Targeting ethical considerations tied to image-based mobile health diagnostic support specific to clinicians in low-resource settings: the Brocher proposition

Background: mHealth applications assist workflow, help move towards equitable access to care, and facilitate care delivery. They have great potential to impact care in low-resource countries, but have significant ethical concerns pertaining to patient autonomy, safety, and justice. Objective: To achieve consensus among stakeholders on how to address concerns pertaining to autonomy, safety, and justice among mHealth developers and users in low-resource settings, in particular for the application of image-based consultation for diagnostic support. Methods: A consensus approach was taken during a three-day workshop using a purposive sample of global mHealth stakeholders (n = 27) professionally and geographically spread. Throughout a series of introductory talks, group brainstorming, plenary reviews, and synthesis by the moderators, lists of actions were generated that address the concerns engendered by mHealth applications on autonomy, justice and safety, taking into account the development, implementation, and scale-up phases of an mHealth application lifecycle. Results: Several types of actions were recommended; key ones among them included building in risk mitigation measures from the development stage, establishing inclusive consultation processes, using open sources platform whenever possible, training all clinical users, and bearing in mind that the gold standard of care is face-to-face consultation with the patient. Recommendations of patient, community and health system participation and of governance were identified as cutting across the mHealth lifecycle. Conclusion: Priorities agreed-upon at the meeting echo those put forward concerning other domains and locations of application of mHealth. Those more forcefully articulated are the need to adopt and maintain participatory processes as well as promoting self-governance. They are expected to cut across the mHealth lifecycle and are prerequisites to the safeguard of autonomy, safety and justice.

Validity and utility of instruments for screening of depression in women attending antenatal clinics in Blantyre district in Malawi

Introduction: Screening instruments should be brief, valid and easy to use if they are to be useful in a busy antenatal clinic in low-resource settings. A short instrument can be used in a busy antenatal clinic in combination with a more detailed instrument once referred. This study aimed at assessing the validity of a range of depression screening instruments and to test the utility of combining these instruments for use in antenatal clinics in Blantyre district, Malawi.Methods: This was a sensitivity analysis study using a sub-sample of 97 pregnant women drawn from a cross-sectional study (sample size = 480) that was screening for depression in eight antenatal clinics. Data from the cross-sectional study for the 97 pregnant women on the 3-item screener, Edinburgh Postnatal Depression Scale (EPDS), Hopkins Symptoms Checklist-15 (HSCL-15) and Self-Reporting Questionnaire (SRQ), was compared with a gold standard, the Mini International Neuropsychiatric Interview (MINI). Sensitivity, specificity and area under curve (AUC) were calculated to test for validity of the instruments. The utility of various combinations of the instruments was tested using the compensatory, conjunctive, probability and sequential rules.Results: The 3-item screener, EPDS, HSCL-15 and SRQ were valid instruments for screening antenatal depression. Sequential combination of the 3-item screener and SRQ had superior discriminant ability over similar combinations of the 3-item screener and either EPDS or HSCL-15 (sensitivity = 78%, specificity = 88%, AUC = 0.885).Discussion: The 3-item screener, EPDS, HSCL-15 and SRQ are valid instruments for screening depression in local antenatal clinics. The sequential combination of the 3-item screener and SRQ may be a practical, accurate and suitable method for multistage screening of depression in antenatal clinics in Blantyre district, Malawi.

Depression in older adults: prevalence and risk factors in a primary health care sample

Background: Depression in the geriatric population has been identified as a significant problem in view of the associated negative outcomes regarding poor functioning, increased perception of poor health and increased utilisation of medical services. Significantly associated with increased morbidity and mortality, depression has been found to be an independent cause of disability as well as adding to disability due to primary physical illnesses. Early identification and treatment of depression reduces medical costs and lessens caregiver burden. Epidemiological data and prevalence rates of geriatric depression in Africa are limited, although such data are vital to mobilise and plan government mental health initiatives aimed at screening and early intervention. Objective: To determine the prevalence of depression and associated clinical and socio-demographic factors amongst older adult patients attending a primary health care clinic in the Ethekwini District in Kwa-Zulu Natal, South Africa. Methods: The 15-item Geriatric Depression Scale and a socio-demographic questionnaire were administered in English to 255 geriatric outpatients, randomly selected, at a local community clinic in Durban. Data analysis: Data were analysed using SPSS version 23®. Descriptive statistics were used to summarise the sample demographics and response rate and non-parametric statistics were used to test for associations and differences. Results: A Cronbach’s alpha for the GDS was calculated (p = 0.793). Some 40% of participants screened positive for depression. Female gender, widowhood and a negative subjective health status rating were significantly associated with depression and marriage appeared to be protective (p < 0.001). Participants with a poor subjective health rating were 21 times more likely to be depressed and widowhood conferred an almost fourfold increased risk of being depressed, with widows at greater risk than widowers. No association between depression and specific medical conditions was identified. Conclusion: There is a high rate of undetected depression among the elderly attending a local primary health care clinic with widowhood and poor subjective health being strong predictors of mood disorders. The findings warrant replication in bigger samples. (Full text of the research articles are available online at www.medpharm.tandfonline.com/ojfp) S Afr Fam Pract 2017; DOI: 10.1080/20786190.2016.1272250

Profile of depression in women attending antenatal clinics in Blantyre District, Malawi

Introduction

Depression is one of major health problems affecting pregnant women in low resource settings. It can lead to poor uptake of antenatal services. Data about prevalence of antenatal depression and associated risk factors remain scanty in Malawi. The study settings were eight selected antenatal clinics in Blantyre district, Malawi. The aim of this study was to assess prevalence of antenatal depression and associated risk factors among pregnant women attending antenatal clinics in Blantyre district, Malawi.

Methods

This was a quantitative study which used a random sample of 97 pregnant women. Ethical approval was granted by relevant bodies. Descriptive and inferential statistics were used to analyse data.

Results

Prevalence of antenatal depression in Blantyre district was 25.8% (n = 25). Risk factors associated with antenatal depression included: “being distressed by anxiety or depression for more than two weeks during this pregnancy”; “feeling that pregnancy has been a positive experience”; “having a history of feeling miserable or depressed for two weeks or more before this pregnancy”; “relationship with partner is an emotionally supportive one”; “experiencing major stresses, changes or losses in the course of this pregnancy”; “having history of physical abuse when growing up”, and “having concerns about being or becoming a mother”.

Conclusion

This study has shown that antenatal depression is prevalent in Malawi. It suggests that psychosocial interventions targeting pregnant women may be necessary to reduce antenatal depression and associated risk factors. However, further research regarding ways for assisting pregnant women to build and strengthen their psychosocial support structures is needed.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

The use of mobile phones to deliver acceptance and commitment therapy in the prevention of mother-child HIV transmission in Nigeria

The objective of this study was to determine if introducing acceptance and commitment therapy in the prevention of mother to child HIV transmission (PMTCT) programme using weekly mobile phone messages would result in improved mental health status of HIV-positive, pregnant women in Nigeria. We used a Solomon four-group (two intervention and two control groups) randomised design. The study population was 144 randomly selected, HIV-positive pregnant women attending four randomly selected PMTCT centres in Nigeria. The intervention groups were exposed to one session of acceptance and commitment therapy with weekly value-based health messages sent by mobile phone for three months during pregnancy. The control groups received only post-HIV test counselling. A total of 132 participants (33 per site) were enrolled in the study from the two intervention and two control sites. In the pre-tests, the intervention and control groups did not differ significantly with regard to demographics. Evaluation of the pre- and post-tests of the intervention group indicated significantly higher Action and Acceptance Questionnaire (AAQ-II) scores. The introduction of a mobile phone acceptance and commitment therapy programme may result in greater psychological flexibility in women diagnosed with HIV.

The sensitivity and specificity of subjective memory complaints and the subjective memory rating scale, deterioration cognitive observee, mini-mental state examination, six-item screener and clock drawing test in dementia screening

BACKGROUND

The effectiveness of dementia screening depends on the availability of suitable screening tools with good sensitivity and specificity to confidently distinguish normal age-related cognitive decline from dementia. The aim of this study was to evaluate the discriminant validity of 7 screening measures for dementia.

METHODS

A sample of 140 participants aged ≥60 years living in a residential facility for the aged were assessed clinically and assigned caseness for dementia using the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revised diagnostic criteria. Sensitivity and specificity of a selection of the following screening measures were tested using receiver operating characteristic (ROC) analysis for individual and combined tests: the Mini-Mental State Examination (MMSE), Six-Item Screener (SIS), Subjective Memory Complaint, Subjective Memory Complaint Clinical (SMCC), Subjective Memory Rating Scale (SMRS), Deterioration Cognitive Observee (DECO) and the Clock Drawing Test (CDT).

RESULTS

Using ROC analyses, the SMCC, MMSE and CDT were found to be 'moderately accurate' in screening for dementia with an area under the curve (AUC) >0.70. The AUCs for the SIS (0.526), SMRS (0.661) and DECO (0.687) classified these measures as being 'less accurate'. At recommended cutoff scores, the SMCC had a sensitivity of 90.9% and specificity of 45.7%; the MMSE had a sensitivity of 63.6% and a specificity of 76.0%, and the CDT had a sensitivity of 44.4% and a specificity of 88.9%. Combining the SMCC and MMSE did not improve their predictive power except for a modest increase when using the sequential rule.

CONCLUSION

The SMCC is composed of valid screening questions that have high sensitivity, are simple to administer and ideal for administration at the community or primary health care level as a first level of 'rule-out' screening. The MMSE can be included at a second stage of screening at the general hospital level and the CDT in specialist clinical settings. Sequential use of the SMCC and MMSE will improve the specificity of the former and the sensitivity of the latter.

Mild cognitive impairment and dementia in a heterogeneous elderly population: prevalence and risk profile

OBJECTIVE

To describe the demographic, clinical and risk profile of Mild Cognitive Impairment and dementia in a sample of elderly South Africans within a residential setting.

METHOD

One hundred and forty participants residing in a group of residential homes for the elderly were assessed by psychiatrists and assigned diagnoses of dementia or Mild Cognitive Impairment (MCI). Participants diagnosed with dementia were also offered haematological investigations and a CT scan of the brain.

RESULTS

The sample consisted of 140 participants comprising 46.4% White, 29.3% Coloured, 20% Asian and 4.3% Black participants. There were 97 (69.3%) females and 106 (75.7%) participants had less than 12 years of education. Eleven (7.9%) dementia and 38 (27.1%) MCI cases were diagnosed. Increasing age was associated with cognitive impairment (MCI and dementia) (p=.020) but there was no association between gender and cognitive impairment (p=.165). MCI was significantly associated with a lower education level (p=.036) and no association was found between depression (current-p=.646; past-p=.719) and dementia or MCI. The presence of vascular risk factors (n=140) ranged from 66.4% (hypertension) to 14.3% (stroke). Subjective memory complaints were significantly associated with cognitive impairment (p=.001). Except for the use of the telephone (p=.225) and the television (p=.08), impairment in all domains of instrumental activities of daily living that were assessed were significantly associated with a dementia diagnosis.

CONCLUSION

The study showed that cognitive impairment was associated with increasing age and low education levels. The presence of vascular risk factors places this population at risk for future cognitive decline.

Effectiveness and feasibility of telepsychiatry in resource constrained environments? A systematic review of the evidence

OBJECTIVE

A review of systematic reviews of the effectiveness and feasibility of videoconference-based telepsychiatry services for resource constrained environments was conducted. Specifically with the aim of producing an evidence-based review of the effectiveness and feasibility of videoconference-based telepsychiatry services in resource constrained countries like South Africa.

METHODS

Eight key questions on telepsychiatry effectiveness and feasibility were identified and inclusion and exclusion criteria were developed. Review of citations from 2000-2011 from CINAHL, Medline, Pubmed, PsycInfo, EBSCOhost, SABINET, Cochrane Database of Systematic Reviews (CCTR), Cochrane Controlled Trial Registry (CCTR), Database of Abstracts of Reviews of Effectiveness (DARE), unpublished abstracts through NEXUS and internet search engines (Google/Google scholar) was conducted.

RESULTS

Ten systematic reviews were included for review. Despite the methodological limitations and heterogeneity of the systematic reviews, there appears to be good evidence of effectiveness (reliability and improved outcomes) and feasibility (use, satisfaction, acceptability and cost) for videoconference-based telepsychiatry internationally. The application of this evidence in lower middle income countries is dependent on the integration of telepsychiatry into local health system contexts.

CONCLUSION

Based on the evidence, resource constrained countries such as South Africa should be encouraged to develop telepsychiatry programs along with rigorous evaluation methods.

Developing telepsychiatry services in KwaZulu-Natal -- an action research study

OBJECTIVE

In 2009, the Departments of Psychiatry and Telehealth of the University of KwaZulu-Natal (UKZN) initiated a three year project to develop telepsychiatry services in KwaZulu-Natal. This paper describes the challenges and opportunities of this project.

METHOD

This was a collaborative, in situ health service project and an action research framework was adopted. Over the three years, following a needs assessment and an e-health Readiness Assessment, two action research cycles were completed. Cycle 1: The preparation, implementation and evaluation of educational material, technical requirements and clinical guidelines and clinical support materials. Cycle 2: Preparation and evaluation of educational and clinical outreach sessions.

RESULTS

Videoconference education sessions were beneficial to health staff without post-qualification psychiatry training. A flexible format for education improved knowledge outcomes. Clinical sessions are feasible, but require administration and technical support for facilitation. With facilitator training, 128Kbps is a suitable bandwidth for education but 384Kbps is preferred for clinical consultation.

CONCLUSION

Telepsychiatry offers tremendous potential to facilitate the three strategies suggested by the World Psychiatric Association to address the treatment gap, save time and costs and improve access to the small pool of specialist psychiatrists in resource constrained environments.

Research in lower middle income countries - recommendations for a national mental health research agenda in South Africa

In the current mental health environment in South Africa, the development of a relevant mental health research agenda poses several challenges. This paper provides a brief overview of the current state of published research in mental health and, using a translation research framework, makes recommendations for five strategic directions to be considered in the development of a national mental health research agenda.

Admission rates as an indicator of the prevalence of severe asthma in the community

BACKGROUND

A reliable indicator of the prevalence of severe asthma in the community is needed to monitor population-based asthma control strategies. We examined the potential use of asthma admissions to hospital as such an indicator.

METHODS

We recruited subjects from the Emergency Department (ED) of a children's hospital. The attending doctor completed the 'physician questionnaire' which included questions on the patient's asthma severity and interval severity/chronicity of asthma. The parent/guardian completed the 'parent questionnaire'. It included questions on demography, asthma knowledge and attitudes, asthma history and social support. We performed univariate and multiple logistic regression to determine predictors for hospital admission.

RESULTS

Interval severity of asthma, pre-treatment severity of wheeze and low post-treatment pulse oximetry best predicted whether children presenting with asthma were admitted. Demographic variables, factors associated with access to health services and factors related to the asthma history and management were not significant predictors of admission.

DISCUSSION

At the population level, it may be possible to utilise routine hospital admission rates as an indicator of the prevalence of severe asthma in the community, especially within the context of monitoring trends in asthma prevalence. Our study was conducted in a metropolitan tertiary paediatric hospital. The reliability of hospital admission rates as indicators of the prevalence of severe asthma in other hospital settings, in different population groups and over time remains to be established.

The discharge process for palliative care patients

This article describes the response of staff at a specialist palliative care service to the need for effective discharge planning. Hospice and community nurses were invited to give their views on the discharge of palliative care patients. The authors discuss the strategy for change and how it was implemented and evaluated.