interventions involving policy makers, HCPs, and the general population to diminish the stigma tied to mental illness and the traditional gender norms that negatively influence healthcare-seeking patterns; such actions can improve the health of many citizens.

Stakeholder perspectives on integration of mental health services into primary care: a mixed methods study in Northern Iraq

BACKGROUND

Integrating evidence-based mental health services into primary care has been identified as one strategy for overcoming the treatment gap in low and middle-income countries, yet their uptake into standard practice remains poor. The purpose of this study was to understand stakeholder perspectives regarding barriers and facilitators to integration of mental health services into primary care settings in Northern Iraq.

METHODS

Using a convergent mixed methods study design, quantitative and qualitative questionnaires assessed respondent perceptions of implementation factors under the domains of Autonomy, Acceptability, Appropriateness, Feasibility, Penetration/Accessibility, Sustainability, and Organizational Climate. We interviewed four types of stakeholders: clients, providers of mental health services, non-mental health (MH) staff working at the centers, and center directors. Interviews were conducted with clients at the completion of services, and with all other stakeholder groups in the latter half of the first year of program implementation, by Kurdish-speaking interviewer pairs. Qualitative and quantitative data were analyzed separately and merged using qualitative data transformation to quantify frequency of theme and integrate with quantitative findings through woven narrative.

RESULTS

123 clients, 26 providers, 40 non-MH staff, and 12 directors provided data. Positive perceptions of the program's acceptability, appropriateness, feasibility, and positive impacts were reported across all stakeholder levels. Providers reported that the program length (8-12 sessions) was a challenge. Clients described logistical challenges (e.g.: transportation, childcare, home duties); support from family and friends appeared to be critical. Lack of private space, insufficient staffing, and need for greater government support were also important issues.

CONCLUSIONS

This mixed methods study is unique in its inclusion of non-MH staff and director perspectives on integration of mental health services in primary care clinics. Their inclusion proved vital since they included critical human resource barriers to feasibility. Providers reported generally positive integration experiences but that some colleagues (clinic staff not involved in mental health services) were unsupportive. Most non-MH staff were supportive, but some did report negative impacts on their working environment. Future studies of integration of mental health services into other service platforms should include the perspectives of stakeholders not involved in provision of mental health services.

Mental health care use in men with comorbid diabetes and depression: The role of age and race

Objectives:

Older adults with diabetes have double the normal average risk for depression. While women also report higher rates of depression, men are less likely than women to recognize symptoms and seek assistance for mental health treatment. Racial disparities in mental health care use among men have also been identified. While age and gender differences in mental health care use have been accounted for in adults with comorbid diabetes and depression little is known about within group differences among men. The purpose of this study was to examine the influence of age and race on mental health service use in a sample of men with comorbid diabetes and depression.

Methods:

This study utilized secondary data from a large health care delivery system serving in a Midwestern urban city and included 335 Black, and non-Latino White men with comorbid type 2 diabetes and depression.

Results and Discussion:

Findings indicate that men under the age of 55 were less likely to experience a 6-month or more delay in receiving a psychiatric medication prescription after their initial depression diagnosis. Black men over 55 years of age were significantly more likely to experience a delay of over six months to receiving psychiatric medication. More research is needed to explore preferred depression treatment methods for older Black men with type 2 diabetes, in addition to any issues with access to pharmacological medications to treat depression.

Mental Health Diagnostic Frameworks, Imputed Causes of Mental Illness, and Alternative Treatments in Northern Tanzania: Exploring Mental Health Providers' Perspectives

In Tanzania, a nation with a large mental health treatment gap, local stakeholders' perspectives are critical for informing effective treatment. The practice-based perspectives of mental health providers may be particularly instructive. Existing foundational literature on the professional population in this region is scarce. We conducted semi-structured interviews with 29 mental health providers in northern Tanzania. Interviews focused on three topics: use of international diagnostic frameworks for mental illness, beliefs about causes of mental health concerns, and alternative treatments sought by clients. Interview data were coded and analyzed using consensual qualitative research and the constant comparative method. Usage of diagnostic frameworks varied widely. Providers believed frameworks accurately described many patients but neglected somatic symptoms and contained diagnoses that they had never witnessed. Providers described supernatural and spiritual attributions of mental illness as substantially impacting treatment decisions. Other notable attributions included physical illness, drug/alcohol use, and heredity. Providers reported their clients routinely sought treatment from traditional and spiritual healers prior to seeking care in the formal health system. This study builds a foundation for the ongoing development of the mental health system in northern Tanzania. Findings also support exploration of integrative models of care and task-shifting to incorporate traditional and spiritual beliefs.

Intimate partner violence during pregnancy in relation to non-psychotic mental health disorders in Rwanda: a cross-sectional population-based study

OBJECTIVES

To investigate the prevalence of non-psychotic mental health disorders (MHDs) and the association between exposure to all forms of intimate partner violence (IPV) during pregnancy and MHDs.

DESIGN

Cross-sectional population-based study conducted in the Northern Province of Rwanda and Kigali city.

PARTICIPANTS AND SETTINGS

Totally, 921 women who gave birth ≤13 months before being interviewed were included. Simple random sampling was done to select villages, households and participants. Community health workers helped to identify eligible participants and clinical psychologists, nurses or midwives conducted face-to-face interviews. The collected data were analysed using descriptive statistics and bivariable and multivariable logistic regression modelling RESULTS: The prevalence rates of generalised anxiety disorder, suicide ideation and post-traumatic stress disorder (PTSD) were 19.7%, 10.8% and 8.0%, respectively. Exposure to the four forms of IPV during pregnancy was highly associated with the likelihood of meeting diagnostic criteria for each of the non-psychotic MHDs investigated. Physical, psychological and sexual violence, showed the strongest association with PTSD, with adjusted ORs (aORs) of 4.5, 6.2 and 6.3, respectively. Controlling behaviour had the strongest association with major depressive episode in earlier periods with an aOR of 9.2.

CONCLUSION

IPV and MHDs should be integrated into guidelines for perinatal care. Moreover, community-based services aimed at increasing awareness and early identification of violence and MHDs should be instituted in all villages and health centres in Rwanda. Finally, healthcare providers need to be educated and trained in a consistent manner to manage the most challenging cases quickly, discreetly and efficiently.

Realization of the rights of persons with disabilities in Rwanda

This scoping study assessed the realization of the rights for persons with disabilities in Rwanda since the signing of the United Nations Convention on the Rights of Persons with Disabilities (UN CRPD) in 2008. Underpinned by the five-stage framework of Arksey and O'Malley, the scoping study examined peer-reviewed literature published between 2008 and 2017. Nine electronic databases were searched using keywords specific to disability in Rwanda. Data were charted by three reviewers according to pre-determined and emergent categories. Descriptive statistics were used to describe the data sources. A total of 60 scholarly articles met the inclusion criteria. Within the research, studies pertaining to the UN CRPD Articles of health, awareness raising, accessibility, and children with disabilities were the most published. The literature identified a movement towards the realization of the rights for persons with disabilities in Rwanda since the country signed the UN CRPD. Despite efforts to meet these rights, discrimination against persons with disabilities still exists and greater investment in the disability sector is needed, particularly for justice, social protection, and mental health services. Given the state of the evidence, concerning research gaps also exist in regards to deinstitutionalization and protection issues (i.e., violence and abuse). This consolidation of evidence may help to inform the decision-making priorities for government and civil society organizations in policy and programming and also direct future research.

Forensic psychiatry in Rwanda

Forensic psychiatry has often been neglected in nonwestern countries, including the African continent. Our aim was to assess the practices and needs for improvement in the field of forensic psychiatry in Rwanda. During a one-week visit conducted in October 2017, we interviewed key-informants working at decisional levels in the domains of health, justice and security. Two clinical workshops involving psychiatrists, psychologists and nurses were held in psychiatric facilities, including at Ndera, the main psychiatric hospital of the country. Three axes of development and improvement were identified: First there is a need for a clearer, more coherent and updated legislative framework. Second, the absence of a forensic secured unit, which compromises both quality of care for forensic patients and security of the other patients and staff, should be remediated. Third, the supervision and training in this specialized domain should be provided through international collaborations. Hopefully, Rwanda could become in the next few years a driving force for other African countries in the field of forensic psychiatry.

Mental illness in Bwindi, Uganda: Understanding stakeholder perceptions of benefits and barriers to developing a community-based mental health programme

Background

Mental illness has been increasingly recognised as a source of morbidity in low- and middle-income countries and significant treatment gaps exist worldwide. Studies have demonstrated the effectiveness of task sharing through community-based treatment models for addressing international mental health issues.

Aim

This paper aims to evaluate the perceptions of a wide range of mental health stakeholders in a Ugandan community regarding the benefits and barriers to developing a community-based mental health programme.

Setting

Bwindi Community Hospital (BCH) in south-west Uganda provides services through a team of community health workers to people in the Kanungu District.

Methods

Thematic analysis of 13 semi-structured interviews and 6 focus group discussions involving 54 community members and 13 mental health stakeholders within the BCH catchment area.

Results

Stakeholders perceived benefits to a community-based compared to a hospital-based programme, including improved patient care, lower costs to patients and improved community understanding of mental illness. They also cited barriers including cost, insufficient workforce and a lack of community readiness.

Conclusions

Stakeholders express interest in developing community-based mental health programmes, as they feel that it will address mental health needs in the community and improve community awareness of mental illness. However, they also report that cost is a significant barrier to programme development that will have to be addressed prior to being able to successfully establish such programming. Additionally, many community members expressed unique sociocultural beliefs regarding the nature of mental illness and those suffering from a psychiatric disease.

Community perceptions of mental illness in rural Uganda: An analysis of existing challenges facing the Bwindi Mental Health Programme

Objectives

To assess community perceptions of mental illness in the Bwindi Community Hospital (BCH) catchment area: to recognise beliefs about the causes and the treatments for mental illness. To provide community data to staff at BCH as they work to develop more effective community mental health programmes.

Background

A shortage of mental health providers in Uganda has prompted research into community-based task-sharing models for the provision of mental health services in underserved communities.

Methods

Six focus group discussions, with a total of 54 community members (50% male, n = 27; mean age + s.d. [39.9 + 10.9 years]) from the BCH catchment area, were conducted to assess community member and stakeholder perceptions of mental illness and belief in the feasibility of community-based programming. Qualitative study of data through thematic analysis was conducted to assess the presence of commonly occurring perceptions.

Results

Qualitative thematic analysis revealed two major themes: (1) belief that any given patient’s metal illness results from either an intrinsic or an extrinsic cause and (2) belief in a need to determine treatment of mental illness based on the believed cause.

Conclusion

As BCH designs community-based mental health services, our findings provide support for the need for further education of community members and training of community health workers to address and integrate the above-stated beliefs regarding mental illness.

Mental health care in post-genocide Rwanda: evaluation of a program specializing in posttraumatic stress disorder and substance abuse

BACKGROUND

Following the genocide, millions of Rwandans are likely living with posttraumatic stress disorder (PTSD). Le Centre Psychothérapeutique Icyizere provides the only specialized treatment for PTSD in the Rwandan healthcare system.

METHODS

Demographics, diagnosis, treatment, outcomes, and scores on assessments of functioning and PTSD were recorded from clinical charts of all patients receiving care between October 2013 and 2014. Descriptive statistics and within-group t tests comparing functional impairment and PTSD symptoms at intake to discharge and follow-up were calculated.

RESULTS

A total of 719 patients (55.08% male) received care. Patients were more educated, more likely to live in the capital, and less likely to be married than the general population. Patients reported high desire for, and strong satisfaction with, care. Most patients (55.60%) were still in care by the end of the program evaluation. Functioning improved from intake to discharge (p < 0.001), and improvements were sustained at follow-up (p < 0.001). Most adults were diagnosed with psychotic disorders, substance use disorders, or depression. Only 20 patients were diagnosed with PTSD, and symptoms were improved at discharge (p = 0.003).

CONCLUSIONS

This program evaluation demonstrated the utility of a low-resource information management system to provide clarity about the patient population and outcomes. Results suggest that services are effective and sustainable, although people with PTSD were not the primary recipients of care. Disparities in care by diagnosis, education, marital status, and geography are discussed. Results have contributed to changes in service delivery and care and efforts to increase access to care.