Health system constraints in integrating mental health services into primary healthcare in rural Uganda: perspectives of primary care providers

Do Integrated Community Psychiatry Services in Primary Health Care Settings Improve Continuity of Care? A Mixed-methods Study of Health Care Users' Experiences in South Africa

Background

A community psychiatry service is provided from selected primary health care (PHC) clinics in Gauteng, South Africa. This study described the demographic and clinical characteristics of health care users (HCUs), and explored HCUs' experiences of these services in order to shed light on the challenges of integrating psychiatric services into PHC.

Methods

A mixed-methods study was conducted at two PHC clinics, where 384 clinical records were reviewed and 23 HCUs were interviewed. In Clinic-1, community psychiatry services were co-located, while in Clinic-2, these services were physically integrated into the PHC clinic.

Results

HCUs from both clinics were generally female (55%), had not completed secondary level education (65%), and were unemployed (80%). Both clinics struggled with medication stock-outs and had the same number of community psychiatry health care providers. Compared to the co-located clinic, the physically integrated clinic had insufficient consultation rooms (compromising confidentiality), higher caseloads (910 compared to 580), more HCUs with psychotic disorders (61% compared to 44%) and a history of missed medication (58% compared to 40%). In both clinics, overall care coordination was limited, although some nurses coordinated care for HCUs. While organisational integration approaches improved the proximity of mental health services, there were challenges in continuity of care within and across health care sites.

Conclusion

Coordination and continuity of care were constrained in both clinics, regardless of the organisational integration approaches used. As low- and middle-income countries work towards integrating mental health care into PHC, the implementation of organisational integration approaches should consider physical space, caseload, HCU need, and the inclusion of dedicated providers to coordinate care.

Health system facilitators and barriers to the integration of mental health services into primary care in the Democratic Republic of the Congo: a multimethod study

BACKGROUND

The integration of mental health into primary care-i.e., the process by which a range of essential mental health care and services are made available in existing multipurpose health care settings that did not previously provide them-can be facilitated or hindered by several health system factors that are still poorly understood. This study aimed to identify health system facilitators and barriers to the integration of mental health services into primary care in the Democratic Republic of the Congo (DRC) to improve the success rate of integration programs.

METHODS

We conducted a multimethod, cross-sectional exploratory study. Stakeholders (managers, health service providers, service users, etc.) from sixteen of the twenty-six provinces of the DRC participated. We collected qualitative data through 31 individual, semistructured, face-to-face key informant interviews. We then collected quantitative data through a population-based survey of 413 respondents. We analyzed the interviews via thematic analysis, assigning verbatims to predefined themes and subthemes. For the survey responses, we performed descriptive analysis followed by binomial logistic regression to explore the associations between the variables of interest.

RESULTS

Strong leadership commitment, positive attitudes toward mental health care, the availability of care protocols, mental health task sharing (p < 0.001), and sufficient numbers of primary care providers (PCPs) (p < 0.001) were identified as key health system facilitators of successful integration. However, barriers to integration are mainly related to a poor understanding of what integration is and what it is not, as well as to the poor functionality and performance of health facilities. In addition, stigma, low prioritization of mental health, lack of mental health referents, low retention rate of trained health professionals, lack of reporting tools, lack of standardized national guidelines for integration (p < 0.001), lack of funding (p < 0.001), shortage of mental health specialists to coach PCPs (p < 0.001), and lack of psychotropic medications (p < 0.001) were identified as health system barriers to integration.

CONCLUSION

Improving the functionality of primary care settings before integrating mental health care would be beneficial for greater success. In addition, addressing identified barriers, such as lack of funding and mental health-related stigma, requires multistakeholder action across all building blocks of the health system.

Exploring Effective Approaches: Integrating Mental Health Services into HIV Clinics in Northern Uganda

Background

Integrating mental health services into HIV clinics is recognized as a promising strategy. However, the literature reveals gaps, particularly in the unique context of Northern Uganda, where factors such as historical conflict, stigma, and limited resources pose potential barriers.

Material and Methods

This qualitative study, conducted between October and November 2023, employed a phenomenological design. The study involved primary healthcare facilities across diverse urban and rural settings, focusing on healthcare providers, village health teams, and service users. A purposive sampling approach ensured diverse demographics and perspectives. In-depth interviews and focus group discussions were conducted, with healthcare providers and service users participating individually, and village health teams engaged in group discussions. Thematic analysis was employed during data analysis.

Results

Findings revealed a predominance of females among healthcare providers (18 of 30) and service users (16 of 25), as well as in VHTs. Average ages were 33.4 (healthcare providers), 38.5 (service users), and 35.1 (VHTs). Most healthcare providers (15) held diplomas, while 12 service users and 4 VHTs had certificates. The majority of healthcare providers (n=20) and 4 VHTs had 6-10 years of experience. Thematic analysis highlighted three key themes: benefits of integrated mental health services, implementation challenges, and the role of community engagement and cultural sensitivity.

Conclusion

This study contributes valuable insights into the integration of mental health services into HIV clinics in Northern Uganda. The perceived benefits, challenges, and importance of cultural sensitivity and community engagement should guide future interventions, fostering a holistic approach that enhances the overall well-being of individuals living with HIV/AIDS in the region. Policymakers can use this information to advocate for resource allocation, training programs, and policy changes that support the integration of mental health services into HIV clinics in a way that addresses the identified challenges.

An mHealth Intervention to Address Depression and Improve Antiretroviral Therapy Adherence Among Youths Living With HIV in Uganda: Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

People living with HIV often struggle with mental health comorbidities that lower their antiretroviral therapy (ART) adherence. There is growing evidence that depression treatment may improve ART adherence and result in improved HIV outcomes. Given that mental health services are severely underequipped in low-resource settings, including in Uganda, new solutions to increase access to mental health care and close the treatment gap are urgently needed. This protocol paper presents the Suubi-Mhealth study, which proposed to develop a mobile health (mHealth) intervention for use among Ugandan youths (14-17 years) with comorbid HIV and depression, taking into account their unique contextual, cultural, and developmental needs.

OBJECTIVE

The proposed study is guided by the following objectives: (1) to develop and iteratively refine an intervention protocol for Suubi-Mhealth based on formative work to understand the needs of youths living with HIV; (2) to explore the feasibility and acceptability of Suubi-Mhealth on a small scale to inform subsequent refinement; (3) to test the preliminary impact of Suubi-Mhealth versus a waitlist control group on youths' outcomes, including depression and treatment adherence; and (4) to examine barriers and facilitators for integrating Suubi-Mhealth into health care settings.

METHODS

Youths will be eligible to participate in the study if they are (1) 14-17 years of age, (2) HIV-positive and aware of their status, (3) receiving care and ART from one of the participating clinics, and (4) living within a family. The study will be conducted in 2 phases. In phase 1, we will conduct focus group discussions with youths and health care providers, for feedback on the proposed intervention content and methods, and explore the feasibility and acceptability of the intervention. In phase II, we will pilot-test the preliminary impact of the intervention on reducing depression and improving ART adherence. Assessments will be conducted at baseline, 1-, 2-, and 6-months post intervention completion.

RESULTS

Participant recruitment for phase 1 is completed. Youths and health care providers participated in focus group discussions to share their feedback on the proposed Suubi-Mhealth intervention content, methods, design, and format. Transcription and translation of focus group discussions have been completed. The team is currently developing Suubi-Mhealth content based on participants' feedback.

CONCLUSIONS

This study will lay important groundwork for several initiatives at the intersection of digital therapeutics, HIV treatment, and mental health, especially among sub-Saharan African youths, as they transition through adolescence and into adult HIV care settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05965245; https://clinicaltrials.gov/study/NCT05965245.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/54635.

Healthcare workers' perceptions and experiences of primary healthcare integration: a scoping review of qualitative evidence

BACKGROUND

Primary healthcare (PHC) integration has been promoted globally as a tool for health sector reform and universal health coverage (UHC), especially in low-resource settings. However, for a range of reasons, implementation and impact remain variable. PHC integration, at its simplest, can be considered a way of delivering PHC services together that sometimes have been delivered as a series of separate or 'vertical' health programmes. Healthcare workers are known to shape the success of implementing reform interventions. Understanding healthcare worker perceptions and experiences of PHC integration can therefore provide insights into the role healthcare workers play in shaping implementation efforts and the impact of PHC integration. However, the heterogeneity of the evidence base complicates our understanding of their role in shaping the implementation, delivery, and impact of PHC integration, and the role of contextual factors influencing their responses.

OBJECTIVES

To map the qualitative literature on healthcare workers' perceptions and experiences of PHC integration to characterise the evidence base, with a view to better inform future syntheses on the topic.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 28 July 2020. We did not search for grey literature due to the many published records identified.

SELECTION CRITERIA

We included studies with qualitative and mixed methods designs that reported on healthcare worker perceptions and experiences of PHC integration from any country. We excluded settings other than PHC and community-based health care, participants other than healthcare workers, and interventions broader than healthcare services. We used translation support from colleagues and Google Translate software to screen non-English records. Where translation was not feasible we categorised these records as studies awaiting classification.

DATA COLLECTION AND ANALYSIS

For data extraction, we used a customised data extraction form containing items developed using inductive and deductive approaches. We performed independent extraction in duplicate for a sample on 10% of studies allowed for sufficient agreement to be reached between review authors. We analysed extracted data quantitatively by counting the number of studies per indicator and converting these into proportions with additional qualitative descriptive information. Indicators included descriptions of study methods, country setting, intervention type, scope and strategies, implementing healthcare workers, and client target population.

MAIN RESULTS

The review included 184 studies for analysis based on 191 included papers. Most studies were published in the last 12 years, with a sharp increase in the last five years. Studies mostly employed methods with cross-sectional qualitative design (mainly interviews and focus group discussions), and few used longitudinal or ethnographic (or both) designs. Studies covered 37 countries, with close to an even split in the proportions of high-income countries (HICs) and low- and middle-income countries (LMICs). There were gaps in the geographical spread for both HICs and LMICs and some countries were more dominant, such as the USA for HICs, South Africa for middle-income countries, and Uganda for low-income countries. Methods were mainly cross-sectional observational studies with few longitudinal studies. A minority of studies used an analytical conceptual model to guide the design, implementation, and evaluation of the integration study. The main finding was the various levels of diversity found in the evidence base on PHC integration studies that examined healthcare workers' perceptions and experiences. The review identified six different configurations of health service streams that were being integrated and these were categorised as: mental and behavioural health; HIV, tuberculosis (TB) and sexual reproductive health; maternal, women, and child health; non-communicable diseases; and two broader categories, namely general PHC services, and allied and specialised services. Within the health streams, the review mapped the scope of the interventions as full or partial integration. The review mapped the use of three different integration strategies and categorised these as horizontal integration, service expansion, and service linkage strategies. The wide range of healthcare workers who participated in the implementation of integration interventions was mapped and these included policymakers, senior managers, middle and frontline managers, clinicians, allied healthcare professionals, lay healthcare workers, and health system support staff. We mapped the range of client target populations.

AUTHORS' CONCLUSIONS

This scoping review provides a systematic, descriptive overview of the heterogeneity in qualitative literature on healthcare workers' perceptions and experience of PHC integration, pointing to diversity with regard to country settings; study types; client populations; healthcare worker populations; and intervention focus, scope, and strategies. It would be important for researchers and decision-makers to understand how the diversity in PHC integration intervention design, implementation, and context may influence how healthcare workers shape PHC integration impact. The classification of studies on the various dimensions (e.g. integration focus, scope, strategy, and type of healthcare workers and client populations) can help researchers to navigate the way the literature varies and for specifying potential questions for future qualitative evidence syntheses.

Healthcare workers' perceptions and experiences of primary healthcare integration: a scoping review of qualitative evidence

BACKGROUND

Primary healthcare (PHC) integration has been promoted globally as a tool for health sector reform and universal health coverage (UHC), especially in low-resource settings. However, for a range of reasons, implementation and impact remain variable. PHC integration, at its simplest, can be considered a way of delivering PHC services together that sometimes have been delivered as a series of separate or 'vertical' health programmes. Healthcare workers are known to shape the success of implementing reform interventions. Understanding healthcare worker perceptions and experiences of PHC integration can therefore provide insights into the role healthcare workers play in shaping implementation efforts and the impact of PHC integration. However, the heterogeneity of the evidence base complicates our understanding of their role in shaping the implementation, delivery, and impact of PHC integration, and the role of contextual factors influencing their responses.

OBJECTIVES

To map the qualitative literature on healthcare workers' perceptions and experiences of PHC integration to characterise the evidence base, with a view to better inform future syntheses on the topic.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 28 July 2020. We did not search for grey literature due to the many published records identified.

SELECTION CRITERIA

We included studies with qualitative and mixed methods designs that reported on healthcare worker perceptions and experiences of PHC integration from any country. We excluded settings other than PHC and community-based health care, participants other than healthcare workers, and interventions broader than healthcare services. We used translation support from colleagues and Google Translate software to screen non-English records. Where translation was not feasible we categorised these records as studies awaiting classification.

DATA COLLECTION AND ANALYSIS

For data extraction, we used a customised data extraction form containing items developed using inductive and deductive approaches. We performed independent extraction in duplicate for a sample on 10% of studies allowed for sufficient agreement to be reached between review authors. We analysed extracted data quantitatively by counting the number of studies per indicator and converting these into proportions with additional qualitative descriptive information. Indicators included descriptions of study methods, country setting, intervention type, scope and strategies, implementing healthcare workers, and client target population.

MAIN RESULTS

The review included 184 studies for analysis based on 191 included papers. Most studies were published in the last 12 years, with a sharp increase in the last five years. Studies mostly employed methods with cross-sectional qualitative design (mainly interviews and focus group discussions), and few used longitudinal or ethnographic (or both) designs. Studies covered 37 countries, with close to an even split in the proportions of high-income countries (HICs) and low- and middle-income countries (LMICs). There were gaps in the geographical spread for both HICs and LMICs and some countries were more dominant, such as the USA for HICs, South Africa for middle-income countries, and Uganda for low-income countries. Methods were mainly cross-sectional observational studies with few longitudinal studies. A minority of studies used an analytical conceptual model to guide the design, implementation, and evaluation of the integration study. The main finding was the various levels of diversity found in the evidence base on PHC integration studies that examined healthcare workers' perceptions and experiences. The review identified six different configurations of health service streams that were being integrated and these were categorised as: mental and behavioural health; HIV, tuberculosis (TB) and sexual reproductive health; maternal, women, and child health; non-communicable diseases; and two broader categories, namely general PHC services, and allied and specialised services. Within the health streams, the review mapped the scope of the interventions as full or partial integration. The review mapped the use of three different integration strategies and categorised these as horizontal integration, service expansion, and service linkage strategies. The wide range of healthcare workers who participated in the implementation of integration interventions was mapped and these included policymakers, senior managers, middle and frontline managers, clinicians, allied healthcare professionals, lay healthcare workers, and health system support staff. We mapped the range of client target populations.

AUTHORS' CONCLUSIONS

This scoping review provides a systematic, descriptive overview of the heterogeneity in qualitative literature on healthcare workers' perceptions and experience of PHC integration, pointing to diversity with regard to country settings; study types; client populations; healthcare worker populations; and intervention focus, scope, and strategies. It would be important for researchers and decision-makers to understand how the diversity in PHC integration intervention design, implementation, and context may influence how healthcare workers shape PHC integration impact. The classification of studies on the various dimensions (e.g. integration focus, scope, strategy, and type of healthcare workers and client populations) can help researchers to navigate the way the literature varies and for specifying potential questions for future qualitative evidence syntheses.

Enhancing the Capacity of Providers in Mental Health Integration (ECaP-MHI) in Rural Uganda: The Adaptation Process

Purpose

Uganda adopted the World Health Organization (WHO) model of creating district health management teams (DHMT) comprised of public health officials and administrators to supervise health service delivery at the community level. The purpose of this study was to characterize the perspectives of the DMHT in providing support supervision to primary health-care providers implementing mental health integration using the pre-recorded material. Our aim was to identify barriers to individual uptake and contextual fit, and to solicit solutions for co-designed improvements.

Methods

We conducted a qualitative exploratory study using one-on-one interviews informed by the Practical Robust Implementation and Sustainability Model.

Results

Members of the DHMT identified a systemic gap in supporting mental health integration into primary care, and reported limited knowledge in how to supervise mental health integration and lacked data on mental health delivery and outcomes. They recommended training of the DHMT in supervising mental health integration supported by standard outcome reports, pre-recorded instructional material by psychiatrists, checklists to help guide and standardize the process, and use of visual aids illustrating mental disorders and treatments for low-health literacy populations.

Conclusion

Implementing integrated mental health care using the WHO model of DHMTs as external facilitators and supervisors of primary health-care providers is potentially feasible and scalable, provided that substantial reforms occur such as training in how to provide supervision, standard collection of outcome reports, and practical tools to help guide and facilitate the process.

Barriers and facilitators to the utilization of the intensive adherence counselling framework by healthcare providers in Uganda: a qualitative study

Background

Uganda Ministry of Health (UMOH) embraced the World Health Organization recommendation for people living with human immunodeficiency virus with a detectable viral load (VL) exceeding 1000 copies/mL to receive intensive adherence counselling (IAC). The IAC framework was developed as a step-by-step guide for healthcare providers to systematically support persons with non-suppressed VL to develop a comprehensive plan for adhering to treatment. The objective of this study was to explore the current practice of the healthcare providers when providing IAC, and identify the barriers and facilitators to the utilization of the UMOH IAC framework at two health centers IV level in rural Uganda.

Methods

This was a descriptive cross-sectional qualitative study that explored the current practices of the healthcare providers when providing IAC, and identified the barriers and facilitators to the utilization of the UMOH IAC framework. We used an interview guide with unstructured questions about what the participants did to support the clients with non-suppressed VL, and semi-structured questions following a checklist of categories of barriers and facilitators that affect ‘providers of care’ as provided by the Supporting the Use of Research Evidence for policy in African health systems (SURE) framework. Current practice as well as the categories of barriers and facilitators formed the a priori themes which guided data collection and analysis. In this study we only included healthcare providers (i.e., medical doctors, clinical officer, nurses, and counsellors) as ‘providers of care’ excluding family members because we were interested in the health system.

Results

A total of 19 healthcare providers took part in the interviews. The healthcare providers reported lack of sufficient knowledge on the UMOH IAC framework; most of them did not receive prior training or sensitization when it was first introduced. They indicated that they lacked counselling and communication skills to effectively utilize the IAC framework, and they were not motivated to utilize it because of the high workload at the clinics compounded by the limited workforce.

Conclusions

Although the UMOH IAC framework is a good step-by-step guide for the healthcare providers, there is need to understand their context and assess readiness to embrace the new behavior before expecting spontaneous uptake and utilization.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08495-0.

Understanding post-conflict mental health needs and co-producing a community-based mental health intervention for older adults in Colombia: a research protocol

Background

Older adults in Colombia have seen a number of stressful life events – including the Colombian armed conflict, forced misplacement and recently COVID-19. These events likely have had and are having a substantial impact on people’s mental health and well-being, whilst mental health care provision in Colombia is not sufficient and often access is limited and unaffordable. Therefore, the aim of this study is to understand the impact of stressful life events on the mental health of older adults living in Colombia, and co-produce, pilot, and evaluate a community-based mental health intervention in Turbo.

Methods

This 3-year international mixed-methods study comprises of three phases: Phase I will explore the impact of stressful life events on the mental health of older adults living in Colombia, and their mental health needs, via quantitative needs assessments and qualitative interviews and focus groups; Phase II will involve synthesising the findings from Phase I as well as conducting a systematic review and qualitative interviews with experts into implementing mental health interventions in LMICs to co-produce a community-based mental health intervention with older adults and local community group leaders and care providers; Phase III will involve the piloting and evaluation of the mental health intervention via quantitative and qualitative assessments. Co-production and public involvement underpin each element of this project.

Discussion

Appropriate mental health care is as important as physical health care, but this study also looks at how we might integrate these findings into community-level public health initiatives for application both within Colombia and more widely in both LMICs and more developed countries. This study protocol will act as a guide for the development and adaptation of psychosocial mental health interventions in different cultures and contexts.

Levels of depression, anxiety, and psychological distress among Ugandan adults during the first wave of the COVID-19 pandemic: cross-sectional evidence from a mobile phone-based population survey

OBJECTIVES

Policy measures to slow the spread of coronavirus disease 2019 (COVID-19), such as curfews and business closures, may have negative effects on mental health. Populations in low- and middle-income countries (LMICs) may be particularly affected due to high rates of poverty and less comprehensive welfare systems, but the evidence is scarce. We evaluated predictors of depression, anxiety, and psychological distress in Uganda, which implemented one of the world's most stringent lockdowns.

METHODS

We conducted a mobile phone-based cross-sectional survey from December 2020 through April 2021 among individuals aged 18 years or over in Uganda. We measured depression, anxiety, and psychological distress using the Patient Health Questionnaire (PHQ)-2, the Generalized Anxiety Disorder (GAD)-2, and the PHQ-4. We applied linear regression to assess associations between experiences of COVID-19 (including fear of infection, social isolation, income loss, difficulty accessing medical care, school closings, and interactions with police) and PHQ-4 score, adjusted for sociodemographic characteristics.

RESULTS

29.2% of 4066 total participants reported scores indicating moderate psychological distress, and 12.1% reported scores indicating severe distress. Distress was most common among individuals who were female, had lower levels of education, and lived in households with children. Related to COVID-19, PHQ-4 score was significantly associated with difficulty accessing medical care, worries about COVID-19, worries about interactions with police over lockdown measures, and days spent at home.

CONCLUSIONS

There is an urgent need to address the significant burden of psychological distress associated with COVID-19 and policy responses in LMICs. Pandemic mitigation strategies must consider mental health consequences.

Barriers and facilitators of rendering HIV services by community health workers in sub-Saharan Africa: a meta-synthesis

Objectives

To synthesise qualitative studies that address the barriers to and facilitators of providing HIV services by community health workers (CHWs) in sub-Saharan Africa (SSA).

Design

This meta-synthesis was guided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We included studies that were published between 2009 and 2019. The Ritchie and Spencer framework and the Supporting the Use of Research Evidence framework were used for thematic analysis and framework analysis, respectively. The Qualitative Assessment and Review Instrument was used to assess the quality of selected studies.

Eligibility criteria

Qualitative studies published between 2009 and 2019, that included CHWs linked directly or indirectly to the Ministry of Health and providing HIV services in the communities.

Information sources

An extensive search was conducted on the following databases: EBSCOhost- (ERIC; Health Source-Nursing/Academic Edition; MEDLINE Full Text), Google Scholar and PubMed.

Results

Barriers to rendering of HIV services by CHWs were community HIV stigma; lack of CHW respect, CHWs’ poor education and training; poor stakeholders’ involvement; poor access to the communities; shortage of CHWs; unsatisfactory incentives; lack of CHW support and supervision, lack of equipment and supplies and social barriers due to culture, language and political structures. The altruistic behaviour of CHWs and the availability of job facilitated the provision of HIV services.

Conclusion

The delivery of HIV services by CHWs in SSA is faced by more lingering barriers than facilitators. Planners and policymakers can minimise the barriers by investing in both CHW and community training regarding HIV services. Furthermore, sufficient funding should be allocated to the programme to ensure its efficiency.

PROSPERO registration number

CRD42020160012.

Adherence to clinical guidelines in integration of mental health services into primary health care in Mbarara, southwestern Uganda: a medical records review

Background

The Ugandan Ministry of Health decentralized mental healthcare to the district level; developed the Uganda Clinical Guidelines (UCG); and trained primary health care (PHC) providers in identification, management, and referral of individuals with common mental disorders. This was intended to promote integration of mental health services into PHC in the country. ‘Common mental disorders’ here refers to mental, neurological and substance use conditions as indicated in the UCG. However, the extent of integration of mental health into general healthcare remains unknown. This study aimed to establish the level of adherence of PHC providers to the UCG in the identification and management of mental disorders.

Methods

This was a prospective medical record review of patient information collected in November and December 2018, and March and April 2019 at two health centers (III and IV) in southwestern Uganda. Data (health facility level; sex and age of the patient; and mental disorder diagnosis, management) was collected using a checklist. Continuous data was analyzed using means and standard deviation while categorical data was analyzed using Chi-square. Multivariable logistic regression analysis was performed to establish predictors of PHC provider adherence to the clinical guidelines on integration of mental health services into PHC. The analysis was conducted at a 95% level of significance.

Results

Of the 6093 records of patients at the study health facilities during the study period, 146 (2.4%) had a mental or neurological disorder diagnosis. The commonly diagnosed disorders were epilepsy 91 (1.5%) and bipolar 25 (0.4%). The most prescribed medications were carbamazepine 65 (44.5%), and phenobarbital 26 (17.8%). The medicines inappropriately prescribed at health center III for a mental diagnosis included chlorpromazine for epilepsy 3 (2.1%) and haloperidol for epilepsy 1 (0.7%). Female gender (aOR: 0.52, 95% CI 0.39–0.69) and age 61+ years (aOR: 3.02, 95% CI 1.40–6.49) were predictors of a mental disorder entry into the HMIS register.

Conclusion

There was a noticeable change of practice by PHC providers in integrating mental health services in routine care as reflected by the rise in the number of mental disorders diagnosed and treated and entered into the modified paper based HMIS registers.

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.

Development of an integrated, holistic care package for people with lymphoedema for use at the level of the Primary Health Care Unit in Ethiopia

BACKGROUND

Neglected Tropical Diseases (NTDs) are a group of several communicable and non-communicable diseases prevalent in tropical and subtropical areas. The co-endemicity of these diseases, the similarity of their clinical signs, and the need to maximize limited financial and human resources suggest the importance of adoptingan integratedapproach to their prevention and treatment.

AIMS

This study describes the development of a comprehensive package of physical, mental health and psychosocial care for people with lower-limb lymphoedema caused bypodoconiosis, lymphatic filariasis (LF)or leprosy as part of the EnDPoINT program in Ethiopia.

METHOD

The care package was developed using a mixed-methods approach, consisting of a literature review, situational analysis, Theory of Change (ToC) workshops, qualitative research, and additional workshops to fine-tune the draft care package. The care package was developed between March 2018 and January 2020 in Addis Ababa and the implementation research site, Awi zone in the North-West of Ethiopia.

RESULTS

The holistic care package includes components implemented at three levels of the health care system:health organization, facility, and community. Sections of the care package are directed at strengthening capacity building, program management, community engagement, awareness-raising, stigma-reduction, morbidity management, disability prevention, follow-up visits, referral linkage, community-based rehabilitation, and monitoring and evaluation.

CONCLUSIONS

The study developed a holistic integrated care package for lower limb disorder and co-morbid mental health problems caused by podoconiosis, LF or leprosy. The approach has the potential to significantly reduce lower limb disorder-associated morbidity, disability, and psychosocial problems. It also standardizes a scalable approach appropriate for the Ethiopian setting and, most likely, other countries where these NTDs are present.

Barriers and Facilitators for Implementing Mental Health Services into the Ethiopian Health Extension Program: A Qualitative Study

PURPOSE

The Ethiopian Ministry of Health has integrated mental health services into the community health service, but it has not yet been implemented. Therefore, this study aimed to explore the barriers and facilitators of mental health service implementation in the Ethiopian community health program.

METHODS

A qualitative case study was conducted in the Ethiopian primary health care system in 2019. We have conducted about eight key informant interviews with policymakers, service managers, and service providers. The interviews were tape-recorded, transcribed, translated, and analyzed manually using the World Health Organization building blocks framework.

RESULTS

The Health Ministry of Ethiopia has recently included mental health services into the health extension package but not yet implemented as part of integrated services. The identified barriers were low political commitment, shortage of resources, non-functional referral system, lack of interest from private health service organizations, attitudinal problems from both the society and service providers, and lack of consistent reporting system of the mental health problems. However, the well-designed primary health care system, trained health extension workers, changing political commitment and attitude of the community could facilitate the mental health service implementation.

CONCLUSION

A series of activities are expected, especially from the healthcare system managers to implement, follow, and evaluate mental health services implementation at the health extension programs.

Addressing Common Mental Health Disorders Among Incarcerated People Living with HIV: Insights from Implementation Science for Service Integration and Delivery

PURPOSE

Despite evidence of disproportionate burden of HIV and mental health disorders among incarcerated people, scarce services exist to address common mental health disorders, including major depressive and anxiety disorders, post-traumatic stress disorder, and substance use disorders, among incarcerated people living with HIV (PLHIV) in sub-Saharan Africa (SSA). This paper aims to summarize current knowledge on mental health interventions of relevance to incarcerated PLHIV and apply implementation science theory to highlight strategies and approaches to deliver mental health services for PLHIV in correctional settings in SSA.

RECENT FINDINGS

Scarce evidence-based mental health interventions have been rigorously evaluated among incarcerated PLHIV in SSA. Emerging evidence from low- and middle-income countries and correctional settings outside SSA point to a role for cognitive behavioral therapy-based talking and group interventions implemented using task-shifting strategies involving lay health workers and peer educators. Several mental health interventions and implementation strategies hold promise for addressing common mental health disorders among incarcerated PLHIV in SSA. However, to deliver these approaches, there must first be pragmatic efforts to build corrections health system capacity, address human rights abuses that exacerbate HIV and mental health, and re-conceptualize mental health services as integral to quality HIV service delivery and universal access to primary healthcare for all incarcerated people.

Barriers and facilitators of rendering HIV services by community health workers in sub-Saharan Africa: a meta-synthesis protocol

INTRODUCTION

In sub-Saharan Africa (SSA), Human Immunodeficiency Virus (HIV) is the leading cause of morbidity and mortality. Community healthcare workers (CHWs) worldwide have been reported to be effective in strengthening the HIV programme by providing services such as adherence support, HIV education and safe sex education as part of their roles. The main aim of this meta-synthesis is to synthesise qualitative evidence on studies that have been conducted in SSA countries to understand the barriers to and facilitators of providing HIV services by CHWs across all settings METHODS AND ANALYSIS: This meta-synthesis will be guided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses. An initial search was conducted on 15 November 2019 for studies published between 2009 and 2019 using the population exposure outcome nomenclature. We searched the EBSCOHost- (ERIC; Health Source-Nursing/Academic Edition), Google Scholar and PubMed databases for the relevant studies. The Ritchie and Spencer framework will be used for data synthesis and the Supporting the Use of Research Evidence Framework analysis will be used to analyse data. We will conduct critical appraisal on selected studies using the Qualitative Assessment and Review Instrument to limit risk of bias.

ETHICS AND DISSEMINATION

This review does not involve any human participants and therefore ethical approval will not be required. We will publish the protocol as well as the findings in any relevant journal and various media namely conferences; symposia, local and international health stakeholders.

PROSPERO REGISTRATION NUMBER

CRD42020160012.

CONCLUSION

Evidence from this review will provide synthesised evidence to the utilisation of CHWs in HIV services in SSA.

Implementing clinical guidelines to promote integration of mental health services in primary health care: a qualitative study of a systems policy intervention in Uganda

Background

Clinical practice guidelines (CPG) are developed based on a synthesis of evidence regarding the best options for the assessment, diagnosis and treatment of diseases and are recognized as essential quality improvement tools. However, despite growing availability of CPG, research evaluating their use for mental disorders in Uganda is lacking. For a successful implementation of CPG to be achieved, a number of considerations need to be put in place.

Objective

This study aimed to assess the feasibility and acceptability of the educational intervention that we developed towards improvement of the primary health care providers (PHCPs) uptake of the Uganda Clinical Guidelines (UCG) in integrating mental health services into PHC in Mbarara district, southwestern Uganda.

Methods

This was a descriptive cross-sectional qualitative study with a semi-structured in-depth interview guide. The educational intervention we were assessing had four components: (i) summarized UCG on common mental disorders; (ii) modified Health Management Information System (HMIS) registers to include mental health; (iii) clinician's checklist outlining the steps to be followed; and iv) support supervision/training.

Results

Six themes emerged from the study while the components of the intervention formed the apriori subthemes. Key results based on the subthemes show: (i) summarized UCG: the participants liked the packaging stating that it eased their work, was time saving and user friendly; (ii) modified register: participants appreciated the modifications made to the register updating the existing record in the Health Management Information System (HMIS) registers to include mental health disorders; (iii) TRAINING and support supervision: the PHCPs attributed the success in using the summarized UCG to the training they received, and they further expressed the need to regularize the training in assessment for mental health and support by the mental health specialists.

Conclusion

Our study demonstrates that the use of summarized UCG, modified HMIS registers to include mental health, training and support supervision by mental health specialists in implementing the UCG in integrating mental health at PHC settings is feasible and acceptable by the PHCPs in Mbarara district, southwestern Uganda. Given the need for improved mental health care in Uganda, this intervention could be rigorously evaluated for effectiveness, scalability and generalizability.