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Greenley R, Tamambang R, Koroma A, Fasoranti B, Munetsi E, Chinoko H, Stevens N, Goba N, Kinyabo PA, Bella-Awusah T, Ryan G. SUCCEED Africa: protocol for a multi-method pilot study of a community-based intervention for people with psychosis in Sierra Leone, Nigeria, Zimbabwe and Malawi. Pilot Feasibility Stud 2024; 10:114. [PMID: 39192304 DOI: 10.1186/s40814-024-01536-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 08/05/2024] [Indexed: 08/29/2024] Open
Abstract
BACKGROUND Recent reviews have highlighted the need for participatory research to design and evaluate inclusive, community-based interventions that address the diverse needs of people with lived experience of psychosis, within and beyond the health sector. The SUCCEED Africa consortium aims to co-produce a 6-year programme of research across four countries in West (Sierra Leone, Nigeria) and Southeast Africa (Zimbabwe and Malawi). This protocol describes the pilot study in which SUCCEED's intervention, research tools and processes will be tested on a small scale in each country in preparation for future evaluation research. METHODS The SUCCEED intervention comprises peer support, case management and livelihood activities for people with lived experience of psychosis. The pilot uses a before-and-after study design investigating change in subjective quality of life in adults diagnosed with a primary psychotic disorder or another mental disorder with psychotic symptoms who are offered the SUCCEED intervention over a 4-month period. Nested within this study are the following: a baseline assessment of the feasibility, acceptability and face validity of the selected measurement tool and validity of proxy versus self-completion; and a multi-method process evaluation examining key process indicators and implementation, service and client-level outcomes. Methods include the following: baseline cognitive interviews; semi-structed observation and routine monitoring and evaluation of service delivery; endline interviews and focus group discussions; and a comparison of provider competencies at endline. At each of the four pilot sites, participants will include the following: ten people with lived experience of psychosis, recruited from either health services or community settings using purposive sampling to maximise variation; up to ten adult family members (one per participant with lived experience) involved in their care; the peer support worker, community support worker and supervisor responsible for delivering the intervention; and the data collectors. Recruitment will take place in July and August 2023. DISCUSSION To the best of our knowledge, this will be the first study of a community-based intervention incorporating lay-delivered case management, formal peer support and livelihoods activities for people with lived experience of psychosis in sub-Saharan Africa. Findings will be relevant not only to SUCCEED but also to others interested in promoting rights-based approaches to community mental health in low-resource settings. TRIAL REGISTRATION US National Library of Medicine (ClinicalTrials.gov), Protocol reference ID 28346. Initially registered retrospectively July 20/2023: In review.
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Affiliation(s)
- Rachel Greenley
- Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Rita Tamambang
- Centre for Child and Adolescent Mental Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Alhaji Koroma
- Mental Health Department, University of Makeni, Lunsar-Makeni Highway, Makeni, Sierra Leone
| | - Bisola Fasoranti
- Centre for Child and Adolescent Mental Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Ephiphania Munetsi
- Research Support Centre, Faculty of Medicine and Health Sciences, University of Zimbabwe, Avondale, Harare, Zimbabwe
| | - Hilda Chinoko
- Department of Mental Health, Kamuzu University of Health Sciences, P/Bag 360, Blantyre, Malawi
| | - Nancy Stevens
- Mental Health Department, University of Makeni, Lunsar-Makeni Highway, Makeni, Sierra Leone
| | - Nyaradzo Goba
- Research Support Centre, Faculty of Medicine and Health Sciences, University of Zimbabwe, Avondale, Harare, Zimbabwe
| | - Philani Ama Kinyabo
- Research Support Centre, Faculty of Medicine and Health Sciences, University of Zimbabwe, Avondale, Harare, Zimbabwe
| | - Tolulope Bella-Awusah
- Centre for Child and Adolescent Mental Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
- Department of Child and Adolescent Psychiatry, University College Hospital, Ibadan, Nigeria
- Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Grace Ryan
- Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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Hanlon C, Roberts T, Misganaw E, Malla A, Cohen A, Shibre T, Fekadu W, Teferra S, Kebede D, Mulushoa A, Girma Z, Tsehay M, Kiross D, Lund C, Fekadu A, Morgan C, Alem A. Studying the context of psychoses to improve outcomes in Ethiopia (SCOPE): Protocol paper. PLoS One 2024; 19:e0293232. [PMID: 38722946 PMCID: PMC11081395 DOI: 10.1371/journal.pone.0293232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 04/08/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND Global evidence on psychosis is dominated by studies conducted in Western, high-income countries. The objectives of the Study of Context Of Psychoses to improve outcomes in Ethiopia (SCOPE) are (1) to generate rigorous evidence of psychosis experience, epidemiology and impacts in Ethiopia that will illuminate aetiological understanding and (2) inform development and testing of interventions for earlier identification and improved first contact care that are scalable, inclusive of difficult-to-reach populations and optimise recovery. METHODS The setting is sub-cities of Addis Ababa and rural districts in south-central Ethiopia covering 1.1 million people and including rural, urban and homeless populations. SCOPE comprises (1) formative work to understand care pathways and community resources (resource mapping); examine family context and communication (ethnography); develop valid measures of family communication and personal recovery; and establish platforms for community engagement and involvement of people with lived experience; (2a) a population-based incidence study, (2b) a case-control study and (2c) a cohort study with 12 months follow-up involving 440 people with psychosis (390 rural/Addis Ababa; 50 who are homeless), 390 relatives and 390 controls. We will test hypotheses about incidence rates in rural vs. urban populations and men vs. women; potential aetiological role of khat (a commonly chewed plant with amphetamine-like properties) and traumatic exposures in psychosis; determine profiles of needs at first contact and predictors of outcome; (3) participatory workshops to develop programme theory and inform co-development of interventions, and (4) evaluation of the impact of early identification strategies on engagement with care (interrupted time series study). Findings will inform development of (5) a protocol for (5a) a feasibility cluster randomised controlled trial of interventions for people with recent-onset psychosis in rural settings and (5b) two uncontrolled pilot studies to test acceptability, feasibility of co-developed interventions in urban and homeless populations.
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Affiliation(s)
- Charlotte Hanlon
- Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, Centre for Global Mental Health, King’s College London, London, United Kingdom
- Department of Psychiatry and WHO Collaborating Centre in Mental Health Research and Capacity Building, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Tessa Roberts
- Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, Centre for Global Mental Health, King’s College London, London, United Kingdom
- ESRC Centre for Society & Mental Health, King’s College London, London, United Kingdom
| | - Eleni Misganaw
- Mental Health Service User Association, Addis Ababa, Ethiopia
| | - Ashok Malla
- Department of Psychiatry and Douglas Mental Health Institute, McGill University, Montreal, Canada
| | - Alex Cohen
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Wubalem Fekadu
- Department of Psychiatry and WHO Collaborating Centre in Mental Health Research and Capacity Building, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Solomon Teferra
- Department of Psychiatry and WHO Collaborating Centre in Mental Health Research and Capacity Building, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Derege Kebede
- Department of Preventive Medicine, School of Public Health, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Adiyam Mulushoa
- Department of Psychiatry and WHO Collaborating Centre in Mental Health Research and Capacity Building, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Zerihun Girma
- Department of Psychiatry and WHO Collaborating Centre in Mental Health Research and Capacity Building, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Mekonnen Tsehay
- Department of Psychiatry and WHO Collaborating Centre in Mental Health Research and Capacity Building, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Dessalegn Kiross
- Victoria University of Wellington, School of Nursing, Midwifery and Health Practice, Wellington, New Zealand
| | - Crick Lund
- Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, Centre for Global Mental Health, King’s College London, London, United Kingdom
- Department of Psychiatry and Mental Health, Alan J Flisher Centre for Public Mental Health, University of Cape Town, Cape Town, South Africa
| | - Abebaw Fekadu
- Department of Psychiatry and WHO Collaborating Centre in Mental Health Research and Capacity Building, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Craig Morgan
- ESRC Centre for Society & Mental Health, King’s College London, London, United Kingdom
| | - Atalay Alem
- Department of Psychiatry and WHO Collaborating Centre in Mental Health Research and Capacity Building, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Gebreegziabhere Y, Habatmu K, Cella M, Alem A. The Ethiopian Cognitive Assessment battery in Schizophrenia (ECAS): a validation study. SCHIZOPHRENIA (HEIDELBERG, GERMANY) 2024; 10:42. [PMID: 38582925 PMCID: PMC10998832 DOI: 10.1038/s41537-024-00462-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 03/15/2024] [Indexed: 04/08/2024]
Abstract
Cognitive impairment is common in people with schizophrenia (PWS). To detect the presence and its consequences, cognitive measures with sound psychometric properties are needed. However, these are lacking especially in low-income countries. Hence, we developed the Ethiopian Cognitive Assessment battery in Schizophrenia (ECAS). In this study, we evaluated the psychometric properties of the ECAS in a cross-sectional study involving 350 PWS. Confirmatory factor analysis demonstrated a one-factor solution. ECAS score correlated significantly but weakly with a disability measure (r = -0.13, p = 0.02) and symptom dimensions of PANSS (r between -0.12 and -0.29, p < 0.05), except for positive symptoms (r = -0.10, p > 0.05). Years of education (β = 0.12, 95% CI (0.09, 0.14), p < 0.001), male sex (β = 0.22, 95% CI (0.05, 0.39)), age β = -0.02, 95% CI (-0.03, -0.01), and medication side effects (β = -0.03, 95% CI (-0.06, -0.01), p = 0.021) were significantly associated with the composite score of ECAS. The Item Response Theory analysis showed that the tool best functions among participants with moderate cognitive impairment (difficulty coefficient between -1.12 and 0.27). The Differential Item Functioning analyses showed that education had a positive contribution on Digit Symbol Substitution Test (MH OR = 2.64, 95% CI (1.34, 5.20)). The results showed that ECAS is valid in assessing cognition in PWS in low-resource settings.
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Affiliation(s)
- Yohannes Gebreegziabhere
- Department of Psychiatry, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
- Department of Nursing, College of Health Sciences, Debre Berhan University, Debre Berhan, Ethiopia.
| | - Kassahun Habatmu
- School of Psychology, College of Education and Behavioral Studies, Addis Ababa University, Addis Ababa, Ethiopia
| | - Matteo Cella
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, England, UK
| | - Atalay Alem
- Department of Psychiatry, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Yang LH, Bass JK, Le PD, Singh R, Gurung D, Velasco PR, Grivel MM, Susser E, Cleland CM, Muñoz RA, Kohrt BA, Bhana A. A Case Study of the Development of a Valid and Pragmatic Implementation Science Measure: The Barriers and Facilitators in Implementation of Task-Sharing Mental Health Interventions (BeFITS-MH) Measure. RESEARCH SQUARE 2024:rs.3.rs-3877031. [PMID: 38343864 PMCID: PMC10854285 DOI: 10.21203/rs.3.rs-3877031/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
Background Few implementation science (IS) measures have been evaluated for validity, reliability and utility - the latter referring to whether a measure captures meaningful aspects of implementation contexts. In this case study, we describe the process of developing an IS measure that aims to assess Barriers and Facilitators in Implementation of Task-Sharing in Mental Health services (BeFITS-MH), and the procedures we implemented to enhance its utility. Methods We summarize conceptual and empirical work that informed the development of the BeFITS-MH measure, including a description of the Delphi process, detailed translation and local adaptation procedures, and concurrent pilot testing. As validity and reliability are key aspects of measure development, we also report on our process of assessing the measure's construct validity and utility for the implementation outcomes of acceptability, appropriateness, and feasibility. Results Continuous stakeholder involvement and concurrent pilot testing resulted in several adaptations of the BeFITS-MH measure's structure, scaling, and format to enhance contextual relevance and utility. Adaptations of broad terms such as "program," "provider type," and "type of service" were necessary due to the heterogeneous nature of interventions, type of task-sharing providers employed, and clients served across the three global sites. Item selection benefited from the iterative process, enabling identification of relevance of key aspects of identified barriers and facilitators, and what aspects were common across sites. Program implementers' conceptions of utility regarding the measure's acceptability, appropriateness, and feasibility were seen to cluster across several common categories. Conclusions This case study provides a rigorous, multi-step process for developing a pragmatic IS measure. The process and lessons learned will aid in the teaching, practice and research of IS measurement development. The importance of including experiences and knowledge from different types of stakeholders in different global settings was reinforced and resulted in a more globally useful measure while allowing for locally-relevant adaptation. To increase the relevance of the measure it is important to target actionable domains that predict markers of utility (e.g., successful uptake) per program implementers' preferences. With this case study, we provide a detailed roadmap for others seeking to develop and validate IS measures that maximize local utility and impact.
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Affiliation(s)
- Lawrence H Yang
- New York University School of Global Public Health, Department of Social and Behavioral Sciences
| | - Judy K Bass
- Johns Hopkins Bloomberg School of Public Health, Department of Mental Health
| | - PhuongThao Dinh Le
- New York University School of Global Public Health, Department of Social and Behavioral Sciences
| | - Ritika Singh
- George Washington University, Division of Global Mental Health, Department of Psychiatry and Behavioral Sciences
| | - Dristy Gurung
- Transcultural Psychosocial Organization (TPO) Nepal; King's College London, Denmark Hill Campus
| | - Paola R Velasco
- Universidad O'Higgins; Universidad Católica de Chile; Universidad de Chile
| | - Margaux M Grivel
- 1 New York University School of Global Public Health, Department of Social and Behavioral Sciences
| | - Ezra Susser
- Columbia University Mailman School of Public Health; New York State Psychiatric Institute
| | - Charles M Cleland
- New York University Grossman School of Medicine, Department of Population Health
| | | | - Brandon A Kohrt
- George Washington University, Division of Global Mental Health, Department of Psychiatry and Behavioral Sciences
| | - Arvin Bhana
- University of KwaZulu-Natal, Centre for Rural Health; South African Medical Research Council, Health Systems Research Unit
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Keynejad RC, Bitew T, Sorsdahl K, Myers B, Honikman S, Medhin G, Deyessa N, Mulushoa A, Fekadu E, Howard LM, Hanlon C. Problem-solving therapy for pregnant women experiencing depressive symptoms and intimate partner violence: A randomised, controlled feasibility trial in rural Ethiopia. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002054. [PMID: 37889918 PMCID: PMC10610520 DOI: 10.1371/journal.pgph.0002054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 09/25/2023] [Indexed: 10/29/2023]
Abstract
Evidence for the feasibility of brief psychological interventions for pregnant women experiencing intimate partner violence (IPV) in rural, low-income country settings is scarce. In rural Ethiopia, the prevalence of antenatal depressive symptoms and lifetime IPV are 29% and 61%, respectively. We aimed to assess the feasibility and related implementation outcomes of brief problem-solving therapy (PST) adapted for pregnant women experiencing IPV (PST-IPV) in rural Ethiopia, and of a randomised, controlled feasibility study design. We recruited 52 pregnant women experiencing depressive symptoms and past-year IPV from two antenatal care (ANC) services. Consenting women were randomised to PST-IPV (n = 25), 'standard' PST (not adapted for women experiencing IPV; n = 12) or enhanced usual care (information about sources of support; n = 15). Masked data collectors conducted outcome assessments nine weeks post-enrolment. Addis Ababa University (#032/19/CDT) and King's College London (#HR-18/19-9230) approved the study. Fidelity to randomisation was impeded by strong cultural norms about what constituted IPV. However, recruitment was feasible (recruitment rate: 1.5 per day; 37% of women screened were eligible). The intervention and trial were acceptable to women (4% declined initial screening, none declined to participate, and 76% attended all four sessions of either active intervention). PST-IPV was acceptable to ANC providers: none dropped out. Sessions lasting up to a mean 52 minutes raised questions about the appropriateness of the model to this context. Competence assessments recommended supplementary communication skills training. Fidelity assessments indicated high adherence, quality, and responsiveness but assessing risks and social networks, and discussing confidentiality needed improvement. Adjustments to optimise a future, fully powered, randomised controlled trial include staggering recruitment in line with therapist availability, more training on the types of IPV and how to discuss them, automating randomisation, a supervision cascade model, and conducting post-intervention outcome assessments immediately and three months postpartum. Registration: Pan African Clinical Trials Registry #PACTR202002513482084 (13/12/2019): https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=9601.
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Affiliation(s)
- Roxanne C. Keynejad
- Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, Section of Women’s Mental Health, King’s College London, Denmark Hill, London, United Kingdom
| | - Tesera Bitew
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Psychology, College of Education and Behavioural Sciences, Injibara University, Injibara, Ethiopia
| | - Katherine Sorsdahl
- Department of Psychiatry and Mental Health, Alan J Flisher Centre for Public Mental Health, University of Cape Town, Cape Town, South Africa
| | - Bronwyn Myers
- Department of Psychiatry and Mental Health, Division of Addiction Psychiatry, University of Cape Town, Cape Town, South Africa
- Curtin enAble Institute, Curtin University, Bentley, Western Australia, Australia
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Simone Honikman
- Department of Psychiatry and Mental Health, Alan J Flisher Centre for Public Mental Health, University of Cape Town, Cape Town, South Africa
- Department of Psychiatry and Mental Health, Perinatal Mental Health Project, University of Cape Town, Cape Town, South Africa
| | - Girmay Medhin
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Negussie Deyessa
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Adiyam Mulushoa
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Eshcolewyine Fekadu
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Louise M. Howard
- Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, Section of Women’s Mental Health, King’s College London, Denmark Hill, London, United Kingdom
| | - Charlotte Hanlon
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, Denmark Hill, London, United Kingdom
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Asher L, Birhane R, Weiss HA, Medhin G, Selamu M, Patel V, De Silva M, Hanlon C, Fekadu A. Community-based rehabilitation intervention for people with schizophrenia in Ethiopia (RISE) cluster-randomised controlled trial: An exploratory analysis of impact on food insecurity, underweight, alcohol use disorder and depressive symptoms. Glob Ment Health (Camb) 2023; 10:e70. [PMID: 38024800 PMCID: PMC10643237 DOI: 10.1017/gmh.2023.67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/27/2023] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
We evaluated the effectiveness of community-based rehabilitation (CBR) in reducing depressive symptoms, alcohol use disorder, food insecurity and underweight in people with schizophrenia. This cluster-randomised controlled trial was conducted in a rural district of Ethiopia. Fifty-four sub-districts were allocated in a 1:1 ratio to the facility-based care [FBC] plus CBR arm and the FBC alone arm. Lay workers delivered CBR over 12 months. We assessed food insecurity (self-reported hunger), underweight (BMI< 18.5 kg/m2), depressive symptoms (PHQ-9) and alcohol use disorder (AUDIT ≥ 8) at 6 and 12 months. Seventy-nine participants with schizophrenia in 24 sub-districts were assigned to CBR plus FBC and 87 participants in 24 sub-districts were assigned to FBC only. There was no evidence of an intervention effect on food insecurity (aOR 0.52, 95% CI 0.16-1.67; p = 0.27), underweight (aOR 0.44, 95% CI 0.17-1.12; p = 0.08), alcohol use disorder (aOR 0.82, 95% CI 0.24-2.74; p = 0.74) or depressive symptoms (adjusted mean difference - 0.06, 95% CI -1.35, 1.22; p = 0.92). Psychosocial interventions in low-resource settings should support access to treatment amongst people with schizophrenia, and further research should explore how impacts on economic, physical and mental health outcomes can be achieved.
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Affiliation(s)
- Laura Asher
- Academic Unit of Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Rahel Birhane
- WHO Collaborating Centre for Mental Health Research and Capacity-Building, Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia
| | - Helen A. Weiss
- MRC International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Girmay Medhin
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Medhin Selamu
- WHO Collaborating Centre for Mental Health Research and Capacity-Building, Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia
| | - Vikram Patel
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - Charlotte Hanlon
- WHO Collaborating Centre for Mental Health Research and Capacity-Building, Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Global Mental Health, Department of Health Service and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Abebaw Fekadu
- WHO Collaborating Centre for Mental Health Research and Capacity-Building, Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia
- Department of Global Health & Infection, Brighton and Sussex Medical School, Brighton, UK
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Ding R, Zhao M, Wang Y, Wang M, Guo D, Liu X, Wang L, Wei W, Zhang W, He P. Community-based rehabilitation interventions on quality of care for people with schizophrenia in China (CRISC): study protocol for a cluster-randomized controlled trial. BMC Psychiatry 2023; 23:339. [PMID: 37173691 PMCID: PMC10176931 DOI: 10.1186/s12888-023-04774-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 04/12/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND International consensus shows that community-based rehabilitation (CBR) service is an effective way to improve functioning and negative symptoms and address the treatment gap for schizophrenia. Rigorous trials are needed in China to demonstrate effective and scalable CBR interventions to significantly improve outcomes for people with schizophrenia and to provide evidence of the economic benefits. The objectives of this trial are to examine the effectiveness of CBR as an adjunct to test the usual facility-cased care (FBC) in comparison to FBC alone in improving a range of outcomes in people with schizophrenia and their caregivers. METHODS This trial is a cluster randomized controlled trial design in China. The trial will be conducted at three districts of Weifang city, Shandong province. Eligible participants will be identified from the psychiatric management system where community-dwelling patients with schizophrenia have been registered. Participants will be recruited after providing informed consent. 18 sub-districts will be randomly allocated in a 1:1 ratio to facility-based care (FBC) plus CBR (intervention arm) or FBC alone (control arm). The structured CBR intervention will be delivered by trained psychiatric nurses or community health workers. We aim to recruit 264 participants. The primary outcomes include symptoms of schizophrenia, personal and social function, quality of life, family burden of caring, etc. The study will be conducted according to good ethical practice, data analysis and reporting guidelines. DISCUSSION If the hypothesized clinical benefit and cost-effectiveness of CBR intervention are confirmed, this trial will provide significant implications for policy makers and practitioners to scale up rehabilitation services, as well as for people with schizophrenia and their family to promote recovery and social inclusion, and to alleviate the burden of care. TRIAL REGISTRATION Chinese Clinical Trial Registry (ChiCTR2200066945). Registered December 22, 2022.
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Affiliation(s)
- Ruoxi Ding
- China Center for Health and Development Studies, Peking University, Beijing, China
- School of Public Health, Peking University, Beijing, China
| | - Miaomiao Zhao
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Center for Mental Health Management, China Hospital Development Institute, Shanghai Jiao Tong University, Shanghai, China
- Mental Health Branch, China Hospital Development Institute, Shanghai Jiao Tong University, Shanghai, China
| | - Yanshang Wang
- School of Public Health, Peking University, Beijing, China
| | - Ming Wang
- School of Public Health, Peking University, Beijing, China
| | - Dan Guo
- China Center for Health and Development Studies, Peking University, Beijing, China
- School of Public Health, Peking University, Beijing, China
| | - Xiao Liu
- School of Management, Weifang Medical University, Weifang, Shandong province, China
| | - Lei Wang
- Weifang Kuiwen District Medical care and Health Industry Development Center, Weifang, Shandong province, China
| | - Wentao Wei
- Weifang City Hanting District Gudi street Pozi hospital, Weifang, Shandong province, China
| | - Wei Zhang
- Weicheng District health comprehensive law enforcement brigade, Weifang, Shandong province, China
| | - Ping He
- China Center for Health and Development Studies, Peking University, Beijing, China.
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Asher L, Birhane R, Weiss HA, Medhin G, Selamu M, Patel V, De Silva M, Hanlon C, Fekadu A. Community-based rehabilitation intervention for people with schizophrenia in Ethiopia (RISE): results of a 12-month cluster-randomised controlled trial. Lancet Glob Health 2022; 10:e530-e542. [PMID: 35303462 PMCID: PMC8938762 DOI: 10.1016/s2214-109x(22)00027-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 12/09/2021] [Accepted: 01/07/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Community-based rehabilitation (CBR) is recommended to address the social and clinical needs of people with schizophrenia in resource-poor settings. We evaluated the effectiveness of CBR at reducing disability at 12 months in people with schizophrenia who had disabling illness after having had the opportunity to access facility-based care for 6 months METHODS: This cluster-randomised controlled trial was conducted in a rural district of Ethiopia. Eligible clusters were subdistricts in Sodo district that had not participated in the pilot study. Available subdistricts were randomised (in a 1:1 ratio) to either the intervention group (CBR plus facility-based care) or to the control group (facility-based care alone). An optimisation procedure (accounting for the subdistrict mean WHO Disability Assessment Schedule (WHODAS) score and the potential number of participants per subdistrict) was applied for each of the eight health facilities in the district. An independent statistician, masked to the intervention or control label, used a computer programme to randomly choose the allocation sequence from the set of optimal ones. We recruited adults with disabling illness as a result of schizophrenia. The subdistricts were eligible for inclusion if they included participants that met the eligibility criteria. Researchers recruiting and assessing participants were masked to allocation status. Facility-based care was a task-shared model of mental health care integrated within primary care. CBR was delivered by lay workers over a 12-month period, comprising of home visits (psychoeducation, adherence support, family intervention, and crisis management) and community mobilisation. The primary outcome was disability, measured with the proxy-rated 36-item WHODAS score at 12 months. The subdistricts that had primary outcome data available were included in the primary analysis. This study is registered with ClinicalTrials.gov, NCT02160249. FINDINGS Enrolment took place between Sept 16, 2015 and Mar 11, 2016. 54 subdistricts were randomised (27 to the CBR plus facility-based care group and 27 to the facility-based care group). After exclusion of subdistricts without eligible participants, we enrolled 79 participants (66% men and 34% women) from 24 subdistricts assigned to CBR plus facility-based care and 87 participants (59% men and 41% women) from 24 subdistricts assigned to facility-based care only. The primary analysis included 149 (90%) participants in 46 subdistricts (73 participants in 22 subdistricts in the CBR plus facility-based care group and 76 participants in 24 subdistricts in the facility-based care group). At 12 months, the mean WHODAS scores were 46·1 (SD 23·3) in the facility-based care group and 40·6 (22·5) in the CBR plus facility-based care group, indicating a favourable intervention effect (adjusted mean difference -8·13 [95% CI -15·85 to -0·40]; p=0·039; effect size 0·35). Four (5%) CBR plus facility-based care group participants and nine (10%) facility-based care group participants had one or more serious adverse events (death, suicide attempt, and hospitalisation). INTERPRETATION CBR delivered by lay workers combined with task-shared facility-based care, was effective in reducing disability among people with schizophrenia. The RISE study CBR model is particularly relevant to low-income countries with few mental health specialists. FUNDING Wellcome Trust.
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Affiliation(s)
- Laura Asher
- Lifespan and Population Health Unit, School of Medicine, University of Nottingham, Nottingham, UK.
| | - Rahel Birhane
- WHO Collaborating Centre for Mental Health Research & Capacity Building, Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Helen A Weiss
- MRC International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Girmay Medhin
- Akililu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Medhin Selamu
- WHO Collaborating Centre for Mental Health Research & Capacity Building, Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia; Centre for Innovative Drug Development and Therapeutic Trials for Africa, Addis Ababa University, Addis Ababa, Ethiopia
| | - Vikram Patel
- Department of Global Health and Social Medicine, Harvard Medical School, Harvard University, Boston, MA, USA; Harvard Chan School of Public Health, Harvard University, Boston, MA, USA
| | | | - Charlotte Hanlon
- WHO Collaborating Centre for Mental Health Research & Capacity Building, Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia; Centre for Innovative Drug Development and Therapeutic Trials for Africa, Addis Ababa University, Addis Ababa, Ethiopia; Centre for Global Mental Health, Department of Health Service and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Abebaw Fekadu
- WHO Collaborating Centre for Mental Health Research & Capacity Building, Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia; Centre for Innovative Drug Development and Therapeutic Trials for Africa, Addis Ababa University, Addis Ababa, Ethiopia; Department of Global Health & Infection, Brighton and Sussex Medical School, Brighton, UK
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9
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Abstract
PURPOSE OF REVIEW We reviewed the existing and recent community models of care in schizophrenia. We examine characteristics, recent updates, evidence, cost-effectiveness, and patients' acceptance for existing and new community-based care models in high-income (HI) and low- and middle-income (LAMI) countries. RECENT FINDINGS Assertive Community Treatment (ACT), Intensive Case Management (ICM), and Crisis Intervention are cost-effective interventions for schizophrenia and time tested in the last few decades in HI countries. The growing evidence suggests that tailor-made ACTs and ICM can effectively reduce substance use, homelessness, and criminal activity in persons with schizophrenia who live in the community. Similarly, in LAMI Countries, a few community-based care models for schizophrenia have been developed and tested based on community-based rehabilitation principles. The modality of a community model of care and interventions for a person with schizophrenia should be chosen based on the person's co-existing psychosocial difficulties and challenges such as homelessness, criminal behaviour, and substance use.
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Affiliation(s)
- Guru S. Gowda
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, 560029 India
| | - Mohan K. Isaac
- Clinical Professor of Psychiatry, Division of Psychiatry, Faculty of Health and Medical Sciences, The University of Western Australia, Fremantle Hospital, Fremantle Hospital, Level 7, T Block, Fremantle, WA 6160 Australia
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van Ginneken N, Chin WY, Lim YC, Ussif A, Singh R, Shahmalak U, Purgato M, Rojas-García A, Uphoff E, McMullen S, Foss HS, Thapa Pachya A, Rashidian L, Borghesani A, Henschke N, Chong LY, Lewin S. Primary-level worker interventions for the care of people living with mental disorders and distress in low- and middle-income countries. Cochrane Database Syst Rev 2021; 8:CD009149. [PMID: 34352116 PMCID: PMC8406740 DOI: 10.1002/14651858.cd009149.pub3] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Community-based primary-level workers (PWs) are an important strategy for addressing gaps in mental health service delivery in low- and middle-income countries. OBJECTIVES: To evaluate the effectiveness of PW-led treatments for persons with mental health symptoms in LMICs, compared to usual care. SEARCH METHODS: MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, ICTRP, reference lists (to 20 June 2019). SELECTION CRITERIA: Randomised trials of PW-led or collaborative-care interventions treating people with mental health symptoms or their carers in LMICs. PWs included: primary health professionals (PHPs), lay health workers (LHWs), community non-health professionals (CPs). DATA COLLECTION AND ANALYSIS: Seven conditions were identified apriori and analysed by disorder and PW examining recovery, prevalence, symptom change, quality-of-life (QOL), functioning, service use (SU), and adverse events (AEs). Risk ratios (RRs) were used for dichotomous outcomes; mean difference (MDs), standardised mean differences (SMDs), or mean change differences (MCDs) for continuous outcomes. For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥0.80 large clinical effects. Analysis timepoints: T1 (<1 month), T2 (1-6 months), T3 ( >6 months) post-intervention. MAIN RESULTS: Description of studies 95 trials (72 new since 2013) from 30 LMICs (25 trials from 13 LICs). Risk of bias Most common: detection bias, attrition bias (efficacy), insufficient protection against contamination. Intervention effects *Unless indicated, comparisons were usual care at T2. "Probably", "may", or "uncertain" indicates "moderate", "low," or "very low" certainty evidence. Adults with common mental disorders (CMDs) LHW-led interventions a. may increase recovery (2 trials, 308 participants; RR 1.29, 95%CI 1.06 to 1.56); b. may reduce prevalence (2 trials, 479 participants; RR 0.42, 95%CI 0.18 to 0.96); c. may reduce symptoms (4 trials, 798 participants; SMD -0.59, 95%CI -1.01 to -0.16); d. may improve QOL (1 trial, 521 participants; SMD 0.51, 95%CI 0.34 to 0.69); e. may slightly reduce functional impairment (3 trials, 1399 participants; SMD -0.47, 95%CI -0.8 to -0.15); f. may reduce AEs (risk of suicide ideation/attempts); g. may have uncertain effects on SU. Collaborative-care a. may increase recovery (5 trials, 804 participants; RR 2.26, 95%CI 1.50 to 3.43); b. may reduce prevalence although the actual effect range indicates it may have little-or-no effect (2 trials, 2820 participants; RR 0.57, 95%CI 0.32 to 1.01); c. may slightly reduce symptoms (6 trials, 4419 participants; SMD -0.35, 95%CI -0.63 to -0.08); d. may slightly improve QOL (6 trials, 2199 participants; SMD 0.34, 95%CI 0.16 to 0.53); e. probably has little-to-no effect on functional impairment (5 trials, 4216 participants; SMD -0.13, 95%CI -0.28 to 0.03); f. may reduce SU (referral to MH specialists); g. may have uncertain effects on AEs (death). Women with perinatal depression (PND) LHW-led interventions a. may increase recovery (4 trials, 1243 participants; RR 1.29, 95%CI 1.08 to 1.54); b. probably slightly reduce symptoms (5 trials, 1989 participants; SMD -0.26, 95%CI -0.37 to -0.14); c. may slightly reduce functional impairment (4 trials, 1856 participants; SMD -0.23, 95%CI -0.41 to -0.04); d. may have little-to-no effect on AEs (death); e. may have uncertain effects on SU. Collaborative-care a. has uncertain effects on symptoms/QOL/SU/AEs. Adults with post-traumatic stress (PTS) or CMDs in humanitarian settings LHW-led interventions a. may slightly reduce depression symptoms (5 trials, 1986 participants; SMD -0.36, 95%CI -0.56 to -0.15); b. probably slightly improve QOL (4 trials, 1918 participants; SMD -0.27, 95%CI -0.39 to -0.15); c. may have uncertain effects on symptoms (PTS)/functioning/SU/AEs. PHP-led interventions a. may reduce PTS symptom prevalence (1 trial, 313 participants; RR 5.50, 95%CI 2.50 to 12.10) and depression prevalence (1 trial, 313 participants; RR 4.60, 95%CI 2.10 to 10.08); b. may have uncertain effects on symptoms/functioning/SU/AEs. Adults with harmful/hazardous alcohol or substance use LHW-led interventions a. may increase recovery from harmful/hazardous alcohol use although the actual effect range indicates it may have little-or-no effect (4 trials, 872 participants; RR 1.28, 95%CI 0.94 to 1.74); b. may have little-to-no effect on the prevalence of methamphetamine use (1 trial, 882 participants; RR 1.01, 95%CI 0.91 to 1.13) and functional impairment (2 trials, 498 participants; SMD -0.14, 95%CI -0.32 to 0.03); c. probably slightly reduce risk of harmful/hazardous alcohol use (3 trials, 667 participants; SMD -0.22, 95%CI -0.32 to -0.11); d. may have uncertain effects on SU/AEs. PHP/CP-led interventions a. probably have little-to-no effect on recovery from harmful/hazardous alcohol use (3 trials, 1075 participants; RR 0.93, 95%CI 0.77 to 1.12) or QOL (1 trial, 560 participants; MD 0.00, 95%CI -0.10 to 0.10); b. probably slightly reduce risk of harmful/hazardous alcohol and substance use (2 trials, 705 participants; SMD -0.20, 95%CI -0.35 to -0.05; moderate-certainty evidence); c. may have uncertain effects on prevalence (cannabis use)/SU/AEs. PW-led interventions for alcohol/substance dependence a. may have uncertain effects. Adults with severe mental disorders *Comparisons were specialist-led care at T1. LHW-led interventions a. may have little-to-no effect on caregiver burden (1 trial, 253 participants; MD -0.04, 95%CI -0.18 to 0.11); b. may have uncertain effects on symptoms/functioning/SU/AEs. PHP-led or collaborative-care a. may reduce functional impairment (7 trials, 874 participants; SMD -1.13, 95%CI -1.78 to -0.47); b. may have uncertain effects on recovery/relapse/symptoms/QOL/SU. Adults with dementia and carers PHP/LHW-led carer interventions a. may have little-to-no effect on the severity of behavioural symptoms in dementia patients (2 trials, 134 participants; SMD -0.26, 95%CI -0.60 to 0.08); b. may reduce carers' mental distress (2 trials, 134 participants; SMD -0.47, 95%CI -0.82 to -0.13); c. may have uncertain effects on QOL/functioning/SU/AEs. Children with PTS or CMDs LHW-led interventions a. may have little-to-no effect on PTS symptoms (3 trials, 1090 participants; MCD -1.34, 95%CI -2.83 to 0.14); b. probably have little-to-no effect on depression symptoms (3 trials, 1092 participants; MCD -0.61, 95%CI -1.23 to 0.02) or on functional impairment (3 trials, 1092 participants; MCD -0.81, 95%CI -1.48 to -0.13); c. may have little-or-no effect on AEs. CP-led interventions a. may have little-to-no effect on depression symptoms (2 trials, 602 participants; SMD -0.19, 95%CI -0.57 to 0.19) or on AEs; b. may have uncertain effects on recovery/symptoms(PTS)/functioning. AUTHORS' CONCLUSIONS PW-led interventions show promising benefits in improving outcomes for CMDs, PND, PTS, harmful alcohol/substance use, and dementia carers in LMICs.
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Affiliation(s)
- Nadja van Ginneken
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK
| | - Weng Yee Chin
- Department of Family Medicine and Primary Care, The University of Hong Kong, Pokfulam, Hong Kong
| | | | - Amin Ussif
- Norwegian Institute of Public Health, Oslo, Norway
| | - Rakesh Singh
- Department of Community Health Sciences, School of Medicine and School of Public Health, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Ujala Shahmalak
- Division of Population Health, Health Services Research & Primary Care, The University of Manchester, Manchester, UK
| | - Marianna Purgato
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Antonio Rojas-García
- Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, London, UK
| | - Eleonora Uphoff
- Cochrane Common Mental Disorders, Centre for Reviews and Dissemination, University of York, York, UK
| | - Sarah McMullen
- Division of Population Health, Health Services Research & Primary Care, The University of Manchester, Manchester, UK
| | | | - Ambika Thapa Pachya
- Department of Community Health Sciences, School of Medicine and School of Public Health, Patan Academy of Health Sciences, Lalitpur, Nepal
| | | | - Anna Borghesani
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | | | - Lee-Yee Chong
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Simon Lewin
- Norwegian Institute of Public Health, Oslo, Norway
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
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11
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Smartt C, Ketema K, Frissa S, Tekola B, Birhane R, Eshetu T, Selamu M, Prince M, Fekadu A, Hanlon C. Pathways into and out of homelessness among people with severe mental illness in rural Ethiopia: a qualitative study. BMC Public Health 2021; 21:568. [PMID: 33752638 PMCID: PMC7986271 DOI: 10.1186/s12889-021-10629-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 03/15/2021] [Indexed: 11/23/2022] Open
Abstract
Background Little is known about the pathways followed into and out of homelessness among people with experience of severe mental illness (SMI) living in rural, low-income country settings. Understanding these pathways is essential for the development of effective interventions to address homelessness and promote recovery. The aim of this study was to explore pathways into and out of homelessness in people with SMI in rural Ethiopia. Methods In-depth interviews were conducted with 15 people with SMI who had experienced homelessness and 11 caregivers. Study participants were identified through their participation in the PRIME project, which implemented a multi-component district level plan to improve access to mental health care in primary care in Sodo district, Ethiopia. People enrolled in PRIME who were diagnosed with SMI (schizophrenia, schizoaffective disorder or bipolar disorder) and who had reported experiencing homelessness at recruitment formed the sampling frame for this qualitative study. We used OpenCode 4.0 and Microsoft Excel for data management. Thematic analysis was conducted using an inductive approach. Results Study participants reported different patterns of homelessness, with some having experienced chronic and others an intermittent course. Periods of homelessness occurred when family resources were overwhelmed or not meeting the needs of the person with SMI. The most important pathways into homelessness were reported to result from family conflict and the worsening of mental ill health, interplaying with substance use in many cases. Participants also mentioned escape and/or wanting a change in environment, financial problems, and discrimination from the community as contributing to them leaving the home. Pathways out of homelessness included contact with (mental and physical) health care as a catalyst to the mobilization of other supports, family and community intervention, and self-initiated return. Conclusions Homelessness in people with SMI in this rural setting reflected complex health and social needs that were not matched by adequate care and support. Our study findings indicate that interventions to prevent and tackle homelessness in this and similar settings ought to focus on increasing family support, and ensuring access to acceptable and suitable housing, mental health care and social support. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-10629-8.
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Affiliation(s)
- Caroline Smartt
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, Health Service and Population Research Department, Centre for Global Mental Health, London, UK.,King's College London, King's Global Health Institute, London, UK
| | | | - Souci Frissa
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, Health Service and Population Research Department, Centre for Global Mental Health, London, UK.,King's College London, King's Global Health Institute, London, UK
| | - Bethlehem Tekola
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, Health Service and Population Research Department, Centre for Global Mental Health, London, UK.,King's College London, King's Global Health Institute, London, UK
| | - Rahel Birhane
- Addis Ababa University, College of Health Sciences, School of Medicine, Department of Psychiatry, WHO Collaborating Centre for Mental Health Research and Capacity-Building, Addis Ababa, Ethiopia.,Addis Ababa University, Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa, Ethiopia
| | - Tigist Eshetu
- Addis Ababa University, College of Health Sciences, School of Medicine, Department of Psychiatry, WHO Collaborating Centre for Mental Health Research and Capacity-Building, Addis Ababa, Ethiopia
| | - Medhin Selamu
- Addis Ababa University, College of Health Sciences, School of Medicine, Department of Psychiatry, WHO Collaborating Centre for Mental Health Research and Capacity-Building, Addis Ababa, Ethiopia.,Addis Ababa University, Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa, Ethiopia
| | - Martin Prince
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, Health Service and Population Research Department, Centre for Global Mental Health, London, UK.,King's College London, King's Global Health Institute, London, UK
| | - Abebaw Fekadu
- Addis Ababa University, College of Health Sciences, School of Medicine, Department of Psychiatry, WHO Collaborating Centre for Mental Health Research and Capacity-Building, Addis Ababa, Ethiopia.,Addis Ababa University, Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa, Ethiopia.,Department of Global Health & Infection, Brighton and Sussex Medical School, Brighton, UK
| | - Charlotte Hanlon
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, Health Service and Population Research Department, Centre for Global Mental Health, London, UK. .,King's College London, King's Global Health Institute, London, UK. .,Addis Ababa University, College of Health Sciences, School of Medicine, Department of Psychiatry, WHO Collaborating Centre for Mental Health Research and Capacity-Building, Addis Ababa, Ethiopia. .,Addis Ababa University, Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa, Ethiopia.
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12
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Asher L, Birhane R, Teferra S, Milkias B, Worku B, Habtamu A, Kohrt BA, Hanlon C. "Like a doctor, like a brother": Achieving competence amongst lay health workers delivering community-based rehabilitation for people with schizophrenia in Ethiopia. PLoS One 2021; 16:e0246158. [PMID: 33630893 PMCID: PMC7906313 DOI: 10.1371/journal.pone.0246158] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 01/15/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND There are gaps in our understanding of how non-specialists, such as lay health workers, can achieve core competencies to deliver psychosocial interventions in low- and middle-income countries. METHODS We conducted a 12-month mixed-methods study alongside the Rehabilitation Intervention for people with Schizophrenia in Ethiopia (RISE) pilot study. We rated a total of 30 role-plays and 55 clinical encounters of ten community-based rehabilitation (CBR) lay workers using an Ethiopian adaptation of the ENhancing Assessment of Common Therapeutic factors (ENACT) structured observational rating scale. To explore factors influencing competence, six focus group discussions and four in-depth interviews were conducted with 11 CBR workers and two supervisors at three time-points. We conducted a thematic analysis and triangulated the qualitative and quantitative data. RESULTS There were improvements in CBR worker competence throughout the training and 12-month pilot study. Therapeutic alliance competencies (e.g., empathy) saw the earliest improvements. Competencies in personal factors (e.g., substance use) and external factors (e.g., assessing social networks) were initially rated lower, but scores improved during the pilot. Problem-solving and giving advice competencies saw the least improvements overall. Multimodal training, including role-plays, field work and group discussions, contributed to early development of competence. Initial stigma towards CBR participants was reduced through contact. Over time CBR workers occupied dual roles of expert and close friend for the people with schizophrenia in the programme. Competence was sustained through peer supervision, which also supported wellbeing. More intensive specialist supervision was needed. CONCLUSION It is possible to equip lay health workers with the core competencies to deliver a psychosocial intervention for people with schizophrenia in a low-income setting. A prolonged period of work experience is needed to develop advanced skills such as problem-solving. A structured intervention with clear protocols, combined with peer supervision to support wellbeing, is recommended for good quality intervention delivery. Repeated ENACT assessments can feasibly and successfully be used to identify areas needing improvement and to guide on-going training and supervision.
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Affiliation(s)
- Laura Asher
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Rahel Birhane
- Department of Psychiatry, College of Health Sciences, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Solomon Teferra
- Department of Psychiatry, College of Health Sciences, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Barkot Milkias
- Department of Psychiatry, College of Health Sciences, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Benyam Worku
- Department of Psychiatry, College of Health Sciences, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Alehegn Habtamu
- Department of Psychiatry, College of Health Sciences, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Brandon A. Kohrt
- Division of Global Mental Health, Department of Psychiatry, George Washington University, Washington DC, United States of America
| | - Charlotte Hanlon
- Department of Psychiatry, College of Health Sciences, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Psychology and Neuroscience, Health Service and Population Research Department, King’s College London, Institute of Psychiatry, Centre for Global Mental Health, London, United Kingdom
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Denu ZA, Yassin MO, Bisetegn TA, Biks GA, Gelaye KA. The 12 items Amharic version WHODAS-2 showed cultural adaptation and used to measure disability among road traffic trauma victims in Ethiopia. BMC Psychol 2021; 9:1. [PMID: 33388086 PMCID: PMC7777354 DOI: 10.1186/s40359-020-00492-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 11/24/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Adapting and translating already developed tools to different cultures is a complex process, but once done, it increases the validity of the construct to be measured. This study aimed to assess the 12 items WHODAS-2 and test its psychometric properties among road traffic injury victims in Ethiopia. This study aimed to translate the 12 items WHODAS- 2 interview-based tools into Amharic and examine the psychometric properties of the new version among road traffic injury victims. METHODS The 12 items WHODAS 2 was first translated into Amharic by two experts. Back translation was done by two English experts. A group of experts reviewed the forward and backward translation. A total of 240 patients with road traffic injury completed the questionnaires at three selected Hospitals in Amhara Regional State. Internal consistency was; assessed using Chronbach's alpha, convergent, and divergent validity, which were; tested via factor analysis. Confirmatory factor analysis (CFA); was computed, and the model fit; was examined. RESULTS The translated Amharic version 12 -items WHODAS-2 showed that good cross-cultural adaptation and internal consistency (Chronbach's α =0.88). The six factor structure best fits data (model fitness indices; CFI = 0.962, RMSEA = 0.042, RMR = 0.072, GFI = 0.961, chi-square value/degree of freedom = 1.42, TLI = 0.935 and PCLOSE = 0.68). Our analysis showed that from the six domains, mobility is the dominant factor explaining 95% of variability in disability. CONCLUSION The 12 items interview-based Amharic version WHODAS-2; showed good cultural adaptation at three different settings of Amhara Regional State and can be used to measure dis-ability following a road traffic injury.
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Affiliation(s)
- Zewditu Abdissa Denu
- Department of Anesthesia, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
| | - Mensur Osman Yassin
- Department of Surgery, School of Medicine College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Telake Azale Bisetegn
- Department of Health Communication and Behavioral Science, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Gashaw Andargie Biks
- Department of Health Policy and Management, Institute of Public health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Kassahun Alemu Gelaye
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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14
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Keynejad RC, Bitew T, Sorsdahl K, Myers B, Honikman S, Medhin G, Deyessa N, Sevdalis N, Tol WA, Howard L, Hanlon C. Problem solving therapy (PST) tailored for intimate partner violence (IPV) versus standard PST and enhanced usual care for pregnant women experiencing IPV in rural Ethiopia: protocol for a randomised controlled feasibility trial. Trials 2020; 21:454. [PMID: 32487250 PMCID: PMC7268746 DOI: 10.1186/s13063-020-04331-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 04/19/2020] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND In rural Ethiopia, 72% of women are exposed to lifetime intimate partner violence (IPV); IPV is most prevalent during pregnancy. As well as adversely affecting women's physical and mental health, IPV also increases the risk of child morbidity and mortality associated with maternal depression, thus making antenatal care an important opportunity for intervention. Adapting generic, task-shared, brief psychological interventions for perinatal depression and anxiety to address the needs and experiences of women affected by IPV may improve acceptability to women and feasibility for health workers. This randomised controlled feasibility trial will compare brief problem solving therapy (PST) specifically adapted for pregnant women experiencing IPV (PST-IPV) with standard PST and enhanced usual care to determine the feasibility of a future fully powered randomised controlled trial. METHODS Seventy-five pregnant women scoring five or more on the Patient Health Questionnaire, endorsing a tenth question about functional impact and reporting past-year IPV, will be recruited from antenatal care clinics in predominantly rural districts in Ethiopia. Consenting participants will be randomised to either four sessions of PST-IPV, four sessions of standard PST or information about sources of support (enhanced usual care) in a three-arm design. The interventions will be delivered by trained, supervised antenatal care staff using a task-sharing model. Assessments will be made at baseline and after 9 weeks by masked outcome assessors and will include measures of depression symptoms (primary outcome), post-traumatic stress, anxiety symptoms, functional impact, past-month IPV and hypothesised mediators (secondary outcomes). A mixed-method process evaluation will determine the feasibility of a future randomised controlled trial, assess the feasibility, acceptability, fidelity and quality of implementation of PST-IPV, generate testable hypotheses about causal mechanisms, and identify potential contextual factors influencing outcomes. DISCUSSION Despite mental health being a critical concern for women experiencing IPV, there is limited evidence for brief, task-shared psychological interventions adapted for their needs in low- and middle-income countries. Contextually tailored interventions for pregnant women experiencing IPV in low- and middle-income countries require development and process evaluation. This randomised controlled feasibility trial will yield results on the feasibility of conducting a fully powered trial, relevant to researchers, primary and antenatal care clinicians in resource-limited settings. TRIAL REGISTRATION Pan-African clinical trials registry: PACTR202002513482084. Prospectively registered on 13 December 2019.
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Affiliation(s)
- Roxanne C. Keynejad
- Section of Women’s Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Tesera Bitew
- College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Institute of Educational and Behavioural Science, Debre Markos University, Debre Markos, Ethiopia
| | - Katherine Sorsdahl
- Alan J. Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Bronwyn Myers
- Alcohol Tobacco and Other Drug Use Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Simone Honikman
- Perinatal Mental Health Project, Alan J. Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Girmay Medhin
- Aklilu-Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Negussie Deyessa
- College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Nick Sevdalis
- Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Wietse A. Tol
- Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD USA
- United States of America (USA) & Peter C. Alderman Program for Global Mental Health, HealthRight International, New York, New York, NY USA
| | - Louise Howard
- Section of Women’s Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Charlotte Hanlon
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
- World Health Organization Collaborating Centre for Mental Health Research and Capacity-Building, Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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15
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Tirfessa K, Lund C, Medhin G, Selamu M, Birhane R, Hailemichael Y, Fekadu A, Hanlon C. Impact of integrated mental health care on food insecurity of households of people with severe mental illness in a rural African district: a community-based, controlled before-after study. Trop Med Int Health 2020; 25:414-423. [PMID: 31925844 DOI: 10.1111/tmi.13370] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To evaluate the impact of integrated mental health care upon food insecurity (FI) in households of people with severe mental illness (SMI) in a rural Ethiopian district, and to investigate mediation by improved work impairment and discrimination. METHODS A community-based, controlled before-after study was conducted. People with probable SMI were identified in the community, diagnosed by primary healthcare workers, with diagnostic confirmation from a psychiatric nurse. Households of a person with SMI were matched to control households. District-wide integration of mental health care was implemented. Change in FI status over 12 months of follow-up was measured using the Household Food Insecurity Access Scale. Multivariable models were used to assess improvement in FI. Direct and indirect mediators of change in FI status were modelled using path analysis. RESULTS A total of 239 (81.8%) people with SMI and 273 (96.5%) control households were assessed after 12 months. Maintenance of food security or improvement in food insecurity status was observed in 51.5% of households of a person with SMI vs. 39.7% of control households (adjusted risk ratio 1.41: 95% CI 1.11, 1.80). Reduction in symptom severity was indirectly associated with improved FI status via an impact on reducing work impairment and discrimination (P < 0.001). CONCLUSIONS Improving access to mental health care may reduce food insecurity in households of people with SMI. Optimising engagement in care and adding interventions to improve work functioning and tackle discrimination may further reduce food insecurity.
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Affiliation(s)
- Kebede Tirfessa
- Department of Psychiatry, WHO Collaborating Centre for Mental Health Research and Capacity-Building, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,College of Education and Behavioral Studies, Kotebe Metropolitan University, Addis Ababa, Ethiopia
| | - Crick Lund
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, UK.,Alan J Flisher Centre for Public Mental Health, University of Cape Town, Cape Town, South Africa
| | - Girmay Medhin
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Medhin Selamu
- Department of Psychiatry, WHO Collaborating Centre for Mental Health Research and Capacity-Building, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Rahel Birhane
- Department of Psychiatry, WHO Collaborating Centre for Mental Health Research and Capacity-Building, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Abebaw Fekadu
- Department of Psychiatry, WHO Collaborating Centre for Mental Health Research and Capacity-Building, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,Centre for Innovative Drug Development and Therapeutic Trials for Africa, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,Global Health & Infection Department, Brighton and Sussex Medical School, Brighton, UK
| | - Charlotte Hanlon
- Department of Psychiatry, WHO Collaborating Centre for Mental Health Research and Capacity-Building, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, UK.,Centre for Innovative Drug Development and Therapeutic Trials for Africa, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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16
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Fekadu A, Medhin G, Lund C, DeSilva M, Selamu M, Alem A, Asher L, Birhane R, Patel V, Hailemariam M, Shibre T, Thornicroft G, Prince M, Hanlon C. The psychosis treatment gap and its consequences in rural Ethiopia. BMC Psychiatry 2019; 19:325. [PMID: 31664977 PMCID: PMC6819476 DOI: 10.1186/s12888-019-2281-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 09/10/2019] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND The "treatment gap" (TG) for mental disorders, widely advocated by the WHO in low-and middle-income countries, is an important indicator of the extent to which a health system fails to meet the care needs of people with mental disorder at the population level. While there is limited research on the TG in these countries, there is even a greater paucity of studies looking at TG beyond a unidimensional understanding. This study explores several dimensions of the TG construct for people with psychosis in Sodo, a rural district in Ethiopia, and its implications for building a more holistic capacity for mental health services. METHOD The study was a cross-sectional survey of 300 adult participants with psychosis identified through community-based case detection and confirmed through subsequent structured clinical evaluations. The Butajira Treatment Gap Questionnaire (TGQ), a new customised tool with 83 items developed by the Ethiopia research team, was administered to evaluate several TG dimensions (access, adequacy and effectiveness of treatment, and impact/consequence of the treatment gap) across a range of provider types corresponding with the WHO pyramid service framework. RESULTS Lifetime and current access gap for biomedical care were 41.8 and 59.9% respectively while the corresponding figures for faith and traditional healing (FTH) were 15.1 and 45.2%. Of those who had received biomedical care for their current episode, 71.7% did not receive minimally adequate care. Support from the community and non-governmental organisations (NGOs) were negligible. Those with education (Adj. OR: 2.1; 95% CI: 1.2, 3.8) and history of use of FTH (Adj. OR: 3.2; 95% CI: 1.9-5.4) were more likely to use biomedical care. Inadequate biomedical care was associated with increased lifetime risk of adverse experiences, such as history of restraint, homelessness, accidents and assaults. CONCLUSION This is the first study of its kind. Viewing TG not as a unidimensional, but as a complex, multi-dimensional construct, offers a more realistic and holistic understanding of health beliefs, help-seeking behaviors, and need for care. The reconceptualized multidimensional TG construct could assist mental health services capacity building advocacy and policy efforts and allow community and NGOs play a larger role in supporting mental healthcare.
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Affiliation(s)
- Abebaw Fekadu
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia. .,Global Health & Infection Department, Brighton and Sussex Medical School, Brighton, UK. .,College of Health Sciences, School of Medicine, Department of Psychiatry, Addis Ababa University, Addis Ababa, Ethiopia.
| | - Girmay Medhin
- 0000 0001 1250 5688grid.7123.7Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Crick Lund
- 0000 0004 1937 1151grid.7836.aAlan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, Addis Ababa University, University of Cape Town, Cape Town, South Africa ,0000 0001 2322 6764grid.13097.3cCentre for Global Mental Health, Health Service and Population Research Department, King’s College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Mary DeSilva
- 0000 0004 0427 7672grid.52788.30The Wellcome Trust, London, UK
| | - Medhin Selamu
- 0000 0001 1250 5688grid.7123.7College of Health Sciences, School of Medicine, Department of Psychiatry, Addis Ababa University, Addis Ababa, Ethiopia
| | - Atalay Alem
- 0000 0001 1250 5688grid.7123.7College of Health Sciences, School of Medicine, Department of Psychiatry, Addis Ababa University, Addis Ababa, Ethiopia
| | - Laura Asher
- 0000 0004 1936 8868grid.4563.4Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Rahel Birhane
- 0000 0001 1250 5688grid.7123.7College of Health Sciences, School of Medicine, Department of Psychiatry, Addis Ababa University, Addis Ababa, Ethiopia
| | - Vikram Patel
- 000000041936754Xgrid.38142.3cDepartment of Global Health & Social Medicine, Harvard Medical School, Boston, USA
| | - Maji Hailemariam
- 0000 0001 1250 5688grid.7123.7College of Health Sciences, School of Medicine, Department of Psychiatry, Addis Ababa University, Addis Ababa, Ethiopia
| | - Teshome Shibre
- 0000 0004 1936 8200grid.55602.34Department of Psychiatry, Dalhousie University, Horizon Zone 3, Fredericton, NB Canada
| | - Graham Thornicroft
- 0000 0001 2322 6764grid.13097.3cCentre for Global Mental Health, Health Service and Population Research Department, King’s College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Martin Prince
- 0000 0001 2322 6764grid.13097.3cCentre for Global Mental Health, Health Service and Population Research Department, King’s College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Charlotte Hanlon
- 0000 0001 1250 5688grid.7123.7College of Health Sciences, School of Medicine, Department of Psychiatry, Addis Ababa University, Addis Ababa, Ethiopia ,0000 0001 2322 6764grid.13097.3cCentre for Global Mental Health, Health Service and Population Research Department, King’s College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
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17
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Hanlon C, Medhin G, Selamu M, Birhane R, Dewey M, Tirfessa K, Garman E, Asher L, Thornicroft G, Patel V, Lund C, Prince M, Fekadu A. Impact of integrated district level mental health care on clinical and social outcomes of people with severe mental illness in rural Ethiopia: an intervention cohort study. Epidemiol Psychiatr Sci 2019; 29:e45. [PMID: 31405401 PMCID: PMC8061260 DOI: 10.1017/s2045796019000398] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 06/12/2019] [Accepted: 06/19/2019] [Indexed: 11/26/2022] Open
Abstract
AIM There is limited evidence of the safety and impact of task-shared care for people with severe mental illnesses (SMI; psychotic disorders and bipolar disorder) in low-income countries. The aim of this study was to evaluate the safety and impact of a district-level plan for task-shared mental health care on 6 and 12-month clinical and social outcomes of people with SMI in rural southern Ethiopia. METHODS In the Programme for Improving Mental health carE, we conducted an intervention cohort study. Trained primary healthcare (PHC) workers assessed community referrals, diagnosed SMI and initiated treatment, with independent research diagnostic assessments by psychiatric nurses. Primary outcomes were symptom severity and disability. Secondary outcomes included discrimination and restraint. RESULTS Almost all (94.5%) PHC worker diagnoses of SMI were verified by psychiatric nurses. All prescribing was within recommended dose limits. A total of 245 (81.7%) people with SMI were re-assessed at 12 months. Minimally adequate treatment was received by 29.8%. All clinical and social outcomes improved significantly. The impact on disability (standardised mean difference 0.50; 95% confidence interval (CI) 0.35-0.65) was greater than impact on symptom severity (standardised mean difference 0.28; 95% CI 0.13-0.44). Being restrained in the previous 12 months reduced from 25.3 to 10.6%, and discrimination scores reduced significantly. CONCLUSIONS An integrated district level mental health care plan employing task-sharing safely addressed the large treatment gap for people with SMI in a rural, low-income country setting. Randomised controlled trials of differing models of task-shared care for people with SMI are warranted.
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Affiliation(s)
- C. Hanlon
- Health Service and Population Research Department, King's College London, Institute of Psychiatry, Psychology and Neuroscience, Centre for Global Mental Health, London, UK
- WHO Collaborating Centre for Mental Health Research and Capacity Building, Department of Psychiatry, Addis Ababa University, College of Health Sciences, School of Medicine, Addis Ababa, Ethiopia
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - G. Medhin
- Addis Ababa University, Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| | - M. Selamu
- WHO Collaborating Centre for Mental Health Research and Capacity Building, Department of Psychiatry, Addis Ababa University, College of Health Sciences, School of Medicine, Addis Ababa, Ethiopia
| | - R. Birhane
- WHO Collaborating Centre for Mental Health Research and Capacity Building, Department of Psychiatry, Addis Ababa University, College of Health Sciences, School of Medicine, Addis Ababa, Ethiopia
| | - M. Dewey
- Health Service and Population Research Department, King's College London, Institute of Psychiatry, Psychology and Neuroscience, Centre for Global Mental Health, London, UK
| | - K. Tirfessa
- Kotebe Metropolitan University, College of Education and Behavioral Studies, Addis Ababa, Ethiopia
| | - E. Garman
- Department of Psychiatry and Mental Health, Alan J Flisher Centre for Public Mental Health, University of Cape Town, Cape Town, Republic of South Africa
| | - L. Asher
- Division of Epidemiology and Public Health, University of Nottingham, School of Medicine, Nottingham, UK
| | - G. Thornicroft
- Health Service and Population Research Department, King's College London, Institute of Psychiatry, Psychology and Neuroscience, Centre for Global Mental Health, London, UK
| | - V. Patel
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, USA
- Sangath Non-Governmental Organisation, Goa, India
| | - C. Lund
- Health Service and Population Research Department, King's College London, Institute of Psychiatry, Psychology and Neuroscience, Centre for Global Mental Health, London, UK
- Department of Psychiatry and Mental Health, Alan J Flisher Centre for Public Mental Health, University of Cape Town, Cape Town, Republic of South Africa
| | - M. Prince
- Health Service and Population Research Department, King's College London, Institute of Psychiatry, Psychology and Neuroscience, Centre for Global Mental Health, London, UK
| | - A. Fekadu
- WHO Collaborating Centre for Mental Health Research and Capacity Building, Department of Psychiatry, Addis Ababa University, College of Health Sciences, School of Medicine, Addis Ababa, Ethiopia
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Global Health & Infection Department, Brighton and Sussex Medical School, Brighton, UK
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18
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Tirfessa K, Lund C, Medhin G, Hailemichael Y, Fekadu A, Hanlon C. Food insecurity among people with severe mental disorder in a rural Ethiopian setting: a comparative, population-based study. Epidemiol Psychiatr Sci 2019; 28:397-407. [PMID: 29143723 PMCID: PMC6998966 DOI: 10.1017/s2045796017000701] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 10/13/2017] [Indexed: 11/06/2022] Open
Abstract
AIM In low-income African countries, ensuring food security for all segments of the population is a high priority. Mental illness is associated consistently with poverty, but there is little evidence regarding the association with food insecurity. The aim of this study was to compare the levels of food insecurity in people with severe mental disorders (SMD) with the general population in a rural African setting with a high burden of food insecurity. METHOD Households of 292 community-ascertained people with a specialist-confirmed diagnosis of SMD (including schizophrenia and bipolar disorder) were compared with 284 households without a person with SMD in a rural district in south Ethiopia. At the time of the study, no mental health services were available within the district. Food insecurity was measured using a validated version of the Household Food Insecurity Access Scale. Disability was measured using the World Health Organisation Disability Assessment Schedule 2.0. RESULT Severe household food insecurity was reported by 32.5% of people with SMD and 15.9% of respondents from comparison households: adjusted odds ratio 2.82 (95% confidence interval 1.62 to 4.91). Higher annual income was associated independently with lower odds of severe food insecurity. When total disability scores were added into the model, the association between SMD and food insecurity became non-significant, indicating a possible mediating role of disability. CONCLUSION Efforts to alleviate food insecurity need to target people with SMD as a vulnerable group. Addressing the disabling effects of SMD would also be expected to reduce food insecurity. Access to mental health care integrated into primary care is being expanded in this district as part of the Programme for Improving Mental health carE (PRIME). The impact of treatment on disability and food insecurity will be evaluated.
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Affiliation(s)
- K. Tirfessa
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- College of Education and Behavioral Studies, Kotebe Metropolitan University, Addis Ababa, Ethiopia
| | - C. Lund
- Department of Psychiatry and Mental Health, Alan J Flisher Centre for Public Mental Health, University of Cape Town, Cape Town, Republic of South Africa
- Health Service and Population Research Department, Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - G. Medhin
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Y. Hailemichael
- School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - A. Fekadu
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Psychological Medicine, Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - C. Hanlon
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Health Service and Population Research Department, Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Castro S, Leite CF, Coenen M, Buchalla CM. The World Health Organization Disability Assessment Schedule 2 (WHODAS 2.0): remarks on the need to revise the WHODAS. CAD SAUDE PUBLICA 2019; 35:e00000519. [PMID: 31365697 DOI: 10.1590/0102-311x00000519] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 04/30/2019] [Indexed: 11/22/2022] Open
Abstract
Functioning and disability are concepts in increasing use in clinical settings and in public health. From the public health perspective, the use of functioning as a third health indicator could show more than the frequency of a disease and its death rates, offering information on how the population performs its activities and participation. Clinically, the functioning assessment can provide information for patient-centered health care and specific clinical interventions according to their functioning profile. WHODAS 2.0 is a generic tool to assess health and functioning according to the ICF functioning model. It is an alternative to assess functioning in a less time-consuming way, whereas the duration of the application is one of the main ICF critiques. This paper aims to present some of WHODAS 2.0 inconsistencies and weaknesses as well as strategies to cope with them. In this paper, we present some weaknesses related to the WHODAS layout; wording and scoring process. Some suggestions for strategies to correct these weaknesses are presented, as well.
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Process Evaluation of a Pilot Intervention for Psychosocial Rehabilitation for Service Users with Schizophrenia in North West Province, South Africa. Community Ment Health J 2018; 54:1089-1096. [PMID: 30094739 DOI: 10.1007/s10597-018-0318-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 08/06/2018] [Indexed: 10/28/2022]
Abstract
This study investigated a non-specialist delivered programme for psychosocial rehabilitation for service users with schizophrenia in a low-resource South African setting. Forty-four service users with schizophrenia living in the community, receiving ongoing medication through primary care, participated in a structured support group. Quantitative measures (WHODAS 12 item, Brief Psychiatric Rating Scale and Internalized Stigma of Mental Illness Inventory) were assessed at baseline and 12 months. Sixteen service users were interviewed on their experiences. WHODAS data showed a small reduction. ISMI assessment showed a statistically significant reduction. Qualitative data revealed: improved self-esteem and increased illness knowledge, reduced risk taking, reduced social isolation and improved pro-social behavior, improved financial management and engagement in income generation activities as well as improved acceptance by the community. This study provides preliminary evidence on the benefits of this programme that warrant further study incorporating experimental methods.
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Cheng JF, Chen CY, Lin MC, Huang XY. To explore the efficacy of community rehabilitation for facilitating daily function among patients with mental illness. Perspect Psychiatr Care 2018; 54:580-585. [PMID: 29667203 DOI: 10.1111/ppc.12283] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Revised: 03/17/2018] [Accepted: 04/01/2018] [Indexed: 11/29/2022] Open
Abstract
PURPOSE To explore the efficacy of community rehabilitation for facilitating daily function among patients with mental illness. DESIGN AND METHODS A quasi-experimental design was used. Two hundred and sixty-four participants completed a daily living function scale questionnaire and provided disease-related information. FINDINGS Community rehabilitation was shown to be efficient in helping to stabilize mental illness and enhance daily function. Daily function had a significant and positive correlation with disease stability. PRACTICE IMPLICATIONS Community rehabilitation for patients with mental illness can effectively stabilize and prevent disability among those with mental illness.
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Affiliation(s)
- Jui-Fen Cheng
- Department of Nursing, China Medical University and Hospital, Taichung, Taiwan, ROC
| | - Chung-Ying Chen
- Bali Psychiatric Center, Ministry of Health & Welfare, Bali District, New Taipei City, Taiwan, ROC
| | - Mei-Chu Lin
- Department of Nursing, Tsaotun Psychiatric Center, Ministry of Health and Welfare, Tsaotun Township, Nantou County Taichung, Taiwan, ROC
| | - Xuan-Yi Huang
- Department of Nursing, National Taipei University of Nursing and Health Sciences, Peitou District, Taipei City, Taiwan, ROC
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Souraya S, Hanlon C, Asher L. Involvement of people with schizophrenia in decision-making in rural Ethiopia: a qualitative study. Global Health 2018; 14:85. [PMID: 30134989 PMCID: PMC6103856 DOI: 10.1186/s12992-018-0403-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 08/01/2018] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND The involvement of people with psychosocial disabilities in decision-making is a fundamental component of a person-centred and recovery-oriented model of care, but there has been little investigation of this approach in low- and middle-income countries. The aim of this study was to explore the involvement of people with schizophrenia in decision-making relating to their care in rural Ethiopia. METHODS A qualitative study was conducted in rural Ethiopia as part of the Rehabilitation Intervention for people with Schizophrenia in Ethiopia (RISE) project, involving two focus group discussions (n = 10) with community-based rehabilitation workers, and 18 in-depth interviews with people with schizophrenia, caregivers, health officers, supervisors and a community-based rehabilitation worker. Thematic analysis was used to examine major themes related to involvement in decision-making in this specific setting. RESULTS Involvement of people with schizophrenia in decision-making in this rural Ethiopian setting was limited and coercive practices were evident. People with schizophrenia tended to be consulted about their care only when they were considered clinically 'recovered'. Caregivers typically had a prominent role in decision-making, but they also acquiesced to the views of health care professionals. People with schizophrenia and caregivers were often unable to execute their desired choice due to inaccessible and unaffordable treatment. CONCLUSIONS Community-based rehabilitation, as a model of care, may give opportunities for involvement of people with schizophrenia in decision-making. In order to increase involvement of people with schizophrenia in rural Ethiopia there needs to be greater empowerment of service users, wider availability of treatment choices and a facilitating policy environment. Further studies are needed to explore concepts of person-centred care and recovery across cultural settings.
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Affiliation(s)
- Sally Souraya
- Department of Population Health, Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK. .,Health Services and Population Research Department, Centre for Global Mental Health, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK.
| | - Charlotte Hanlon
- Health Services and Population Research Department, Centre for Global Mental Health, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK.,Department of Psychiatry, Addis Ababa University, College of Health Sciences, School of Medicine, Addis Ababa, Ethiopia
| | - Laura Asher
- Department of Population Health, Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK.,Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK
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Asher L, Hanlon C, Birhane R, Habtamu A, Eaton J, Weiss HA, Patel V, Fekadu A, De Silva M. Community-based rehabilitation intervention for people with schizophrenia in Ethiopia (RISE): a 12 month mixed methods pilot study. BMC Psychiatry 2018; 18:250. [PMID: 30075715 PMCID: PMC6091097 DOI: 10.1186/s12888-018-1818-4] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 07/16/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Community-based rehabilitation (CBR), or community-based inclusive development, is an approach to address the complex health, social and economic needs of people with schizophrenia in low and middle-income countries. Formative work was undertaken previously to design a culturally appropriate CBR intervention for people with schizophrenia in Ethiopia. The current study explored the acceptability and feasibility of CBR in practice, as well as how CBR may improve functioning among people with schizophrenia. METHODS This mixed methods pilot study took place in rural Ethiopia between December 2014 and December 2015. Ten people with schizophrenia who were unresponsive to treatment with medication alone, and their caregivers, participated in CBR. CBR was led by lay workers with five weeks training and involved home visits (education, family intervention and support returning to work) and community mobilisation. Theory of change was used to guide the pilot evaluation. Qualitative and quantitative data were collected at baseline, six months and 12 months. Forty in-depth interviews and two focus group discussions were conducted with 31 individuals comprising people with schizophrenia, caregivers, CBR workers, supervisors, health officers and community members. RESULTS The RISE CBR intervention may have a positive impact on functioning through the pathways of enhanced family support, improved access to health care, increased income and improved self-esteem. CBR was acceptable to CBR workers, community leaders and health officers. Some CBR workers found it challenging to accept the choices of people with schizophrenia. These concerns were felt to be resolvable with supplementary training for CBR workers. The intervention was feasible but further evaluation is needed on a larger scale. CONCLUSION In low and middle-income countries, CBR may be an acceptable and feasible adjuvant approach to facility-based care for people with schizophrenia. However, contextual factors, including poverty and inaccessible anti-psychotic medication, remain substantial challenges. There were indications that CBR can impact on functioning but the RISE trial will determine effectiveness.
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Affiliation(s)
- Laura Asher
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, NG5 1PB UK
- Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Charlotte Hanlon
- Department of Psychiatry, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Global Mental Health, Health Services and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Rahel Birhane
- Department of Psychiatry, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Alehegn Habtamu
- Department of Psychiatry, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Julian Eaton
- Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK
- CBM International, Cambridge, UK
| | - Helen A. Weiss
- MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Vikram Patel
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
| | - Abebaw Fekadu
- Department of Psychiatry, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
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Cheng JF, Huang XY, Lin MC, Wang YH, Yeh TP. A mental health home visit service partnership intervention on improving patients' satisfaction. Arch Psychiatr Nurs 2018; 32:610-616. [PMID: 30029756 DOI: 10.1016/j.apnu.2018.03.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 01/03/2018] [Accepted: 03/11/2018] [Indexed: 11/30/2022]
Abstract
AIMS To investigate a partnership intervention of the community-based and hospital-based home visit to improve patients' satisfaction. METHODS A time series quasi-experimental quantitative design was used. The experimental group had "partnership intervention", while the control group maintained routine home visits. Patient satisfaction was measured pre-intervention, six months and 12 months after the partnership intervention. RESULTS Six and 12 months after partnership intervention, in the experimental group, items related to stabilizing disease conditions, improving daily living abilities, enhancing communication ability and providing relevant resources were significantly higher than pre-intervention. However, 12 months after the intervention, the influence of the intervention became weaken. CONCLUSIONS The partnership intervention can significantly improve patients' satisfaction with home visit service.
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Affiliation(s)
- Jui-Fen Cheng
- School of Nursing, China Medical University and Hospital, No.91 Hsueh-Shih Road, North District, Taichung 40402, Taiwan, ROC.
| | - Xuan-Yi Huang
- Department of Nursing, National Taipei University of Nursing and Health Sciences, No.365, Ming-te Road, Peitou Distric, Taipei City 11219, Taiwan, ROC.
| | - Mei-Chu Lin
- Department of Nursing, Tsaotun Psychiatric Center, Ministry of Health and Welfare, Taichung, 161 Yu-Pin Road, Tsaotun Township, Nantou County 54249, Taiwan, ROC
| | - Ya-Hui Wang
- Department of Nursing, Tsaotun Psychiatric Center, Ministry of Health and Welfare, Taichung, 161 Yu-Pin Road, Tsaotun Township, Nantou County 54249, Taiwan, ROC
| | - Tzu-Pei Yeh
- Department of Nursing, China Medical University and Hospital, No.91 Hsueh-Shih Road, North District, Taichung 40402, Taiwan, ROC.
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Habtamu K, Alem A, Medhin G, Fekadu A, Hanlon C. Functional impairment among people with severe and enduring mental disorder in rural Ethiopia: a cross-sectional study. Soc Psychiatry Psychiatr Epidemiol 2018; 53:803-814. [PMID: 29947862 DOI: 10.1007/s00127-018-1546-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 06/06/2018] [Indexed: 01/19/2023]
Abstract
PURPOSE Evidence regarding functional impairment in people with severe mental disorders (SMD) is sparse in low- and middle-income countries. The aim of this study was to identify factors associated with functional impairment in people with enduring SMD in a rural African setting. METHODS A cross-sectional study was conducted at the baseline of a health service intervention trial. A total of 324 participants were recruited from an existing community-ascertained cohort of people with SMD (n = 218), and attendees at the Butajira General Hospital psychiatric clinic (n = 106). Inclusion criteria defined people with SMD who had ongoing need for care: those who were on psychotropic medication, currently symptomatic or had a relapse in the preceding 2 years. The World Health Organization Disability Assessment schedule (WHODAS-2.0) and the Butajira Functioning Scale (BFS) were used to assess functional impairment. Multivariable negative binomial regression models were fitted to investigate the association between demographic, socio-economic and clinical characteristics, and functional impairment. RESULTS Increasing age, being unmarried, rural residence, poorer socio-economic status, symptom severity, continuous course of illness, medication side effects, and internalized stigma were associated with functional impairment across self-reported and caregiver responses for both the WHODAS and the BFS. Diagnosis per se was not associated consistently with functional impairment. CONCLUSION To optimize functioning in people with chronic SMD in this setting, services need to target residual symptoms, poverty, medication side effects, and internalized stigma. Testing the impact of community interventions to promote recovery will be useful. Advocacy for more tolerable treatment options is warranted.
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Affiliation(s)
- Kassahun Habtamu
- School of Psychology, College of Education and Behavioral Studies, Addis Ababa University, P.O.BOX: 1176, Addis Ababa, Ethiopia. .,Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
| | - Atalay Alem
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Girmay Medhin
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Abebaw Fekadu
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,Department of Psychological Medicine, Centre for Affective Disorders, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Charlotte Hanlon
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,Health Services and Population Research Department, Centre for Global Mental Health, Kings College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
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Abstract
PURPOSE OF REVIEW The aim was to synthesize recent evidence on schizophrenia illness experience and outcomes and models of care in low and middle-income countries (LMICs). RECENT FINDINGS There is a plurality of explanatory models for psychosis and increasing evidence that context influences experiences of stigma. People with schizophrenia in LMICs are vulnerable to food insecurity, violence and physical health problems, in addition to unmet needs for mental healthcare. Family support may help to improve outcomes if present, but caregivers may be overwhelmed by the challenges faced. Despite efforts to increase availability, evidence-based care remains inaccessible to many people with schizophrenia. Non-randomized evaluations in South Africa and Mexico indicate that psychosocial support groups for people with schizophrenia and caregivers may be acceptable and useful. Randomized controlled trials in Pakistan and China show that culturally adapted cognitive-behavioural therapy can reduce symptom severity. There is emerging evidence that alternative medicine, such as Tai Chi, may be beneficial, but to date most studies are of low quality. The challenges of biomedical-traditional provider collaborations have been highlighted. Evaluations of integrated mental healthcare in primary care are underway and promise to provide vital information about how to scale-up quality care. SUMMARY Acceptable and effective responses to schizophrenia in LMICs should be cognisant of both cultural context and universal concerns. Efforts to enhance the quality of family support should be central to models of care.
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Theory of change for complex mental health interventions: 10 lessons from the programme for improving mental healthcare. Glob Ment Health (Camb) 2018; 5:e24. [PMID: 30128160 PMCID: PMC6094401 DOI: 10.1017/gmh.2018.13] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 02/23/2018] [Accepted: 03/08/2018] [Indexed: 11/24/2022] Open
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Sessions KL, Wheeler L, Shah A, Farrell D, Agaba E, Kuule Y, Merry SP. Mental illness in Bwindi, Uganda: Understanding stakeholder perceptions of benefits and barriers to developing a community-based mental health programme. Afr J Prim Health Care Fam Med 2017; 9:e1-e7. [PMID: 29227132 PMCID: PMC5803513 DOI: 10.4102/phcfm.v9i1.1462] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Revised: 08/23/2017] [Accepted: 09/10/2017] [Indexed: 11/24/2022] Open
Abstract
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.
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Asher L, Patel V, De Silva MJ. Community-based psychosocial interventions for people with schizophrenia in low and middle-income countries: systematic review and meta-analysis. BMC Psychiatry 2017; 17:355. [PMID: 29084529 PMCID: PMC5661919 DOI: 10.1186/s12888-017-1516-7] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 10/18/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is consensus that the treatment of schizophrenia should combine anti-psychotic medication and psychosocial interventions in order to address complex social, economic and health needs. It is recommended that family therapy or support; community-based rehabilitation; and/or self-help and support groups should be provided for people with schizophrenia in low and middle-income countries. The effectiveness of community-based psychosocial interventions in these settings is unclear. METHODS Studies evaluating community-based psychosocial interventions for people with schizophrenia were identified through database searching up to April 2016. Randomised controlled trials were included if they compared the intervention group with a control group receiving treatment as usual including medication. Only studies set in low and middle-income countries were included. Random effects meta-analyses were performed separately for each intervention type. RESULTS Eleven randomised controlled trials in five middle-income countries were identified, with a total of 1580 participants. The content of included interventions varied from single-faceted psychoeducational interventions, to multi-component rehabilitation-focused interventions, to case management interventions. A third of the included studies did not incorporate any community involvement in the intervention. The quality of evidence was often low. Amongst the seven studies that reported on symptom severity up to 18 months post intervention, the pooled standardised mean difference (SMD) across all intervention types was 0.95 (95% CI 0.28, 1.61; P 0.005; I 2 = 95%; n = 862), representing a strong effect. A strong effect on symptom severity remained after excluding two studies with a high risk of bias (SMD 0.80; 95% CI 0.07, 1.53; P 0.03; I 2 = 94%; n = 676). Community-based psychosocial interventions may also have beneficial impacts on functioning (SMD 1.12; 95% CI 0.25, 2.00; P 0.01; I 2 = 94%; n = 511) and reducing hospital readmissions (SMD 0.68; 95% CI 0.27, 1.09; P 0.001; I2 = 33%; n = 167). CONCLUSION The limited evidence from low and middle-income countries supports the feasibility and effectiveness of community-based psychosocial interventions for schizophrenia, even in the absence of community mobilisation. Community-based psychosocial interventions should therefore be provided in these settings as an adjuvant service in addition to facility-based care for people with schizophrenia.
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Affiliation(s)
- Laura Asher
- Centre for Global Mental Health, Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Vikram Patel
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India
- Sangath, Porvorim, Goa India
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
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Hailemariam M, Fekadu A, Prince M, Hanlon C. Engaging and staying engaged: a phenomenological study of barriers to equitable access to mental healthcare for people with severe mental disorders in a rural African setting. Int J Equity Health 2017; 16:156. [PMID: 28851421 PMCID: PMC5576237 DOI: 10.1186/s12939-017-0657-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 08/22/2017] [Indexed: 11/12/2022] Open
Abstract
Background In low-and middle-income countries, integration of mental health into primary care is recommended to reduce the treatment gap. In this study we explored barriers to initial and ongoing engagement of people with severe mental disorders (SMD) in rural Ethiopia after implementing integrated primary mental healthcare services. Methods A qualitative approach was employed. In-depth interviews were conducted with 50 key informants: service users/caregivers engaged with care (n = 17), non-engagers and their caregivers (n = 10), those who had initiated treatment but disengaged and their caregivers (n = 12) and primary healthcare professionals (n = 11). Two focus group discussions were conducted with community health workers (10 per group). Thematic analysis was used. Results Most respondents reported improved access to care, usually equated with medication, and were motivated to remain engaged due to experienced benefits of care. However, four main barriers to engagement emerged. (1) Poverty: resulting in inability to pay for medication and undermining vital social support affected engagement for all respondents. (2) Unreliable medication supplies and lack of second line options for inadequate response or intolerable side-effects. (3) The long-term nature of the illness: expectations of cure, stigma of chronic illness, low awareness about the illness and treatment and declining social support over time. (4) The nature of SMD: difficulty conveying the person when acutely disturbed and no flexibility for proactive outreach or legal frameworks to provide care when patients lacked capacity. In those who never engaged, geographical inaccessibility was an important barrier. Alternative cultural explanations for illness were only mentioned as a barrier only by two of the respondents. Conclusion Economic interventions may be needed to support ongoing engagement in care for people with SMD. Systems of care for chronic illness need to be strengthened in combination with legal frameworks. Expanded options for affordable and effective medication and psychosocial interventions are required for person-centred care. Electronic supplementary material The online version of this article (10.1186/s12939-017-0657-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Maji Hailemariam
- Department of Psychiatry, College of Health Sciences, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia.
| | - Abebaw Fekadu
- Department of Psychiatry, College of Health Sciences, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia.,Center for Innovative Drug Development and Therapeutic Trials for Africa, Addis Ababa University, Addis Ababa, Ethiopia.,Institute of Psychiatry, Psychology and Neuroscience, Department of Psychological Medicine, Centre for Affective Disorders, King's College London, London, UK
| | - Martin Prince
- Institute of Psychiatry, Psychology and Neuroscience, Health Services and Population Research Department, Centre for Global Mental Health, King's College London, London, UK
| | - Charlotte Hanlon
- Department of Psychiatry, College of Health Sciences, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia.,Institute of Psychiatry, Psychology and Neuroscience, Health Services and Population Research Department, Centre for Global Mental Health, King's College London, London, UK
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Hanlon C. Next steps for meeting the needs of people with severe mental illness in low- and middle-income countries. Epidemiol Psychiatr Sci 2017; 26:348-354. [PMID: 27995844 PMCID: PMC6998682 DOI: 10.1017/s2045796016001013] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The explicit inclusion of mental health within the Sustainable Development Goals is a welcome development, borne out of powerful advocacy using public health, economic and human rights arguments. As funding comes on line for scale-up of evidence-based mental health care by task-sharing with primary care, it is time to take stock about care for people affected by severe mental illness (SMI). The existing evidence base for task shared care for SMI provides an imperative to get started, but is skewed towards relatively more affluent and urban populations in middle-income countries where specialist mental health professionals provide most of the care. Randomised, controlled trials and rigorous implementation research on task shared service models are underway which will go some way to improving understanding of the quality, safety, effectiveness and acceptability of more widely generalisable care for people with SMI. A sub-group of people with SMI have more complex and long-term needs for care, with a high risk of homelessness, imprisonment and human rights violations as family and social supports become overwhelmed. Case studies from non-governmental organisations provide examples of holistic approaches to rehabilitation, recovery and empowerment of people with SMI, but rigorous comparative studies are needed to identify the most efficient, effective and scalable approaches to care. Health system constraints are emerging as the over-riding barriers to successful task-sharing, highlighting a need to develop and evaluate chronic care models for people with SMI that succeed in reducing premature mortality, improving wellbeing and achieving better social outcomes. Addressing these evidence gaps is essential if task-sharing mental health care is going to deliver on its promise of promoting recovery for the full range of people affected by SMI.
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Affiliation(s)
- C. Hanlon
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, PO 9086, Addis Ababa, Ethiopia
- Health Services and Population Research Department, Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
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Asher L, Fekadu A, Teferra S, De Silva M, Pathare S, Hanlon C. "I cry every day and night, I have my son tied in chains": physical restraint of people with schizophrenia in community settings in Ethiopia. Global Health 2017; 13:47. [PMID: 28693614 PMCID: PMC5504711 DOI: 10.1186/s12992-017-0273-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 06/28/2017] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND A primary rationale for scaling up mental health services in low and middle-income countries is to address human rights violations, including physical restraint in community settings. The voices of those with intimate experiences of restraint, in particular people with mental illness and their families, are rarely heard. The aim of this study was to understand the experiences of, and reasons for, restraint of people with schizophrenia in community settings in rural Ethiopia in order to develop constructive and scalable interventions. METHODS A qualitative study was conducted, involving 15 in-depth interviews and 5 focus group discussions (n = 35) with a purposive sample of people with schizophrenia, their caregivers, community leaders and primary and community health workers in rural Ethiopia. Thematic analysis was used. RESULTS Most of the participants with schizophrenia and their caregivers had personal experience of the practice of restraint. The main explanations given for restraint were to protect the individual or the community, and to facilitate transportation to health facilities. These reasons were underpinned by a lack of care options, and the consequent heavy family burden and a sense of powerlessness amongst caregivers. Whilst there was pervasive stigma towards people with schizophrenia, lack of awareness about mental illness was not a primary reason for restraint. All types of participants cited increasing access to treatment as the most effective way to reduce the incidence of restraint. CONCLUSION Restraint in community settings in rural Ethiopia entails the violation of various human rights, but the underlying human rights issue is one of lack of access to treatment. The scale up of accessible and affordable mental health care may go some way to address the issue of restraint. TRIAL REGISTRATION Clinicaltrials.gov NCT02160249 Registered 3rd June 2014.
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Affiliation(s)
- Laura Asher
- Centre for Global Mental Health, Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Abebaw Fekadu
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Solomon Teferra
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Harvard University, Boston, USA
| | - Mary De Silva
- Centre for Global Mental Health, Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Soumitra Pathare
- Centre for Mental Health Law and Policy, Indian Law Society, Pune, India
| | - Charlotte Hanlon
- Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Centre for Global Mental Health, Health Services and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
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A little could go a long way: financing for mental healthcare in low- and middle-income countries. Epidemiol Psychiatr Sci 2017; 26:248-251. [PMID: 28065173 PMCID: PMC6998698 DOI: 10.1017/s2045796016001116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Wainberg ML, Scorza P, Shultz JM, Helpman L, Mootz JJ, Johnson KA, Neria Y, Bradford JME, Oquendo MA, Arbuckle MR. Challenges and Opportunities in Global Mental Health: a Research-to-Practice Perspective. Curr Psychiatry Rep 2017; 19:28. [PMID: 28425023 PMCID: PMC5553319 DOI: 10.1007/s11920-017-0780-z] [Citation(s) in RCA: 280] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Globally, the majority of those who need mental health care worldwide lack access to high-quality mental health services. Stigma, human resource shortages, fragmented service delivery models, and lack of research capacity for implementation and policy change contribute to the current mental health treatment gap. In this review, we describe how health systems in low- and middle-income countries (LMICs) are addressing the mental health gap and further identify challenges and priority areas for future research. RECENT FINDINGS Common mental disorders are responsible for the largest proportion of the global burden of disease; yet, there is sound evidence that these disorders, as well as severe mental disorders, can be successfully treated using evidence-based interventions delivered by trained lay health workers in low-resource community or primary care settings. Stigma is a barrier to service uptake. Prevention, though necessary to address the mental health gap, has not solidified as a research or programmatic focus. Research-to-practice implementation studies are required to inform policies and scale-up services. Four priority areas are identified for focused attention to diminish the mental health treatment gap and to improve access to high-quality mental health services globally: diminishing pervasive stigma, building mental health system treatment and research capacity, implementing prevention programs to decrease the incidence of mental disorders, and establishing sustainable scale up of public health systems to improve access to mental health treatment using evidence-based interventions.
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Affiliation(s)
- Milton L Wainberg
- Department of Psychiatry, Columbia University Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 24, New York, NY, 10032, USA.
| | - Pamela Scorza
- Department of Psychiatry, Columbia University Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 24, New York, NY, 10032, USA
| | - James M Shultz
- Center for Disaster and Extreme Event Preparedness (DEEP Center), University of Miami Miller School of Medicine, Miami, FL, 33160, USA
| | - Liat Helpman
- Department of Psychiatry, Columbia University Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 24, New York, NY, 10032, USA
| | - Jennifer J Mootz
- Department of Psychiatry, Columbia University Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 24, New York, NY, 10032, USA
| | - Karen A Johnson
- Department of Psychiatry, Columbia University Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 24, New York, NY, 10032, USA
| | - Yuval Neria
- Department of Psychiatry, Columbia University Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 24, New York, NY, 10032, USA
| | - Jean-Marie E Bradford
- Department of Psychiatry, Columbia University Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 24, New York, NY, 10032, USA
| | - Maria A Oquendo
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, 3535 Market Street, Suite 200, Philadelphia, PA, 19104-3309, USA
| | - Melissa R Arbuckle
- Department of Psychiatry, Columbia University Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 24, New York, NY, 10032, USA
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