Depressive disorder, bipolar disorder, and associated factors among adults, in the Eastern part of Ethiopia

BACKGROUND

Depressive disorder is one of the severe and common mental illnesses in the general population. Bipolar disorder is a severe, persistent mental illness associated with significant morbidity and mortality. However, there is a paucity of data on the prevalence of depressive disorder, and bipolar disorder in our study area.

OBJECTIVE

This study aimed to assess the prevalence of depressive and bipolar disorders among adults in Kersa, Haramaya, and Harar Health and Demographic Surveillance Sites in Eastern Ethiopia.

METHODS

A community-based cross-sectional study was conducted among 1,416 participants. A multi-stage sampling was employed to select the participants. DSM-5 diagnostic criteria was used to assess depressive disorder and bipolar disorder. Data was collected using a standard questionnaire. Data were entered into Epi-Data 3.1 and analyzed using SPSS version 26. Both binary and multivariate logistic regression analyses were done. Those with a p-value < 0.05 in the final model were considered statistically significant.

RESULTS

The overall prevalence of depressive and bipolar disorders among our study participants was 6.7% (95% CI: 5.40, 8.20) and 2.1% (95% CI: (1.40, 3.00), respectively. The independent predictors of depressive disorder included a family history of mental illness, chronic medical illnesses, unemployment, low educational status, divorced or widowed, poor social support, and current alcohol use or khat chewing. Single, males, divorced or widowed, and current consumers of alcohol were independent predictors for bipolar disorder.

CONCLUSIONS AND RECOMMENDATION

The results of our investigation showed that bipolar illness and depression were significant public health issues. It was shown that although bipolar disorder is highly prevalent in the society, depression is a widespread concern. As a result, it is imperative that the relevant body grow and enhance the provision of mental health services. Furthermore, research on the effects and burdens of bipolar disorder in the community is required.

Post-traumatic stress disorder and its associated factors among war-affected residents in Woldia town, North East Ethiopia, 2022; community based cross-sectional study

INTRODUCTION

Post-traumatic stress disorder is marked by increased stress and anxiety following exposure to a traumatic or stressful event. Events of conflict and war-related traumas were commonly reported situations and people who have undergone through have a higher tendency to develop PTSD Woldia town had been under a serious military surge and a five-month encroachment, so the expected destruction in property, impact on physical, social and mental health of civilians was potentially high. More importantly, there is no study that investigated the significance of association between war-related traumatic events and post-traumatic stress disorder in the area. so this study aims to assess prevalence of post-traumatic stress disorder and its associated factors among war-affected residents in Woldia town, North East Ethiopia, 2022.

METHOD

A community-based cross-sectional study design was employed by using a multi-stage systematic random sampling technique from May-15 to June-15/2022. A total of 609 participants were enrolled. PTSD was measured by the post-traumatic stress disorder checklist for DSM-5 (PCL-5). Data were entered by Epi data version 4.6.0.2 and analyzed using STATA version 14. Bivariable and Multivariable logistic regression analysis was done to identify associated factors to PTSD and P-values less than 0.05 were considered statistically significant.

RESULTS

The overall prevalence of PTSD was 56.28%. Destruction/looting of property (AOR = 1.6,95%CI,1.11-2.47), murder/injury of family member (AOR = 2.1,95% CI,1.37-3.22), witness of murder of family member/others (AOR = 1.6,95% CI,1.01-2.71), unlawful imprisonment (AOR = 1.7, 95%CI, 1.06-2.74), depression (AOR = 2, 95%CI, 1.37-2.93), anxiety (AOR = 3.3, 95%CI,2.26-4.97), experience trauma on themselves (AOR = 2.0,95%CI,1.22-3.58), poor (AOR = 3.1,95%CI,1.60-6.04) and moderate (AOR = 3.0, 95%CI, 1.56-5.87) social support were statistically associated with PTSD at a p-value < 0.05.

CONCLUSION

The study reveals that the prevalence of PTSD was high in Woldia town following an armed conflict between Federal Government and Tigray forces. Destruction/looting of property, murder/injury of family, witness murder of family/others, unlawful imprisonment, depression, anxiety, experience on themselves, poor and moderate social support were statistically associated with PTSD. Hence, encourage organization working on mental health, routine patient assessment with a history of trauma, facilitating means to support affected residents is recommended.

Willingness to Receive mHealth Services Among Patients with Diabetes on Chronic Follow-up in Public Hospitals in Eastern Ethiopia: Multicenter Mixed-Method Study

Background

Management of diabetes requires a long-term care strategy, including support for adherence to a healthy lifestyle and treatment. Exploring the willingness of patients with diabetes to receive mHealth services is essential for designing efficient and effective services. This study aimedto determine willingness to receive mHealth services and associated factors, as well as explore the barriers to receive mHealth services among patients with diabetes.

Methods

A multicenter mixed-method study was employed from September 1 to November 30, 2022. For the quantitative part, a total of 365 patients with diabetes receiving chronic follow-up at three public hospitals were enrolled. Data were gathered using structured questionnaires administered by interviewers, entered into Epi-data version 4.6, and analyzed using Stata version 17. A binary and multivariable logistic regression model was computed to identify the associated factors. For qualitative, eight key informants and seven in-depth interviews were conducted. After verbatim transcription and translation, the data were thematically analyzed using ATLAS.ti V. 7.5.

Results

Overall, 77.3% had access to a mobile phone, and 74.5% of them were willing to receive mHealth services. Higher odds of willingness to receive mHealth services were reported among patients with an age below 35 years [AOR = 4.11 (1.15-14.71)], attended formal education [AOR = 2.63 (1.19-5.77)], without comorbidity [AOR = 3.6 (1.54-8.41)], <1-hour travel to reach a health facility [AOR = 3.57 (1.03-12.36)], answered unknown calls [AOR = 2.3 (1.04-5.13)], and were satisfied with health-care provider service [AOR = 2.44 (1.04-5.72)]. In the qualitative part, infrastructure, health facilities, socioeconomic factors, and patients' behavioral factors were major identified barriers to receiving mHealth services.

Conclusion

In this study, the willingness to receive mHealth services for those who have access to mobile phones increased. Additionally, the study highlighted common barriers to receiving mHealth services.

The Magnitude of Hypertension and Its Contributing Factors Among Patients Receiving Antiretroviral Therapy in Public Hospitals in Harar City, Eastern Ethiopia: A Cross-Sectional Study

Background

Although people living with HIV (PLHIV) are surviving longer due to the development of highly active antiretroviral therapy (HAART), hypertension continues to be a significant obstacle for human immunodeficiency virus (HIV) positive patients.

Purpose

This study aims to determine the prevalence of hypertension and its contributing factors among patients receiving HAART in public hospitals in Harar City, Eastern Ethiopia.

Patients and Methods

A hospital-based cross-sectional study was conducted among adult PLHIV who receive HAART in public hospitals in Harar City, Eastern Ethiopia, from 20 March to 14 April 2023. A simple random sampling technique was employed to select a total of 406 clients (382 participated in the study). Data were collected through patient interview and chart review using a questionnaire. The binary logistic regression was used for data analysis. The association was declared statistically significant at a p-value less than 0.05.

Results

The magnitude/prevalence of hypertension was 23% (95% CI: 19.1, 27.5) in study settings from a total of 382 adults who participated in this study. Factors significantly associated with hypertension in a multivariable binary logistic regression model include residence (rural residence, AOR = 1.95, 95% CI: 1.04, 3.65); body mass index (obese, AOR = 4.35, 95% CI: 1.08, 16.77); cigarette smoking (past cigarette smoking, AOR = 4.7, 95% CI: 1.10, 21.8); and HAART regimen change (AOR = 0.44, 95% CI: 0.20, 0.97).

Conclusion

The prevalence of hypertension observed among adult PLHIV in the study settings was high. Adults from rural areas, with a history of past smoking cigarette, and obesity need close attention during their clinic visits for more health education to reduce risk factors. The changed HAART regimen was associated with a reduced risk of hypertension. Generally, hypertensive PLHIV need consideration for their double burden of communicable and non-communicable diseases during disease management and hospital guideline development.

Adherence to diabetic foot care recommendations and associated factors among people with diabetes in Eastern Ethiopia: a multicentre cross-sectional study

OBJECTIVE

This study aimed to determine the level of adherence to foot care recommendations and associated factors among people with diabetes on follow-up in public hospitals in Eastern Ethiopia.

SETTING

An institutional-based cross-sectional study was conducted in public hospitals found in Eastern Ethiopia from 25 February to 25 March 2022.

PARTICIPANTS

A total of 419 patients with chronic diabetes who visited diabetic clinics in public hospitals in Eastern Ethiopia for follow-up were included.

MAIN OUTCOME MEASURE

The level of adherence to diabetic foot care recommendations and associated factors.

RESULTS

The findings indicated that 44.3% (95% CI: 39.3, 49.0) of people with diabetes had inadequate adherence to diabetic foot care recommendations. Age between 28-37 (adjusted OR (AOR)=1.10; 95% CI: 1.27, 5.63) and 38-47 years (AOR=2.19; 95% CI: 2.74, 8.89), rural residence (AOR=1.71; 95% CI: 1.15, 2.57), absence of comorbidity (AOR=2.22; 95% CI:1.34, 5.14), obesity (AOR=1.43; 95% CI: 1.10, 5.05) and inadequate foot care knowledge (AOR=2.10; 95% CI: 1.52, 4.35) were factors significantly associated with inadequate adherence to diabetic foot care recommendations.

CONCLUSION

More than two-fifths of people with diabetes had inadequate adherence to diabetic foot care recommendations. Younger age, rural residence, absence of comorbidity, obesity and inadequate foot care knowledge were significantly associated with inadequate adherence to diabetic foot care recommendations. It is very essential to educate people with diabetes about the importance of foot care recommendations in preventing and delaying the risks of foot-related problems and complications.

Utilization of preconception care and associated factors among pregnant mothers in Fiche Town, Central Ethiopia: a community-based cross-sectional study 2021

Introduction

Preconception care is an important preventive intervention for adverse pregnancy outcomes. It is recognized as a strategy to optimize women's health and pregnancy outcomes in Western countries. However, preconception care is underutilized in sub-Saharan Africa, like Ethiopia, where maternal mortality is high. Evidence is scarce in the study area about the prevalence and factors associated with preconception care utilization. Therefore this study aimed to assess the proportion of preconception care utilization and associated factors among pregnant mothers in Fiche town, central Ethiopia, 2021.

Method

A community-based cross-sectional study was done from May 10 to June 25, 2021. A systematic random sample technique was used to choose 393 pregnant women for the study. A structured, pre-tested, interviewer-administered questionnaire was used to collect data. The data were entered into Epi Data version 3.1 and then exported into SPSS version 25 for analysis. A Bivariable and multivariable logistic regression analysis was used to check for the association. Odds ratio along with 95% was used to describe the association. Finally, a significant association was declared at a p-value less than 0.05.

Results

388 respondents participated in this study, making the response rate 98.7%. Of total study participants only 84 (21.6%; 95% CI, 18, 25.8) utilized preconception care. The study found that diploma or higher level of education (AOR = 3.47, 95% CI: 1.27, 9.53), psychological and financial support from a partner (AOR = 3.86, 95% CI: 2.1, 7.10), joint discussion and plan with a partner (AOR = 3.32, 95% CI: 1.55, 7.13), history of chronic disease (AOR = 3.47, 95% CI: 1.67, 7.25), and good knowledge about preconception care (AOR = 2.42, 95% CI: 1.34, 4.38) were significantly associated with preconception care utilization.

Conclusions

Overall, less than a quarter of the pregnant mothers utilized preconception care, indicating that awareness is very low. Pregnant mothers who have a higher educational level, have good communication and support from their partners, have chronic health problems, and have good knowledge about preconception care were more likely to utilize the service. Preconception care is a better opportunity to intervene and maintain the mother in the continuum of care.

Suicidal ideation, attempt and associated factors among people with cancer attending cancer center, eastern Ethiopia

Background

Suicide is one of the most common public health problems and the second leading cause of death among individuals 15-29 years of age. Suicidal ideation and attempt are one of the common psychiatric emergence in patients with cancer that needs early detection and management before patients end their lives. Therefore, the aim of the study was to assess the magnitude of suicidal ideation, attempts, and associated factors among people with cancer in Eastern Ethiopia.

Methods

An institutional-based cross-sectional study design was conducted among 362 participants. A composite international diagnostic interview was used to evaluate suicidal ideation and attempt. Epi-Data version 4.6.2 was used for data entry, and SPSS version 20 was used for analysis. Logistic regression analysis was done to identify associated factors for both suicidal ideation and attempt. p-values less than 0.05 are considered statistically significant, and the strength of the association will be represented by an adjusted odds ratio with a 95% confidence interval.

Results

The magnitude of suicidal ideation and attempt among people with in this study was 22.9% [95% CI, 18.7-27.4] and 9.8% [95%CI, 6.7-12.8] respectively. Being living alone [AOR = 4.90, 95% CI, 2.08-11.90], and having depressive symptoms [AOR = 3.28, 95% CI, 1.37-7.73], female ([AOR = 1.53, 95% CI, 1.30-3.23], anxiety symptoms [AOR = 3.06, 95% CI, 1.35-6.73)] and having poor social support [AOR = 3.08, 95% CI, 1.72-5.05], were significantly associated suicidal ideation whereas, Being living alone [AOR = 2.89, 95% CI, 1.09-7.65], having a depressive symptoms [AOR = 4.88, 95% CI, 1.45-13.28], being divorced/widowed [AOR = 3.46, 95% CI, 1.09-10.09] and stage four cancer [AOR = 5.53, 95% CI 2.97-7.47] were significantly associated with suicidal attempt.

Conclusion

Nearly one-quarter and one-tenth of people with cancer have suicide ideation and attempt, respectively. Suicidal behavior among cancer patients was found in this study to be a common problem. Living alone, having depressive and anxiety symptoms, being a female, having poor social support, and being in forth stage of cancer were risk factors for suicide. Therefore, early screening, diagnosing, and treating suicide and its factors will be mandatory and expected from health care providers and non-governmental organizations.

Khat chewing and associated factors among public secondary school students in Harar town, Eastern Ethiopia: a multicenter cross-sectional study

Background

Khat is a huge, evergreen tree that grows at high altitudes throughout the Arabian Peninsula and in the region stretching from eastern to southern Africa. Cathinone, cathine, and norephedrine are psychoactive ingredients contained in khat. Ethiopian teenagers, especially those in secondary school, frequently use khat. This use of khat may lead to students frequently missing class and experiencing subpar academic performance. However, the study area lacks information regarding the prevalence of khat use and the factors associated with it.

Objective

This study's primary goal is to determine the prevalence of khat chewing and related factors among secondary school students in public schools in Harar, Eastern Ethiopia, in 2022.

Methods

A multicenter cross-sectional study design was employed from June 01-June 30, 2022, in three public secondary schools in Harar town in a sample of 485 students. Systematic random sampling was used to choose the study sample. Data were gathered using self-administered questionnaires, and the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) was used to assess khat chewing. Epidata version 4.6 was used to enter the data, while STATA version 14 was used to analyze them. To determine the factors related to khat chewing, bivariate and multivariate logistic regression analysis was conducted, and statistical significance was determined at a 95% confidence level with a P-value under 0.05.

Results

Out of 485 eligible participants, 455 responded to this survey, giving a response rate of 93.8%. Overall, 33.2% (95% CI: 29.2%-37.6%) of the sample's participants reported currently chewing khat. Age ranged from 20 to 25 years (AOR = 2.04; 95% CI: 1.19-3.48), male students (AOR = 7.03; 95% CI: 4.35-12.57), current alcohol user (AOR 6.48; 95% CI: 2.30-18.28), presence of chewer friends (AOR 3.86; 95% CI: 2.38-6.24), and depression (AOR 1.84, 95%CI: 1.02-3.30), were strongly associated with khat chewing at a p-value of < 0.05.

Conclusion

Khat chewing was very common among students in Eastern Ethiopia's public secondary schools. Ages between 20 and 25 years, being a male, being current alcohol users, having chewer buddies, and depression are all significantly linked to khat use. Thus, schools should create and implement audience-specific behavioral change communication to deter and stop students from chewing khat. Additionally, it is important to ban the sale of khat to young adults and adolescents, promote medical care for khat users, and foster peer advocacy for support services.

Process Evaluation of Health System Responsiveness Level and Associated Factors Among Mothers Gave Birth at Obstetric Ward in a Tertiary Hospital, Southwest of Ethiopia: Mixed Study Methods

Background

The term responsiveness emerged during the World Health Organization (WHO) report in 2000 as new and essential goals of the health systems to meet the needs of people to their expectations from different services being given in healthcare systems. Obstetric violence and childbirth mistreatment are global problems, but the worst obstetric violence usually occurs in underdeveloped countries. Thus, the main objective of this study was to evaluate the responsiveness of obstetric service at Jimma University Medical Center.

Methods

A single-case study design with quantitative and qualitative data collection was employed. Availability with 17 indicators and health system responsiveness with 24 indicators were used. Consecutive sampling technique was used to select the clients and qualitative data were collected from key informants. SPSS version 25 was used for the analysis of quantitative data, whereas thematic analysis was conducted for qualitative data. A multiple linear regression model was fitted after all assumptions were checked and fit to ensure the relation of the dependent variable with independent variables.

Results

The overall evaluation was 75.6% and judged good. The resource availability and health system responsiveness were 85.5% and 69.7%, which were judged very good and fair, respectively. A stethoscope and thermometer were not available, while 40% glucose, dexamethasone, and intravenous fluid were the most frequently stocked-out supplies. Dignity (72.1%), confidentiality (71.4%), and prompt attention (70%) were the top three good scores for the health system's responsiveness. Health system responsiveness significantly associated with the following: Not attending formal education, attending college and above, place of delivery (health center), mode of delivery (cesarean section), and being merchant.

Conclusion & Recommendation

The health system responsiveness of delivery service in study setting was good. All stakeholders should work for improving the health system's responsiveness in delivery service.

Prevalence and determinants of maternal near miss in Ethiopia: a systematic review and meta-analysis, 2015-2023

BACKGROUND

One of the most challenging problems in developing countries including Ethiopia is improving maternal health. About 303,000 mothers die globally, and one in every 180 is at risk from maternal causes. Developing regions account for 99% of maternal deaths. Maternal near miss (MNM) resulted in long-term consequences. A systematic review and meta-analysis was performed to assess the prevalence and predictors of maternal near miss in Ethiopia from January 2015 to March 2023.

METHODS

A systematic review and meta-analysis cover both published and unpublished studies from different databases (PubMed, CINHAL, Scopus, Science Direct, and the Cochrane Library) to search for published studies whilst searches for unpublished studies were conducted using Google Scholar and Google searches. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used. Duplicated studies were removed using Endnote X8. The paper quality was also assessed based on the JBI checklist. Finally, 21 studies were included in the study. Data synthesis and statistical analysis were conducted using STATA Version 17 software. Forest plots were used to present the pooled prevalence using the random effect model. Heterogeneity and publication bias was evaluated using Cochran's Q test, (Q) and I squared test (I²). Subgroup analysis based on study region and year of publication was performed.

RESULT

From a total of 705 obtained studies, twenty-one studies involving 701,997 pregnant or postpartum mothers were included in the final analysis. The national pooled prevalence of MNM in Ethiopia was 140/1000 [95% CI: 80, 190]. Lack of formal education [AOR = 2.10, 95% CI: 1.09, 3.10], Lack of antenatal care [AOR = 2.18, 95% CI: 1.33, 3.03], history of cesarean section [AOR = 4.07, 95% CI: 2.91, 5.24], anemia [AOR = 4.86, 95% CI: 3.24, 6.47], and having chronic medical disorder [AOR = 2.41, 95% CI: 1.53, 3.29] were among the predictors of maternal near misses from the pooled estimate.

CONCLUSION

The national prevalence of maternal near miss was still substantial. Antenatal care is found to be protective against maternal near miss. Emphasizing antenatal care to prevent anemia and modifying other chronic medical conditions is recommended as prevention strategies. Avoiding primary cesarean section is recommended unless a clear indication is present. Finally, the country should place more emphasis on strategies for reducing MNM and its consequences, with the hope of improving women's health.

Prevalence of common mental disorders and associated factors among adults living in Harari regional state, eastern Ethiopia: a community based cross-sectional study

Background

Common mental disorders are highly prevalent in the population, affecting people across all regions of the world. In Ethiopia, mental disorders are the leading non-communicable disorders. World Health Organization (WHO) report shows that 4,480,113 (4.7%) and 3,139,003 (3.3%) people in Ethiopia are estimated to suffer from depression and anxiety, respectively. However, there are only limited studies conducted on common mental disorders in Africa including Ethiopia. Even if there was a previous study conducted among Harari regional state residents 7 years back, nowadays there are many possible factors that could increase the prevalence of common mental disorders in the community like the novel coronavirus pandemic, ethnic war, and current socio-economic crises in Ethiopia.

Objective

To assess the prevalence of common mental disorders and associated factors among adult residents of Harari regional state, eastern Ethiopia.

Methods

A community-based cross-sectional study was conducted from March 1 to March 30, 2022. A systematic random sampling technique was used to select 1,192 study participants. Data were collected by interviewer-administered structured and semi-structured questionnaires. A common mental disorder was assessed by the Self-Reporting Questionnaire of 20-Item (SRQ-20) questionnaire. Data were entered into Epi Data version 3.2 and exported to Stata Version 16 for analysis. The multivariable binary logistic regression analysis with a 95% confidence interval and p < 0.05 was used to identify factors associated with common mental disorders.

Result

From a total of 1,192 eligible participants, 1,168 responded to this survey, giving a response rate of 97.98%. The prevalence of common mental disorders among adults in the Harari Region of this study was 21.31% (95% CI, 18.8-23.60). Being female with Adjusted Odds Ratios (AOR = 1.31, 95%CI, 1.09-2.09), single (AOR = 2.03, 95%CI, 1.37-3.01), divorced (AOR = 3.06, 95%CI, 1.97-4.76), widowed (AOR = 1.79, 95%CI, 1.23-3.26), unemployed (AOR = 1.97, 95%CI, 1.18-3.31), having family history of mental illness (AOR = 3.17, 95%CI, 1.54-6.96) and age greater or equal to 55 years (AOR = 105, 95%CI, 1.69-3.54) were statistically associated with common mental disorders.

Conclusion

The prevalence of common mental disorder in the study area was sharply increased. Being female, single, divorced, widowed, family history of mental illness, being unemployed and age greater or equal to 55 years old were statistically positively associated with common mental disorder. Considering these determinants, screening, early identification, and providing appropriate intervention for common mental disorders in the community should be of great concern.

Prevalence of depressive symptoms and their associated factors among older adults in Yirgalem town, Southern Ethiopia: A community-based cross-sectional study

Background

Depression is a serious mental health issue and the largest contributor to disability worldwide. Elderly people with depression are significantly more likely to experience negative outcomes such as poor physical health, strained social relationships, and decreased quality of life. Studies on geriatric depression are limited in developing nations like Ethiopia.

Objectives

The purpose of this study was to determine the prevalence of depressive symptoms and associated factors among older adults in Yirgalem, Southern Ethiopia, in 2022.

Methods

A community-based cross-sectional study was conducted on a sample of 628 older adults in Yirgalem town from May 15 to June 15, 2022. The study subjects were selected using a multi-stage systematic sampling technique. Data were collected using the 15-item Geriatric depression scale through face-to-face interviews. The collected data were edited, cleaned, coded, and entered into Epi data version 4.6 software and analyzed using STATA version 14. Bivariable and multivariate logistic regression analysis was computed to identify factors associated with depression, and statistical significance was declared at a 95% confidence interval with a P-value less than 0.05.

Results

A total of 620 older adults were included in the study, with a response rate of 97.8%. The prevalence of depressive symptoms among older adults was 51.77% (95% CI: 47.83-55.69). Being a woman (AOR = 2.3, 95% CI: 1.56-3141); being of more advanced age: 70-79 years old (AOR = 1.92, 95% CI: 1.20-3.07), 80-89 years old (AOR = 2.15, 95% CI: 1.27-3.65), 90 and older (AOR = 3.77, 95% CI: 1.95-7.79); living alone (AOR = 1.99, 95% CI = 1.17-3.41); having a chronic illness (AOR = 3.24, 95% CI: 1.06-4.46); having anxiety (AOR = 3.40; 95% CI: 2.25-5.14); and having poor social support (AOR = 3.56, 95% CI: 2.09-6.04) were statistically associated with depressive symptoms at a P-value of less than 0.05.

Conclusion

This study found that depression affects more than half of the elderly residents in the study area. More advanced age, being a woman, living alone, having a chronic illness, having anxiety, and having poor social support were all strongly linked to depression. There is a need to integrate counseling and psychiatric services into the community healthcare system.