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Yanguela J, Pence BW, Udedi M, Banda JC, Kulisewa K, Zimba CC, Malava JK, Akiba C, Dussault JM, Morrison AM, Mphonda S, Hosseinipour MC, Gaynes BN, Wheeler SB. Implementation strategies to build mental health-care capacity in Malawi: a health-economic evaluation. Lancet Glob Health 2024; 12:e662-e671. [PMID: 38408461 PMCID: PMC10958395 DOI: 10.1016/s2214-109x(23)00597-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 12/10/2023] [Accepted: 12/12/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND Depression is a major contributor to morbidity and mortality in sub-Saharan Africa. Due to low system capacity, three in four patients with depression in sub-Saharan Africa go untreated. Despite this, little attention has been paid to the cost-effectiveness of implementation strategies to scale up evidence-based depression treatment in the region. In this study, we investigate the cost-effectiveness of two different implementation strategies to integrate the Friendship Bench approach and measurement-based care in non-communicable disease clinics in Malawi. METHODS The two implementation strategies tested in this study are part of a trial, in which ten clinics were randomly assigned (1:1) to a basic implementation package consisting of an internal coordinator acting as a champion (IC-only group) or to an enhanced package that complemented the basic package with quarterly external supervision, and audit and feedback of intervention delivery (IC + ES group). We included material costs, training costs, costs related to project-wide meetings, transportation and medication costs, time costs related to internal champion activities and depression screening or treatment, and costs of external supervision visits if applicable. Outcomes included the number of patients screened with the patient health questionnaire 2 (PHQ-2), cases of remitted depression at 3 and 12 months, and disability-adjusted life-years (DALYs) averted. We compared the cost-effectiveness of both packages to the status quo (ie, no intervention) using a micro-costing-informed decision-tree model. FINDINGS Relative to the status quo, IC + ES would be on average US$10 387 ($1349-$17 365) more expensive than IC-only but more effective in achieving remission and averting DALYs. The cost per additional remission would also be lower with IC + ES than IC-only at 3 months ($119 vs $223) and 12 months ($210 for IC + ES; IC-only dominated by the status quo at 12 months). Neither package would be cost-effective under the willingness-to-pay threshold of $65 per DALY averted currently used by the Malawian Ministry of Health. However, the IC + ES package would be cost-effective in relation to the commonly used threshold of three times per-capita gross domestic product per DALY averted. INTERPRETATION Investing in supporting champions might be an appropriate use of resources. Although not currently cost-effective by Malawian willingness-to-pay standards compared with the status quo, the IC + ES package would probably be a cost-effective way to build mental health-care capacity in resource-constrained settings in which decision makers use higher willingness-to-pay thresholds. FUNDING National Institute of Mental Health.
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Affiliation(s)
- Juan Yanguela
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Brian W Pence
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Michael Udedi
- Non-Communicable Diseases and Mental Health Division, Malawi Ministry of Health and Population, Department of Clinical Services, Lilongwe, Malawi
| | - Jonathan Chiwanda Banda
- Non-Communicable Diseases and Mental Health Division, Malawi Ministry of Health and Population, Department of Clinical Services, Lilongwe, Malawi
| | - Kazione Kulisewa
- Department of Mental Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | | | - Jullita K Malava
- Malawi Epidemiology and Intervention Research Unit, Chilumba, Karonga District, Malawi
| | | | | | - Abigail M Morrison
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Steve Mphonda
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Mina C Hosseinipour
- University of North Carolina Project-Malawi, Lilongwe, Malawi; Department of Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Bradley N Gaynes
- Division of Global Mental Health, Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
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Mphonda S, Dussault J, Bengtson A, Gaynes BN, Go V, Hosseinipour MC, Kulisewa K, Kutengule A, Meltzer-Brody S, Udedi M, Pence B. Preferences for enhanced treatment options to address HIV care engagement among women living with HIV and perinatal depression in Malawi. BMC Public Health 2023; 23:1922. [PMID: 37794350 PMCID: PMC10552213 DOI: 10.1186/s12889-023-16835-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 09/25/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Option B + offers lifelong ART to pregnant or breastfeeding mothers, but postpartum loss to HIV care, partially driven by perinatal depression (PND), threatens the impact of this policy. This study aims to understand women's and providers' preferences for developing a feasible intervention to address PND and support engagement in HIV care among women living with PND and HIV. METHODS We conducted a total of 6 focus group discussions (FGDs) involving 4 clinics in Lilongwe District from December 2018 through February 2019. We conducted 2 FGDs each among 3 stakeholder groups: clinical staff, prenatal women, and postnatal women. Perinatal participants were living with HIV and screened positively for PND using the validated Edinburgh Postnatal Depression Scale (EPDS). Clinical staff were nurses who were trained antiretroviral therapy (ART) providers. Interviewers led FGDs in Chichewa using a semi-structured guide. Data were analyzed using deductive and inductive coding in NVivo 12 software. RESULTS Women favored ART linkage services, but providers said they already offered such services, with mixed results. Individual counselling was universally supported. A perceived benefit of group counselling was peer support, but there were concerns among women regarding confidentiality and stigma. Women liked mobile appointment reminders but identified low phone ownership as a barrier. Participants recommended home visits as an additional care engagement strategy. Women consistently discussed the need for social support from family members and friends to address PND and support engagement in HIV care. CONCLUSION This study highlights the importance of peer encouragement to support perinatal HIV care engagement among women with HIV and PND. The results from this study can be used to support intervention development to increase HIV care engagement and improve long-term HIV outcomes in women with PND.
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Affiliation(s)
- Steve Mphonda
- UNC-Project Malawi, Private Bag A-104, Lilongwe, Malawi.
| | - Josée Dussault
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Angela Bengtson
- Department of Epidemiology, Brown School of Public Health, Brown University, Providence, RI, USA
| | - Bradley N Gaynes
- Department of Psychiatry, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Vivian Go
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Mina C Hosseinipour
- UNC-Project Malawi, Private Bag A-104, Lilongwe, Malawi
- Department of Medicine, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kazione Kulisewa
- Department of Psychiatry and Mental health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | | | - Samantha Meltzer-Brody
- Department of Psychiatry, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Michael Udedi
- Department of Psychiatry and Mental health, Kamuzu University of Health Sciences, Blantyre, Malawi
- Ministry of Health, Lilongwe, Malawi
| | - Brian Pence
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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LeMasters K, Dussault J, Barrington C, Bengtson A, Gaynes B, Go V, Hosseinipour MC, Kulisewa K, Kutengule A, Meltzer-Brody S, Midiani D, Mphonda S, Udedi M, Pence B. "Pain in my heart": Understanding perinatal depression among women living with HIV in Malawi. PLoS One 2020; 15:e0227935. [PMID: 32502150 PMCID: PMC7274419 DOI: 10.1371/journal.pone.0227935] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Accepted: 05/23/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Perinatal depression (PND) can interfere with HIV care engagement and outcomes. We examined experiences of PND among women living with HIV (WLWH) in Malawi. METHODS We screened 73 WLWH presenting for perinatal care in Lilongwe, Malawi using the Edinburgh Postnatal Depression Scale (EPDS). We conducted qualitative interviews with 24 women experiencing PND and analyzed data using inductive and deductive coding and narrative analysis. RESULTS Women experienced a double burden of physical and mental illness, expressed as pain in one's heart. Receiving an HIV diagnosis unexpectedly during antenatal care was a key contributor to developing PND. This development was influenced by stigmatization and social support. CONCLUSIONS These findings highlight the need to recognize the mental health implications of routine screening for HIV and to routinely screen and treat PND among WLWH. Culturally appropriate mental health interventions are needed in settings with a high HIV burden.
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Affiliation(s)
- Katherine LeMasters
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Carolina Population Center, Chapel Hill, North Carolina, United States of America
| | - Josée Dussault
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Clare Barrington
- Carolina Population Center, Chapel Hill, North Carolina, United States of America
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Angela Bengtson
- Department of Epidemiology, Brown School of Public Health, Brown University, Providence, Rhode Island, United States of America
| | - Bradley Gaynes
- Department of Psychiatry, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Vivian Go
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Mina C. Hosseinipour
- UNC-Project Malawi, Lilongwe, Malawi
- Department of Medicine, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | | | | | - Samantha Meltzer-Brody
- Department of Psychiatry, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | | | | | - Michael Udedi
- College of Medicine, University of Malawi, Lilongwe, Malawi
- Ministry of Health, Lilongwe, Malawi
| | - Brian Pence
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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