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Hopwood H, Sevalie S, Herman MO, Harris D, Collet K, Bah AJ, Beynon F. The burden of mental disorder in Sierra Leone: a retrospective observational evaluation of programmatic data from the roll out of decentralised nurse-led mental health units. Int J Ment Health Syst 2021; 15:31. [PMID: 33832523 PMCID: PMC8033705 DOI: 10.1186/s13033-021-00455-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 03/22/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND In sub-Saharan Africa the treatment gap for mental disorders is high. In 2009, 98.0% of people with mental illness in Sierra Leone were not receiving treatment, partly due to the absence of public psychiatric facilities outside the capital. In response, the Ministry of Health and Sanitation rolled out nurse-led mental health units (MHU) to every district. This study aims to retrospectively evaluate the uptake of these services by examining the pathways to care, diagnosis, management, and treatment gap, to provide insight into the functioning of these units and the potential burden of mental health disorders in Sierra Leone. METHODS We evaluated the roll out of MHU using summary data from all units between 1 st January 2015 and 1 st January 2017, to establish the burden of diagnoses among service users, pathways to care, treatments provided, and treatment gaps. Negative binomial regressions examine bivariate relationships between diagnoses, treatments, and medication inaccessibility with demographics (age and sex), location (Freetown vs the rest and Ebola endemic regions vs the rest) and year. RESULTS We collected data from 15 MHU covering 13 districts in 24 months. There were 2401 referrals. The largest age category was 25-34 (23.4%). The prominent diagnoses were epilepsy (43.5%, associated with children) and psychosis (17.5%, associated with males). Reported depression (8.6%) and suicide attempts (33 patients) were low. Ebola endemic regions reported higher rates of grief, trauma, and medically unexplained symptoms. In 24.7% of cases where medication was required, it was not accessible. CONCLUSIONS Nurse-led MHU can have a modest effect on the treatment gap in resource constrained environments such as Sierra Leone, particularly in epilepsy and psychosis.
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Affiliation(s)
- Helen Hopwood
- King's Sierra Leone Partnership, King's Global Health Partnerships, King's Centre for Global Health and Health Partnerships, School of Population and Environmental Sciences, King's College London, Freetown, Sierra Leone.
| | | | - Moshi Optat Herman
- Kings College London Centre for Global Health and Health Partnerships, School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Dawn Harris
- King's Sierra Leone Partnership, King's Global Health Partnerships, King's Centre for Global Health and Health Partnerships, School of Population and Environmental Sciences, King's College London, Freetown, Sierra Leone
| | | | | | - Fenella Beynon
- King's Sierra Leone Partnership, King's Global Health Partnerships, King's Centre for Global Health and Health Partnerships, School of Population and Environmental Sciences, King's College London, Freetown, Sierra Leone
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Troup J, Fuhr DC, Woodward A, Sondorp E, Roberts B. Barriers and facilitators for scaling up mental health and psychosocial support interventions in low- and middle-income countries for populations affected by humanitarian crises: a systematic review. Int J Ment Health Syst 2021; 15:5. [PMID: 33413526 PMCID: PMC7792016 DOI: 10.1186/s13033-020-00431-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 12/21/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Humanitarian crises increase the burden of mental disorders due to exposure to traumatic events and ongoing daily stressors. Effective mental health and psychosocial support (MHPSS) interventions exist, but barriers and facilitators for scaling up those interventions are less understood. The study aim was to identify barriers and facilitators for scaling up MHPSS interventions for populations affected by humanitarian crises in low- and middle-income countries. METHODS A systematic review following PRISMA guidelines was conducted. Types of scale up were summarised, and barriers and facilitators analysed using the World Health Organization's Expandnet framework of scaling up. Evidence quality was appraised using the Mixed Methods Appraisal Tool. RESULTS Fourteen eligible studies were identified. Most described horizontal types of scale up, integrating services into primary and community care through staff training, task-sharing, and establishing referral and supervision mechanisms. Barriers were reported in a range of framework elements, but primarily related to those in the health system. The overall quality of studies were limited. CONCLUSION Few MHPSS interventions in humanitarian crises appear to have been scaled up, and scaling up efforts were largely horizontal which challenges long-term sustainability. Greater focus should be on both horizontal and vertical scaling up, which should be accompanied by higher quality research.
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Affiliation(s)
- Jordan Troup
- Faculty of Public Health and Policy, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, UK
| | - Daniela C Fuhr
- Faculty of Public Health and Policy, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, UK
| | - Aniek Woodward
- KIT Health, KIT Royal Tropical Institute, Mauritskade 64, Amsterdam, The Netherlands
| | - Egbert Sondorp
- KIT Health, KIT Royal Tropical Institute, Mauritskade 64, Amsterdam, The Netherlands
| | - Bayard Roberts
- Faculty of Public Health and Policy, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, UK.
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James K, Brooks H, Susanti H, Waddingham J, Irmansyah I, Keliat BA, Utomo B, Rose D, Colucci E, Lovell K. Implementing civic engagement within mental health services in South East Asia: a systematic review and realist synthesis of current evidence. Int J Ment Health Syst 2020; 14:17. [PMID: 32175004 PMCID: PMC7063827 DOI: 10.1186/s13033-020-00352-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 02/29/2020] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Civic engagement (CE) has the potential to transform mental health services and could be particularly important for low and middle-income countries (LMICs), which are rapidly developing to respond to the burden of poor mental health. Research from high income countries has found many challenges associated with the meaningful implementation of CE in practice, but this has been underexplored in LIMCS and in South East Asia (SEA) in particular. METHODS We completed a realist synthesis and systematic review of peer reviewed publications and grey literature to identify the context and actions which promote successful implementation of CE approaches in SEA. We used a theory-driven approach-realist synthesis-to analyse data and develop context-mechanism-outcome configurations that can be used to explain how civic engagement approaches operate in South East Asian contexts. We worked closely with patient and public representatives to guide the review from the outset. RESULTS Fifty-seven published and unpublished articles were included, 24 were evaluations of CE, including two Randomized Controlled Trials. The majority of CE interventions featured uptake or adaptation of Western models of care. We identified important cultural differences in the enactment of civic engagement in SEA contexts and four mechanisms which, alongside their contextual barriers and facilitators, can be used to explain how civic engagement produces a range of outcomes for people experiencing mental health problems, their families and communities. Our review illustrates how CE interventions can be successfully implemented in SEA, however Western models should be adapted to fit with local cultures and values to promote successful implementation. Barriers to implementation included distrust of services/outside agencies, stigma, paternalistic cultures, limited resource and infrastructure. CONCLUSION Our findings provide guidance for the implementation of CE approaches within SEA contexts and identify areas for further research. Due to the collectivist nature of many SEA cultures, and the impact of shared traumas on community mental health, CE might best be implemented at community level, with a focus on relational decision making.Registration This review is registered on PROSPERO: CRD42018087841.
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Affiliation(s)
- Karen James
- Centre for Health and Social Care Research, Faculty of Health, Social Care and Education, Kingston and St Georges, 6th Floor Hunter Wing, Cranmer Terrace, London, UK
| | - Helen Brooks
- Department of Health Services Research, Institute of Population Health Sciences, University of Liverpool, Liverpool, UK
| | - Herni Susanti
- Faculty of Nursing, University of Indonesia, Depok, Indonesia
| | | | - Irman Irmansyah
- National Institute of Health Research and Development, Jakarta, Indonesia
- Marzoeki Mahdi Hospital, Bogor, Indonesia
| | | | - Bagus Utomo
- Komunitas Peduli Skizofrenia Indonesia, Jakarta, Indonesia
| | - Diana Rose
- Department of Health Services Research, Kings College London, London, UK
| | | | - Karina Lovell
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
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Surjaningrum ER, Minas H, Jorm AF, Kakuma R. The feasibility of a role for community health workers in integrated mental health care for perinatal depression: a qualitative study from Surabaya, Indonesia. Int J Ment Health Syst 2018; 12:27. [PMID: 29881450 PMCID: PMC5984432 DOI: 10.1186/s13033-018-0208-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 05/25/2018] [Indexed: 01/02/2023] Open
Abstract
Background Indonesian maternal health policies state that community health workers (CHWs) are responsible for detection and referral of pregnant women and postpartum mothers who might suffer from mental health problems (task-sharing). The documents have been published for a while, however reports on the implementation are hardly found which possibly resulted from feasibility issue within the health system. Aims To examine the feasibility of task-sharing in integrated mental health care to identify perinatal depression in Surabaya, Indonesia. Methods Semi-structured interviews were conducted with 62 participants representing four stakeholder groups in primary health care: program managers from the health office and the community, health workers and CHWs, mental health specialists, and service users. Questions on the feasibility were supported by vignettes about perinatal depression. WHO’s health systems framework was applied to analyse the data using framework analysis. Results Findings indicated the policy initiative is feasible to the district health system. A strong basis within the health system for task-sharing in maternal mental health rests on health leadership and governance that open an opportunity for training and supervision, financing, and intersectoral collaboration. The infrastructure and resources in the city provide potential for a continuity of care. Nevertheless, feasibility is challenged by gaps between policy and practices, inadequate support system in technologies and information system, assigning the workforce and strategies to be applied, and the lack of practical guidelines to guide the implementation. Conclusion The health system and resources in Surabaya provide opportunities for task-sharing to detect and refer cases of perinatal depression in an integrated mental health care system. Participation of informal workforce might facilitate in closing the gap in the provision of information on perinatal mental health.
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Affiliation(s)
- Endang R Surjaningrum
- 1Centre for Mental Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia.,2Faculty of Psychology, Airlangga University, Surabaya, Indonesia
| | - Harry Minas
- 1Centre for Mental Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Anthony F Jorm
- 1Centre for Mental Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Ritsuko Kakuma
- 1Centre for Mental Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
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Semrau M, Lempp H, Keynejad R, Evans-Lacko S, Mugisha J, Raja S, Lamichhane J, Alem A, Thornicroft G, Hanlon C. Service user and caregiver involvement in mental health system strengthening in low- and middle-income countries: systematic review. BMC Health Serv Res 2016; 16:79. [PMID: 26931580 PMCID: PMC4774091 DOI: 10.1186/s12913-016-1323-8] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Accepted: 02/17/2016] [Indexed: 11/15/2022] Open
Abstract
Background The involvement of mental health service users and their caregivers in health system policy and planning, service monitoring and research can contribute to mental health system strengthening, but as yet there have been very few efforts to do so in low- and middle-income countries (LMICs). Methods This systematic review examined the evidence and experience of service user and caregiver involvement in mental health system strengthening, as well as models of best practice for evaluation of capacity-building activities that facilitate their greater participation. Both the peer-reviewed and the grey literature were included in the review, which were identified through database searches (MEDLINE, Embase, PsycINFO, Web of Knowledge, Web of Science, Scopus, CINAHL, LILACS, SciELO, Google Scholar and Cochrane), as well as hand-searching of reference lists and the internet, and a snowballing process of contacting experts active in the area. This review included any kind of study design that described or evaluated service user, family or caregiver (though not community) involvement in LMICs (including service users with intellectual disabilities, dementia, or child and adolescent mental health problems) and that were relevant to mental health system strengthening across five categories. Data were extracted and summarised as a narrative review. Results Twenty papers matched the inclusion criteria. Overall, the review found that although there were examples of service user and caregiver involvement in mental health system strengthening in numerous countries, there was a lack of high-quality research and a weak evidence base for the work that was being conducted across countries. However, there was some emerging research on the development of policies and strategies, including advocacy work, and to a lesser extent the development of services, service monitoring and evaluation, with most service user involvement having taken place within advocacy and service delivery. Research was scarce within the other health system strengthening areas. Conclusions Further research on service user and caregiver involvement in mental health system strengthening in LMICs is recommended, in particular research that includes more rigorous evaluation. A series of specific recommendations are provided based on the review. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1323-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Maya Semrau
- King's College London, Institute of Psychiatry, Psychology & Neuroscience, 16 De Crespigny Park, London, SE5 8AF, UK
| | - Heidi Lempp
- King's College London, Faculty of Life Sciences and Medicine, Academic Rheumatology, Clinical Trials Group, Weston Education Centre, 10, Cutcombe Rd., London, SE5 9RJ, UK
| | - Roxanne Keynejad
- King's College London, Institute of Psychiatry, Psychology & Neuroscience, 16 De Crespigny Park, London, SE5 8AF, UK
| | - Sara Evans-Lacko
- King's College London, Institute of Psychiatry, Psychology & Neuroscience, 16 De Crespigny Park, London, SE5 8AF, UK
| | - James Mugisha
- Butabika National Referral and Teaching Hospital, Kampala, Uganda
| | - Shoba Raja
- Special Advisor, BasicNeeds, 158A Parade, Leamington Spa, Warwickshire, CV32 4AE, UK
| | | | - Atalay Alem
- Department of Psychiatry, Addis Ababa University, College of Health Sciences, School of Medicine, Addis Ababa, Ethiopia
| | - Graham Thornicroft
- King's College London, Institute of Psychiatry, Psychology & Neuroscience, 16 De Crespigny Park, London, SE5 8AF, UK
| | - Charlotte Hanlon
- King's College London, Institute of Psychiatry, Psychology & Neuroscience, 16 De Crespigny Park, London, SE5 8AF, UK. .,Department of Psychiatry, Addis Ababa University, College of Health Sciences, School of Medicine, Addis Ababa, Ethiopia.
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van Ginneken N, Tharyan P, Lewin S, Rao GN, Meera SM, Pian J, Chandrashekar S, Patel V. Non-specialist health worker interventions for the care of mental, neurological and substance-abuse disorders in low- and middle-income countries. Cochrane Database Syst Rev 2013:CD009149. [PMID: 24249541 DOI: 10.1002/14651858.cd009149.pub2] [Citation(s) in RCA: 286] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Many people with mental, neurological and substance-use disorders (MNS) do not receive health care. Non-specialist health workers (NSHWs) and other professionals with health roles (OPHRs) are a key strategy for closing the treatment gap. OBJECTIVES To assess the effect of NSHWs and OPHRs delivering MNS interventions in primary and community health care in low- and middle-income countries. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register) (searched 21 June 2012); MEDLINE, OvidSP; MEDLINE In Process & Other Non-Indexed Citations, OvidSP; EMBASE, OvidSP (searched 15 June 2012); CINAHL, EBSCOhost; PsycINFO, OvidSP (searched 18 and 19 June 2012); World Health Organization (WHO) Global Health Library (searched 29 June 2012); LILACS; the International Clinical Trials Registry Platform (WHO); OpenGrey; the metaRegister of Controlled Trials (searched 8 and 9 August 2012); Science Citation Index and Social Sciences Citation Index (ISI Web of Knowledge) (searched 2 October 2012) and reference lists, without language or date restrictions. We contacted authors for additional studies. SELECTION CRITERIA Randomised and non-randomised controlled trials, controlled before-and-after studies and interrupted-time-series studies of NSHWs/OPHR-delivered interventions in primary/community health care in low- and middle-income countries, and intended to improve outcomes in people with MNS disorders and in their carers. We defined an NSHW as any professional health worker (e.g. doctors, nurses and social workers) or lay health worker without specialised training in MNS disorders. OPHRs included people outside the health sector (only teachers in this review). DATA COLLECTION AND ANALYSIS Review authors double screened, double data-extracted and assessed risk of bias using standard formats. We grouped studies with similar interventions together. Where feasible, we combined data to obtain an overall estimate of effect. MAIN RESULTS The 38 included studies were from seven low- and 15 middle-income countries. Twenty-two studies used lay health workers, and most addressed depression or post-traumatic stress disorder (PTSD). The review shows that the use of NSHWs, compared with usual healthcare services: 1. may increase the number of adults who recover from depression or anxiety, or both, two to six months after treatment (prevalence of depression: risk ratio (RR) 0.30, 95% confidence interval (CI) 0.14 to 0.64; low-quality evidence); 2. may slightly reduce symptoms for mothers with perinatal depression (severity of depressive symptoms: standardised mean difference (SMD) -0.42, 95% CI -0.58 to -0.26; low-quality evidence); 3. may slightly reduce the symptoms of adults with PTSD (severity of PTSD symptoms: SMD -0.36, 95% CI -0.67 to -0.05; low-quality evidence); 4. probably slightly improves the symptoms of people with dementia (severity of behavioural symptoms: SMD -0.26, 95% CI -0.60 to 0.08; moderate-quality evidence); 5. probably improves/slightly improves the mental well-being, burden and distress of carers of people with dementia (carer burden: SMD -0.50, 95% CI -0.84 to -0.15; moderate-quality evidence); 6. may decrease the amount of alcohol consumed by people with alcohol-use disorders (drinks/drinking day in last 7 to 30 days: mean difference -1.68, 95% CI -2.79 to -0.57); low-quality evidence).It is uncertain whether lay health workers or teachers reduce PTSD symptoms among children. There were insufficient data to draw conclusions about the cost-effectiveness of using NSHWs or teachers, or about their impact on people with other MNS conditions. In addition, very few studies measured adverse effects of NSHW-led care - such effects could impact on the appropriateness and quality of care. AUTHORS' CONCLUSIONS Overall, NSHWs and teachers have some promising benefits in improving people's outcomes for general and perinatal depression, PTSD and alcohol-use disorders, and patient- and carer-outcomes for dementia. However, this evidence is mostly low or very low quality, and for some issues no evidence is available. Therefore, we cannot make conclusions about which specific NSHW-led interventions are more effective.
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Affiliation(s)
- Nadja van Ginneken
- Centre for Global Mental Health, London School of Hygiene & Tropical Medicine, Keppel St, London, UK, WC1E 7HT
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