Using theory of change to plan for the implementation of a psychological intervention addressing alcohol use disorder and psychological distress in Uganda

In conflict-affected settings, prevalence of alcohol use disorders (AUDs) can be high. However, limited practical information exists on AUD management in low-income settings. Using a theory of change (ToC) approach, we aimed to identify pathways influencing the implementation and maintenance of a new transdiagnostic psychological intervention ("CHANGE"), targeting both psychological distress and AUDs in humanitarian settings. Three half-day workshops in Uganda engaged 41 stakeholders to develop a ToC map. ToC is a participatory program theory approach aiming to create a visual representation of how and why an intervention leads to specific outcomes. Additionally, five semi-structured interviews were conducted to explore experiences of stakeholders that participated in the ToC workshops. Two necessary pathways influencing the implementation and maintenance of CHANGE were identified: policy impact, and mental health service delivery. Barriers identified included policy gaps, limited recognition of social determinants and the need for integrated follow-up care. Interviewed participants valued ToC's participatory approach and expressed concerns about its adaptability in continuously changing contexts (e.g., humanitarian settings). Our study underscores ToC's value in delineating context-specific outcomes and identifies areas requiring further attention. It emphasizes the importance of early planning and stakeholder engagement for sustainable implementation of psychological interventions in humanitarian settings.

Stakeholders' perspectives on integrating the management of depression into routine HIV care in Uganda: qualitative findings from a feasibility study

BACKGROUND

HIV/AIDS continues to be a major global public health problem with Eastern and Southern Africa being the regions most affected. With increased access to effective antiretroviral therapy, HIV has become a chronic and manageable disease, bringing to the fore issues of quality of life including mental wellbeing. Despite this, the majority of HIV care providers in sub-Saharan Africa, including Uganda's Ministry of Health, do not routinely provide mental health care including depression management. The purpose of this paper is to explore stakeholders' perspectives on the feasibility and acceptability of integrating depression management into routine adult HIV care. The paper addresses a specific objective of the formative phase of the HIV + D study aimed at developing and evaluating a model for integrating depression management into routine HIV care in Uganda.

METHODS

This was a qualitative study. Data were collected through in-depth interviews with 11 patients at enrollment and follow-up in the pilot phase, and exit interviews with 11 adherent patients (those who completed their psychotherapy sessions) and six non-adherent patients (those missing at least two sessions) at the end of the pilot phase. Key informant interviews were held with four clinicians, five supervisors and one mental health specialist, as were three focus group discussions with lay health workers. These were purposively sampled at four public health facilities in Mpigi District. Data were analysed thematically.

RESULTS

Patients highlighted the benefits of treating depression in the context of HIV care, including improved adherence to antiretroviral therapy, overcoming sleeplessness and suicidal ideation, and regaining a sense of self-efficacy. Although clinicians and other stakeholders reported benefits of treating depression, they cited challenges in managing depression with HIV care, which were organisational (increased workload) and patient related (extended waiting time and perceptions of preferential treatment). Stakeholders generally shared perspectives on how best to integrate, including recommendations for organisational level interventions-training, harmonisation in scheduling appointments and structural changes-and patient level interventions to enhance knowledge about depression.

CONCLUSIONS

Integrating depression management into routine HIV care in Uganda is acceptable among key stakeholders, but the technical and operational feasibility of integration would require changes both at the organisational and patient levels.

Effectiveness and cost-effectiveness of integrating the management of depression into routine HIV Care in Uganda (the HIV + D trial): A protocol for a cluster-randomised trial

BACKGROUND

An estimated 8-30 % of people living with HIV (PLWH) have depressive disorders (DD) in sub-Saharan Africa. Of these, the majority are untreated in most of HIV care services. There is evidence from low- and middle- income countries of the effectiveness of both psychological treatments and antidepressant medication for the treatment of DD among PLWH, but no evidence on how these can be integrated into routine HIV care. This protocol describes a cluster-randomised trial to evaluate the effectiveness and cost-effectiveness of the HIV + D model for the integration of a collaborative stepped care intervention for DD into routine HIV care, which we have developed and piloted in Uganda.

METHODS

Forty public health care facilities that provide HIV care in Kalungu, Masaka and Wakiso Districts will be randomly selected to participate in the trial. Each facility will recruit 10-30 eligible PLWH with DD and the total sample size will be 1200. The clusters will be randomised 1:1 to receive Enhanced Usual Care alone (EUC, i.e. HIV clinicians trained in Mental Health Gap Action Programme including guidelines on when and where to refer patients for psychiatric care) or EUC plus HIV + D (psychoeducation, Behavioural Activation, antidepressant medication and referral to a supervising mental health worker, delivered in a collaborative care stepwise approach). Eligibility criteria are PLWH attending the clinic, aged ≥ 18 years who screen positive on a depression screening questionnaire (Patient Health Questionnaire, PHQ-9 ≥ 10). The primary outcome is the mean depressive disorder symptom severity scores (assessed using the PHQ-9) at 3 months' post-randomisation, with secondary mental health, disability, HIV and economic outcomes measured at 3 and 12 months. The cost-effectiveness of EUC with HIV + D will be assessed from both the health system and the societal perspectives by collecting health system, patient and productivity costs and mean DD severity scores at 3 months, additional to health and non-health related quality of life measures (EQ-5D-5 L and OxCAP-MH).

DISCUSSION

The study findings will inform policy makers and practitioners on the cost-effectiveness of a stepped care approach to integrate depression management in routine care for PLWH in low-resource settings.

TRIAL REGISTRATION

ISRCTN, ISRCTN86760765. Registered 07 September 2017, https://doi.org/10.1186/ISRCTN86760765 .

Cultural and linguistic adaptation of the multi-dimensional OXCAP-MH for outcome measurement of mental health among people living with HIV/AIDS in Uganda: the Luganda version

BACKGROUND

It is rare to find HIV/AIDS care providers in sub-Saharan Africa routinely providing mental health services, yet 8-30% of the people living with HIV have depression. In an ongoing trial to assess integration of collaborative care of depression into routine HIV services in Uganda, we will assess quality of life using the standard EQ-5D-5L, and the capability-based OxCAP-MH which has never been adapted nor used in a low-income setting. We present the results of the translation and validation process for cultural and linguistic appropriateness of the OxCAP-MH tool for people living with HIV/AIDS and depression in Uganda.

METHODS

The translation process used the Concept Elaboration document, the source English version of OxCAP-MH, and the Back-Translation Review template as provided during the user registration process of the OxCAP-MH, and adhered to the Translation and Linguistic Validation process of the OxCAP-MH, which was developed following the international principles of good practice for translation as per the International Society for Pharmacoeconomics and Outcomes Research's standards.

RESULTS

The final official Luganda version of the OxCAP-MH was obtained following a systematic iterative process, and is equivalent to the English version in content, but key concepts were translated to ensure cultural acceptability, feasibility and comprehension by Luganda-speaking people.

CONCLUSION

The newly developed Luganda version of the OxCAP-MH can be used both as an alternative or as an addition to health-related quality of life patient-reported outcome measures in research about people living with HIV with comorbid depression, as well as more broadly for mental health research.

Health service costs and their association with functional impairment among adults receiving integrated mental health care in five low- and middle-income countries: the PRIME cohort study

This study examines the level and distribution of service costs-and their association with functional impairment at baseline and over time-for persons with mental disorder receiving integrated primary mental health care. The study was conducted over a 12-month follow-up period in five low- and middle-income countries participating in the Programme for Improving Mental health carE study (Ethiopia, India, Nepal, South Africa and Uganda). Data were drawn from a multi-country intervention cohort study, made up of adults identified by primary care providers as having alcohol use disorders, depression, psychosis and, in the three low-income countries, epilepsy. Health service, travel and time costs, including any out-of-pocket (OOP) expenditures by households, were calculated (in US dollars for the year 2015) and assessed at baseline as well as prospectively using linear regression for their association with functional impairment. Cohort samples were characterized by low levels of educational attainment (Ethiopia and Uganda) and/or high levels of unemployment (Nepal, South Africa and Uganda). Total health service costs per case for the 3 months preceding baseline assessment averaged more than US$20 in South Africa, $10 in Nepal and US$3-7 in Ethiopia, India and Uganda; OOP expenditures ranged from $2 per case in India to $16 in Ethiopia. Higher service costs and OOP expenditure were found to be associated with greater functional impairment in all five sites, but differences only reached statistical significance in Ethiopia and India for service costs and India and Uganda for OOP expenditure. At the 12-month assessment, following initiation of treatment, service costs and OOP expenditure were found to be lower in Ethiopia, South Africa and Uganda, but higher in India and Nepal. There was a pattern of greater reduction in service costs and OOP spending for those whose functional status had improved in all five sites, but this was only statistically significant in Nepal.

Correction to: Impact of district mental health care plans on symptom severity and functioning of patients with priority mental health conditions: the Programme for Improving Mental Health Care (PRIME) cohort protocol

An amendment to this paper has been published and can be accessed via the original article.

Social acceptance of alcohol use in Uganda

BACKGROUND

Alcohol use is part of many cultural, religious and social practices, and provides perceived pleasure to many users. In many societies, alcoholic beverages are a routine part of the social landscape for many in the population. Relatively low rates were reported for Alcohol Use Disorders (AUD) in a community-based survey and facility detection survey conducted in the study site contrary to findings in earlier formative studies where alcohol use was reported to be a major health problem. The aim of this study was to understand the reasons for under-reporting and the low detection rate for AUDs, exploring societal perceptions of alcohol use in the study district.

METHODS

The study was conducted in Kamuli District (implementation site for the PRIME project). Semi-structured interviews and focus group discussions were conducted with purposively selected participants that included local and religious leaders, lay people, health workers as well as heavy alcohol drinkers and their spouses. Interviews were tape-recorded and transcribed verbatim. The analysis followed four thematic areas, which include the extent and acceptability of alcohol use, patterns of alcohol use, perceived health problems associated with alcohol use and help-seeking behavior for persons with alcohol related problems.

RESULTS

The findings indicate that alcohol consumption in the study site was common and widely acceptable across all categories of people and only frowned upon if the person becomes a nuisance to others. These findings suggest that the health problems associated with alcohol use are overlooked except when they are life-threatening. Help-seeking for such problems was therefore reported to be relatively rare.

CONCLUSION

Alcohol was readily available in the community and its consumption widely acceptable, with less social sanctions despite the legal restrictions to the minors. The social acceptance results in low recognition of alcohol use related health problems, consequently resulting in poor help-seeking behavior.

Evaluation of the impacts of a district-level mental health care plan on contact coverage, detection and individual outcomes in rural Uganda: a mixed methods approach

Background

The burden of mental disorders in low- and middle-income countries is large. Yet there is a major treatment gap for these disorders which can be reduced by integrating the care of mental disorders in primary care.

Aim

We aimed to evaluate the impact of a district mental health care plan (MHCP) on contact coverage for and detection of mental disorders, as well as impact on mental health symptom severity and individual functioning in rural Uganda.

Results

For adults who attended primary care facilities, there was an immediate positive effect of the MHCP on clinical detection at 3 months although this was not sustained at 12 months. Those who were treated in primary care experienced significant reductions in symptom severity and functional impairment over 12 months. There was negligible change in population-level contact coverage for depression and alcohol use disorder.

Conclusion

The study found that it is possible to integrate mental health care into primary care in rural Uganda. Treatment by trained primary care workers improves clinical and functioning outcomes for depression, psychosis and epilepsy. Challenges remain in accessing the men for care, sustaining the improvement in detection over time, and creating demand for services among those with presumed need.

The experience of mental health service users in health system strengthening: lessons from Uganda

BACKGROUND

Mental, neurological and substance use disorders are a public health burden in Uganda. Mental health service user involvement could be an important strategy for advocacy and improving service delivery, particularly as Uganda redoubles its efforts to integrate mental health into primary health care (PHC). However, little is known on the most effective way to involve service users in mental health system strengthening.

METHODS

This was a qualitative key informant interview study. At national level, 4 interviews were conducted with national level health workers and 3 service user organization representatives. At the district level, 2 interviews were conducted with district level health workers and 5 service user organization representatives. Data were analyzed using content thematic analysis.

FINDINGS

Overall, there was low mental service user participation in health system strengthening at both national and district levels. Health system strengthening activities included policy development, implementation of programs and research. Informants mentioned several barriers to service user involvement in mental health system strengthening. These were grouped into three categories: institutional, community and individual level factors. Institutional level barriers included: limited funding to form, train and develop mental health service user groups, institutional stigma and patronage by founder members of user organizations. Community level barriers included: abject poverty and community stigma. Individual level barriers included: low levels of awareness and presence of self-stigma. Informants also recommended some strategies to enhance service user involvement.

CONCLUSION

The Uganda Ministry of Health should develop a strategy to improve service user participation in mental health system strengthening. This requires an appreciation of the importance of service users in improving service delivery. To address the barriers to service user involvement identified in this study requires concerted efforts by the Uganda Ministry of Health and the district health services, specifically with regard to attitudes of health workers, dealing with stigma at all levels, raising awareness about the rights of service users to participate in health systems strengthening activities, building capacity and financial empowerment of service user organizations.

Partnerships in a Global Mental Health Research Programme-the Example of PRIME

Collaborative research partnerships are necessary to answer key questions in global mental health, to share expertise, access funding and influence policy. However, partnerships between low- and middle-income countries (LMIC) and high-income countries have often been inequitable with the provision of technical knowledge flowing unilaterally from high to lower income countries. We present the experience of the Programme for Improving Mental Health Care (PRIME), a LMIC-led partnership which provides research evidence for the development, implementation and scaling up of integrated district mental healthcare plans in Ethiopia, India, Nepal, South Africa and Uganda. We use Tuckman's first four stages of forming, storming, norming and performing to reflect on the history, formation and challenges of the PRIME Consortium. We show how this resulted in successful partnerships in relation to management, research, research uptake and capacity building and reflect on the key lessons for future partnerships.

Scaling up integrated primary mental health in six low- and middle-income countries: obstacles, synergies and implications for systems reform

BACKGROUND

There is a global drive to improve access to mental healthcare by scaling up integrated mental health into primary healthcare (PHC) systems in low- and middle-income countries (LMICs).

AIMS

To investigate systems-level implications of efforts to scale-up integrated mental healthcare into PHC in districts in six LMICs.

METHOD

Semi-structured interviews were conducted with 121 managers and service providers. Transcribed interviews were analysed using framework analysis guided by the Consolidated Framework for Implementation Research and World Health Organization basic building blocks.

RESULTS

Ensuring that interventions are synergistic with existing health system features and strengthening of the healthcare system building blocks to support integrated chronic care and task-sharing were identified as aiding integration efforts. The latter includes (a) strengthening governance to include technical support for integration efforts as well as multisectoral collaborations; (b) ring-fencing mental health budgets at district level; (c) a critical mass of mental health specialists to support task-sharing; (d) including key mental health indicators in the health information system; (e) psychotropic medication included on free essential drug lists and (f) enabling collaborative and community- oriented PHC-service delivery platforms and continuous quality improvement to aid service delivery challenges in implementation.

CONCLUSIONS

Scaling up integrated mental healthcare in PHC in LMICs is more complex than training general healthcare providers. Leveraging existing health system processes that are synergistic with chronic care services and strengthening healthcare system building blocks to provide a more enabling context for integration are important.

DECLARATION OF INTEREST

None.

Potential strategies for sustainably financing mental health care in Uganda

BACKGROUND

In spite of the pronounced adverse economic consequences of mental, neurological, and substance use disorders on households in most low- and middle-income countries, service coverage and financial protection for these families is very limited. The aim of this study was to generate potential strategies for sustainably financing mental health care in Uganda in an effort to move towards increased financial protection and service coverage for these families.

METHODS

The process of identifying potential strategies for sustainably financing mental health care in Uganda was guided by an analytical framework developed by the Emerging Mental health systems in low and middle income countries (EMERALD project). Data were collected through a situational analysis (public health burden assessment, health system assessment, macro fiscal assessment) and eight key informant interviews with selected stakeholders from sectors including health, finance and civil society. The situational analysis provided contextualization for the strategies, and was complimented by views from key informant interviews.

RESULTS

Findings indicate that the following strategies have the greatest potential for moving towards more equitable and sustainable mental health financing in the Uganda context: implementing National Health Insurance Scheme; shifting to Results Based Financing; decentralizing mental health services that can be provided at community level; and continued advocacy with decision makers with evidence through research.

CONCLUSION

Although several options were identified for sustainably financing mental health care in Uganda, the National Health Insurance Scheme seemed the most viable option. However, for the scheme to be effective, there is need for scale up to community health facilities and implementation in a manner that explicitly includes community level facilities.

Detection and treatment initiation for depression and alcohol use disorders: facility-based cross-sectional studies in five low-income and middle-income country districts

OBJECTIVES

To estimate the proportion of adult primary care outpatients who are clinically detected and initiate treatment for depression and alcohol use disorder (AUD) in low-income and middle-income country (LMIC) settings.

DESIGN

Five cross-sectional studies.

SETTING

Adult outpatient services in 36 primary healthcare facilities in Sodo District, Ethiopia (9 facilities); Sehore District, India (3); Chitwan District, Nepal (8); Dr Kenneth Kaunda District, South Africa (3); and Kamuli District, Uganda (13).

PARTICIPANTS

Between 760 and 1893 adults were screened in each district. Across five districts, between 4.2% and 20.1% screened positive for depression and between 1.2% and 16.4% screened positive for AUD. 96% of screen-positive participants provided details about their clinical consultations that day.

PRIMARY OUTCOMES

Detection of depression, treatment initiation for depression, detection of AUD and treatment initiation for AUD.

RESULTS

Among depression screen-positive participants, clinical detection of depression ranged from 0% in India to 11.7% in Nepal. Small proportions of screen-positive participants received treatment (0% in Ethiopia, India and South Africa to 4.2% in Uganda). Among AUD screen-positive participants, clinical detection of AUD ranged from 0% in Ethiopia and India to 7.8% in Nepal. Treatment was 0% in all countries aside Nepal, where it was 2.2%.

CONCLUSIONS

The findings of this study suggest large detection and treatment gaps for adult primary care patients, which are likely contributors to the population-level mental health treatment gap in LMIC. Primary care facilities remain unfulfilled intervention points for reducing the population-level burden of disease in LMIC.

Suicidal ideation and behaviour among community and health care seeking populations in five low- and middle-income countries: a cross-sectional study

AimsSuicidal behaviour is an under-reported and hidden cause of death in most low- and middle-income countries (LMIC) due to lack of national systematic reporting for cause-specific mortality, high levels of stigma and religious or cultural sanctions. The lack of information on non-fatal suicidal behaviour (ideation, plans and attempts) in LMIC is a major barrier to design and implementation of prevention strategies. This study aims to determine the prevalence of non-fatal suicidal behaviour within community- and health facility-based populations in LMIC.

METHODS

Twelve-month prevalence of suicidal ideation, plans and attempts were established through community samples (n = 6689) and primary care attendees (n = 6470) from districts in Ethiopia, Uganda, South Africa, India and Nepal using the Composite International Diagnostic Interview suicidality module. Participants were also screened for depression and alcohol use disorder.

RESULTS

We found that one out of ten persons (10.3%) presenting at primary care facilities reported suicidal ideation within the past year, and 1 out of 45 (2.2%) reported attempting suicide in the same period. The range of suicidal ideation was 3.5-11.1% in community samples and 5.0-14.8% in health facility samples. A higher proportion of facility attendees reported suicidal ideation than community residents (10.3 and 8.1%, respectively). Adults in the South African facilities were most likely to endorse suicidal ideation (14.8%), planning (9.5%) and attempts (7.4%). Risk profiles associated with suicidal behaviour (i.e. being female, younger age, current mental disorders and lower educational and economic status) were highly consistent across countries.

CONCLUSION

The high prevalence of suicidal ideation in primary care points towards important opportunities to implement suicide risk reduction initiatives. Evidence-supported strategies including screening and treatment of depression in primary care can be implemented through the World Health Organization's mental health Global Action Programme suicide prevention and depression treatment guidelines. Suicidal ideation and behaviours in the community sample will require detection strategies to identify at risks persons not presenting to health facilities.

Impact of district mental health care plans on symptom severity and functioning of patients with priority mental health conditions: the Programme for Improving Mental Health Care (PRIME) cohort protocol

BACKGROUND

The Programme for Improving Mental Health Care (PRIME) sought to implement mental health care plans (MHCP) for four priority mental disorders (depression, alcohol use disorder, psychosis and epilepsy) into routine primary care in five low- and middle-income country districts. The impact of the MHCPs on disability was evaluated through establishment of priority disorder treatment cohorts. This paper describes the methodology of these PRIME cohorts.

METHODS

One cohort for each disorder was recruited across some or all five districts: Sodo (Ethiopia), Sehore (India), Chitwan (Nepal), Dr. Kenneth Kaunda (South Africa) and Kamuli (Uganda), comprising 17 treatment cohorts in total (N = 2182). Participants were adults residing in the districts who were eligible to receive mental health treatment according to primary health care staff, trained by PRIME facilitators as per the district MHCP. Patients who screened positive for depression or AUD and who were not given a diagnosis by their clinicians (N = 709) were also recruited into comparison cohorts in Ethiopia, India, Nepal and South Africa. Caregivers of patients with epilepsy or psychosis were also recruited (N = 953), together with or on behalf of the person with a mental disorder, depending on the district. The target sample size was 200 (depression and AUD), or 150 (psychosis and epilepsy) patients initiating treatment in each recruiting district. Data collection activities were conducted by PRIME research teams. Participants completed follow-up assessments after 3 months (AUD and depression) or 6 months (psychosis and epilepsy), and after 12 months. Primary outcomes were impaired functioning, using the 12-item World Health Organization Disability Assessment Schedule 2.0 (WHODAS), and symptom severity, assessed using the Patient Health Questionnaire (depression), the Alcohol Use Disorder Identification Test (AUD), and number of seizures (epilepsy).

DISCUSSION

Cohort recruitment was a function of the clinical detection rate by primary health care staff, and did not meet all planned targets. The cross-country methodology reflected the pragmatic nature of the PRIME cohorts: while the heterogeneity in methods of recruitment was a consequence of differences in health systems and MHCPs, the use of the WHODAS as primary outcome measure will allow for comparison of functioning recovery across sites and disorders.

Mental health law reforms in Uganda: lessons learnt

Ugandan mental health legislation, which dates from 1964, principally aims to remove persons with mental disorders from the community but also to protect their safety, by keeping them in confinement, although this has been without consideration for clinical care. In response to criticism from various stakeholders and advocates and the need to reflect modern clinical care, Uganda undertook to review and amend the mental health legislation, as part of the Mental Health and Poverty Project (MHaPP). We report on work in progress advancing new legislation.

Treatment Contact Coverage for Probable Depressive and Probable Alcohol Use Disorders in Four Low- and Middle-Income Country Districts: The PRIME Cross-Sectional Community Surveys

CONTEXT

A robust evidence base is now emerging that indicates that treatment for depression and alcohol use disorders (AUD) delivered in low and middle-income countries (LMIC) can be effective. However, the coverage of services for these conditions in most LMIC settings remains unknown.

OBJECTIVE

To describe the methods of a repeat cross-sectional survey to determine changes in treatment contact coverage for probable depression and for probable AUD in four LMIC districts, and to present the baseline findings regarding treatment contact coverage.

METHODS

Population-based cross-sectional surveys with structured questionnaires, which included validated screening tools to identify probable cases. We defined contact coverage as being the proportion of cases who sought professional help in the past 12 months.

SETTING

Sodo District, Ethiopia; Sehore District, India; Chitwan District, Nepal; and Kamuli District, Uganda.

PARTICIPANTS

8036 adults residing in these districts between May 2013 and May 2014.

MAIN OUTCOME MEASURES

Treatment contact coverage was defined as having sought care from a specialist, generalist, or other health care provider for symptoms related to depression or AUD.

RESULTS

The proportion of adults who screened positive for depression over the past 12 months ranged from 11.2% in Nepal to 29.7% in India and treatment contact coverage over the past 12 months ranged between 8.1% in Nepal to 23.5% in India. In Ethiopia, lifetime contact coverage for probable depression was 23.7%. The proportion of adults who screened positive for AUD over the past 12 months ranged from 1.7% in Uganda to 13.9% in Ethiopia and treatment contact coverage over the past 12 months ranged from 2.8% in India to 5.1% in Nepal. In Ethiopia, lifetime contact coverage for probable AUD was 13.1%.

CONCLUSIONS

Our findings are consistent with and contribute to the limited evidence base which indicates low treatment contact coverage for depression and for AUD in LMIC. The planned follow up surveys will be used to estimate the change in contact coverage coinciding with the implementation of district-level mental health care plans.

Perinatal mental health care in a rural African district, Uganda: a qualitative study of barriers, facilitators and needs

BACKGROUND

Perinatal mental illness is a common and important public health problem, especially in low and middle-income countries (LMICs). This study aims to explore the barriers and facilitators, as well as perceptions about the feasibility and acceptability of plans to deliver perinatal mental health care in primary care settings in a low income, rural district in Uganda.

METHODS

Six focus group discussions comprising separate groups of pregnant and postpartum women and village health teams as well as eight key informant interviews were conducted in the local language using a topic guide. Transcribed data were translated into English, analyzed, and coded. Key themes were identified using a thematic analysis approach.

RESULTS

Participants perceived that there was an important unmet need for perinatal mental health care in the district. There was evidence of significant gaps in knowledge about mental health problems as well as negative attitudes amongst mothers and health care providers towards sufferers. Poverty and inability to afford transport to services, poor partner support and stigma were thought to add to the difficulties of perinatal women accessing care. There was an awareness of the need for interventions to respond to this neglected public health problem and a willingness of both community- and facility-based health care providers to provide care for mothers with mental health problems if equipped to do so by adequate training.

CONCLUSION

This study highlights the acceptability and relevance of perinatal mental health care in a rural, low-income country community. It also underscores some of the key barriers and potential facilitators to delivery of such care in primary care settings. The results of this study have implications for mental health service planning and development for perinatal populations in Uganda and will be useful in informing the development of integrated maternal mental health care in this rural district and in similar settings in other low and middle income countries.

Towards understanding governance issues in integration of mental health into primary health care in Uganda

BACKGROUND

There is a growing burden of mental illness in low income countries. The situation is further worsened by the high poverty levels in these countries, resulting in difficult choices for their health sectors as regards to responding to the burden of mental health problems. In Uganda, integration of mental health into primary health care (PHC) has been adopted as the most vital strategy for ensuring mental health service delivery to the general population.

OBJECTIVES

To identify governance related factors that promote/or hinder integration of mental health into PHC in Uganda.

METHODS

A qualitative research design was adopted at national and district level. A total of 18 Key informant interviews were conducted at both levels. Content thematic analysis was the main method of data analysis.

FINDINGS

There were positive gains in working on relevant laws and policies. However, both the mental health law and policy are still in draft form. There is also increased responsiveness/participation of key stakeholders; especially at national level in the planning and budgeting for mental health services. This however seems to be a challenge at both district and community level. In terms of efficiency, human resources, finances, medicines and technologies constitute a major drawback to the integration of mental health into PHC. Ethics, oversight, information and monitoring functions though reported to be in place, become weaker at the district level than at national level due to limited finances, human resources gaps and limited technical capacity. Other governance related issues are also reported in this study.

CONCLUSIONS

There is some progress especially in the legal and policy arena to support integration of mental health into PHC in Uganda. However, adequate resources are still required to facilitate the effective functioning of all governance pillars that make integration of mental health into PHC feasible in Uganda.

Development of a district mental healthcare plan in Uganda

BACKGROUND

Evidence is needed for the integration of mental health into primary care advocated by the national health sector strategic investment plan in Uganda.

AIMS

To describe the processes of developing a district mental healthcare plan (MHCP) in rural Uganda that facilitates integration of mental health into primary care.

METHOD

Mixed methods using a situational analysis, qualitative studies, theory of change workshops and partial piloting of the plan at two levels informed the MHCP.

RESULTS

A MHCP was developed with packages of care to facilitate integration at the organisational, facility and community levels of the district health system, including a specified human resource mix. The partial embedding period supports its practical application. Key barriers to scaling up the plan were identified.

CONCLUSIONS

A real-world plan for the district was developed with involvement of stakeholders. Pilot testing demonstrated its feasibility and implications for future scaling up.

Evaluation of district mental healthcare plans: the PRIME consortium methodology

BACKGROUND

Few studies have evaluated the implementation and impact of real-world mental health programmes delivered at scale in low-resource settings.

AIMS

To describe the cross-country research methods used to evaluate district-level mental healthcare plans (MHCPs) in Ethiopia, India, Nepal, South Africa and Uganda.

METHOD

Multidisciplinary methods conducted at community, health facility and district levels, embedded within a theory of change.

RESULTS

The following designs are employed to evaluate the MHCPs: (a) repeat community-based cross-sectional surveys to measure change in population-level contact coverage; (b) repeat facility-based surveys to assess change in detection of disorders; (c) disorder-specific cohorts to assess the effect on patient outcomes; and (d) multilevel case studies to evaluate the process of implementation.

CONCLUSIONS

To evaluate whether and how a health-system-level intervention is effective, multidisciplinary research methods are required at different population levels. Although challenging, such methods may be replicated across diverse settings.

Acceptability and feasibility of using non-specialist health workers to deliver mental health care: stakeholder perceptions from the PRIME district sites in Ethiopia, India, Nepal, South Africa, and Uganda

Three-quarters of the global mental health burden exists in low- and middle-income countries (LMICs), yet the lack of mental health services in resource-poor settings is striking. Task-sharing (also, task-shifting), where mental health care is provided by non-specialists, has been proposed to improve access to mental health care in LMICs. This multi-site qualitative study investigates the acceptability and feasibility of task-sharing mental health care in LMICs by examining perceptions of primary care service providers (physicians, nurses, and community health workers), community members, and service users in one district in each of the five countries participating in the PRogramme for Improving Mental health carE (PRIME): Ethiopia, India, Nepal, South Africa, and Uganda. Thirty-six focus group discussions and 164 in-depth interviews were conducted at the pre-implementation stage between February and October 2012 with the objective of developing district level plans to integrate mental health care into primary care. Perceptions of the acceptability and feasibility of task-sharing were evaluated first at the district level in each country through open-coding and then at the cross-country level through a secondary analysis of emergent themes. We found that task-sharing mental health services is perceived to be acceptable and feasible in these LMICs as long as key conditions are met: 1) increased numbers of human resources and better access to medications; 2) ongoing structured supportive supervision at the community and primary care-levels; and 3) adequate training and compensation for health workers involved in task-sharing. Taking into account the socio-cultural context is fundamental for identifying local personnel who can assist in detection of mental illness and facilitate treatment and care as well as training, supervision, and service delivery. By recognizing the systemic challenges and sociocultural nuances that may influence task-sharing mental health care, locally-situated interventions could be more easily planned to provide appropriate and acceptable mental health care in LMICs.

•

Task sharing in mental health requires improved training, support, compensation and supervision.

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Overburdening health workers is a risk for task-sharing mental health care.

•

Task-sharing requires clearly defined roles and the use of recognized and trusted trainers.

•

Socio-cultural context is fundamental for effective task sharing strategies in mental health.

•

Cultural brokers can be important stakeholders to identify local cultural idioms of distress.

Challenges and opportunities for implementing integrated mental health care: a district level situation analysis from five low- and middle-income countries

Background

Little is known about how to tailor implementation of mental health services in low- and middle-income countries (LMICs) to the diverse settings encountered within and between countries. In this paper we compare the baseline context, challenges and opportunities in districts in five LMICs (Ethiopia, India, Nepal, South Africa and Uganda) participating in the PRogramme for Improving Mental health carE (PRIME). The purpose was to inform development and implementation of a comprehensive district plan to integrate mental health into primary care.

Methods

A situation analysis tool was developed for the study, drawing on existing tools and expert consensus. Cross-sectional information obtained was largely in the public domain in all five districts.

Results

The PRIME study districts face substantial contextual and health system challenges many of which are common across sites. Reliable information on existing treatment coverage for mental disorders was unavailable. Particularly in the low-income countries, many health service organisational requirements for mental health care were absent, including specialist mental health professionals to support the service and reliable supplies of medication. Across all sites, community mental health literacy was low and there were no models of multi-sectoral working or collaborations with traditional or religious healers. Nonetheless health system opportunities were apparent. In each district there was potential to apply existing models of care for tuberculosis and HIV or non-communicable disorders, which have established mechanisms for detection of drop-out from care, outreach and adherence support. The extensive networks of community-based health workers and volunteers in most districts provide further opportunities to expand mental health care.

Conclusions

The low level of baseline health system preparedness across sites underlines that interventions at the levels of health care organisation, health facility and community will all be essential for sustainable delivery of quality mental health care integrated into primary care.

Developing a national mental health policy: a case study from Uganda

As one article in an ongoing series on Global Mental Health Practice, Joshua Ssebunnya and colleagues provide a case study from Uganda that describes their work developing a national mental health policy.

Viewing Uganda's mental health system through a human rights lens

There has been increased global concern about the human rights violations experienced by people with mental disorders. The aim of this study was to analyse Uganda's mental health care system through a human rights lens. A survey of the existing mental health system in Uganda was conducted using the WHO Assessment Instrument for Mental Health Systems. In addition, 62 interviews and six focus groups were conducted with a broad range of mental health stakeholders at the national and district levels. Despite possessing a draft mental health policy that is in line with many international human rights standards, Uganda's mental health system inadequately promotes and protects, and frequently violates the human rights of people with mental disorders. The mental health legislation is offensive and stigmatizing. It is common for people accessing mental health services to encounter physical and emotional abuse and an inadequate quality of care. Mental health services are inequitably distributed. Within Ugandan society, people with mental disorders also frequently experience widespread stigma and discrimination, and limited support. Promoting and protecting the rights of people with mental disorders has ethical and public health imperatives. A number of policy, legislative and service development initiatives are required.

Lessons from case studies of integrating mental health into primary health care in South Africa and Uganda

Background

While decentralized and integrated primary mental healthcare forms the core of mental health policies in many low- and middle-income countries (LMICs), implementation remains a challenge. The aim of this study was to understand how the use of a common implementation framework could assist in the integration of mental health into primary healthcare in Ugandan and South African district demonstration sites. The foci and form of the services developed differed across the country sites depending on the service gaps and resources available. South Africa focused on reducing the service gap for common mental disorders and Uganda, for severe mental disorders.

Method

A qualitative post-intervention process evaluation using focus group and individual interviews with key stakeholders was undertaken in both sites. The emergent data was analyzed using framework analysis.

Results

Sensitization of district management authorities and the establishment of community collaborative multi-sectoral forums assisted in improving political will to strengthen mental health services in both countries. Task shifting using community health workers emerged as a promising strategy for improving access to services and help seeking behaviour in both countries. However, in Uganda, limited application of task shifting to identification and referral, as well as limited availability of psychotropic medication and specialist mental health personnel, resulted in a referral bottleneck. To varying degrees, community-based self-help groups showed potential for empowering service users and carers to become more self sufficient and less dependent on overstretched healthcare systems. They also showed potential for promoting social inclusion and addressing stigma, discrimination and human rights abuses of people with mental disorders in both country sites.

Conclusions

A common implementation framework incorporating a community collaborative multi-sectoral, task shifting and self-help approach to integrating mental health into primary healthcare holds promise for closing the treatment gap for mental disorders in LMICs at district level. However, a minimum number of mental health specialists are still required to provide supervision of non-specialists as well as specialized referral treatment services.

Stakeholder's perceptions of help-seeking behaviour among people with mental health problems in Uganda

Introduction

Mental health facilities in Uganda remain underutilized, despite efforts to decentralize the services. One of the possible explanations for this is the help-seeking behaviours of people with mental health problems. Unfortunately little is known about the factors that influence the help-seeking behaviours. Delays in seeking proper treatment are known to compromise the outcome of the care.

Aim

To examine the help-seeking behaviours of individuals with mental health problems, and the factors that may influence such behaviours in Uganda.

Method

Sixty-two interviews and six focus groups were conducted with stakeholders drawn from national and district levels. Thematic analysis of the data was conducted using a framework analysis approach.

Results

The findings revealed that in some Ugandan communities, help is mostly sought from traditional healers initially, whereas western form of care is usually considered as a last resort. The factors found to influence help-seeking behaviour within the community include: beliefs about the causes of mental illness, the nature of service delivery, accessibility and cost, stigma.

Conclusion

Increasing the uptake of mental health services requires dedicating more human and financial resources to conventional mental health services. Better understanding of socio-cultural factors that may influence accessibility, engagement and collaboration with traditional healers and conventional practitioners is also urgently required.

Media and mental health in Uganda

OBJECTIVE

The media is largely regarded as an important stakeholder in health service delivery, with a great influence on public attitudes. However, little is known about its interest in mental health and the guiding factors that influence media coverage of mental health issues. This article describes the importance accorded to mental health by the media and the factors that influence media coverage of mental health issues in Uganda.

METHOD

Semi-structured interviews were held with representatives from six prominent media houses as part of the situational analysis of the mental health system in Uganda. Data was analyzed using Nvivo 7 qualitative data analysis software.

RESULTS

The media was found to be interested and actively involved in health initiatives, but with little attention devoted to mental health. Coverage and interest in mental health was noted to be mainly dependent on the individual journalists' interests, and mostly for personal reasons. Low interest was largely attributed to mental health being perceived as a non-priority area, and the fact that mental illness is not a major contributor to mortality. Media coverage and reporting is guided by prioritization of the Health Department.

CONCLUSION

The media in Uganda is an important stakeholder in the health care system with a key role of advocacy, publicity and mass education. Media houses however are less interested in mental health as evidenced by low coverage of mental health issues. This calls for advocacy and sensitization as a way of persuading media for more involvement in mental health initiatives.

The orphaning experience: descriptions from Ugandan youth who have lost parents to HIV/AIDS

The HIV/AIDS epidemic has continued to pose significant challenges to countries in Sub-Saharan Africa. Millions of African children and youth have lost parents to HIV/AIDS leaving a generation of orphans to be cared for within extended family systems and communities. The experiences of youth who have lost parents to the HIV/AIDS epidemic provide an important ingress into this complex, evolving, multi-dimensional phenomenon. A fundamental qualitative descriptive study was conducted to develop a culturally relevant and comprehensive description of the experiences of orphanhood from the perspectives of Ugandan youth. A purposeful sample of 13 youth who had lost one or both parents to HIV/AIDS and who were affiliated with a non-governmental organization providing support to orphans were interviewed. Youth orphaned by HIV/AIDS described the experience of orphanhood beginning with parental illness, not death. Several losses were associated with the death of a parent including lost social capitol, educational opportunities and monetary assets. Unique findings revealed that youth experienced culturally specific stigma and conflict which was distinctly related to their HIV/AIDS orphan status. Exploitation within extended cultural family systems was also reported. Results from this study suggest that there is a pressing need to identify and provide culturally appropriate services for these Ugandan youth prior to and after the loss of a parent(s).

An overview of Uganda's mental health care system: results from an assessment using the world health organization's assessment instrument for mental health systems (WHO-AIMS)

Background

The Ugandan government recognizes mental health as a serious public health and development concern, and has of recent implemented a number of reforms aimed at strengthening the country's mental health system. The aim of this study was to provide a profile of the current mental health policy, legislation and services in Uganda.

Methods

A survey was conducted of public sector mental health policy and legislation, and service resources and utilisation in Uganda, in the year 2005, using the World Health Organization's Assessment Instrument for Mental Health Systems (WHO-AIMS) Version 2.2.

Results

Uganda's draft mental health policy encompasses many positive reforms, including decentralization and integration of mental health services into Primary Health Care (PHC). The mental health legislation is however outdated and offensive. Services are still significantly underfunded (with only 1% of the health expenditure going to mental health), and skewed towards urban areas. Per 100,000 population, there were 1.83 beds in mental hospitals, 1.4 beds in community based psychiatric inpatient units, and 0.42 beds in forensic facilities. The total personnel working in mental health facilities were 310 (1.13 per 100,000 population). Only 0.8% of the medical doctors and 4% of the nurses had specialized in psychiatry.

Conclusion

Although there have been important developments in Uganda's mental health policy and services, there remains a number of shortcomings, especially in terms of resources and service delivery. There is an urgent need for more research on the current burden of mental disorders and the functioning of mental health programs and services in Uganda.

Chronic poverty, wars and mental health: the East African perspective

Globally, poverty has been noted to be a high risk factor for mental disorder. Although there is limited information on the baseline prevalence of mental disorders in low- and middle-income countries, the known risk factors for poor mental health, such as poverty and violence, afflict many of these areas (Miller, 2006). It is clear that poverty and the mental health consequences of war and displacement significantly hinder the achievement of the Millennium Development Goals (Njenga et al, 2006).

Stakeholder perceptions of mental health stigma and poverty in Uganda

Background

World wide, there is plentiful evidence regarding the role of stigma in mental illness, as well as the association between poverty and mental illness. The experiences of stigma catalyzed by poverty revolve around experiences of devaluation, exclusion, and disadvantage. Although the relationship between poverty, stigma and mental illness has been documented in high income countries, little has been written on this relationship in low and middle income countries.

The paper describes the opinions of a range of mental health stakeholders regarding poverty, stigma, mental illness and their relationship in the Ugandan context, as part of a wider study, aimed at exploring policy interventions required to address the vicious cycle of mental ill-health and poverty.

Methods

Semi-structured interviews and focus group discussions (FGDs) were conducted with purposefully selected mental health stakeholders from various sectors. The interviews and FGDs were audio-recorded, and transcriptions were coded on the basis of a pre-determined coding frame. Thematic analysis of the data was conducted using NVivo7, adopting a framework analysis approach.

Results

Most participants identified a reciprocal relationship between poverty and mental illness. The stigma attached to mental illness was perceived as a common phenomenon, mostly associated with local belief systems regarding the causes of mental illness. Stigma associated with both poverty and mental illness serves to reinforce the vicious cycle of poverty and mental ill-health. Most participants emphasized a relationship between poverty and internalized stigma among people with mental illness in Uganda.

Conclusion

According to a range of mental health stakeholders in Uganda, there is a strong interrelationship between poverty, stigma and mental illness. These findings re-affirm the need to recognize material resources as a central element in the fight against stigma of mental illness, and the importance of stigma reduction programmes in protecting the mentally ill from social isolation, particularly in conditions of poverty.

Integration of mental health into primary health care in Uganda: opportunities and challenges

Background Worldwide, a number of reforms have been undertaken with the intention of improving access to mental health services. Notable among these is the integration of mental health services into primary health care, which has been one of the most fundamental healthcare reform recommendations globally.Objectives This paper describes the opportunities for and challenges to the integration of mental health into primary health care in Uganda, as identified in a wider study, aimed at exploring the policy interventions required to address the vicious cycle of mental ill-health and poverty.Methods Semi-structured interviews and focus group discussions (FGDs) were conducted with purposefully selected mental health stakeholders from various sectors. The interviews and FGDs were audio-recorded, and transcripts coded on the basis of a pre-determined coding frame. Thematic analysis of the data was conducted using NVivo7, adopting a framework analysis approach.Results The participants identified a number of opportunities that could be exploited to strengthen the integration process. Notable among these was the political will and prioritisation of mental health at policy level. Poor appreciation of the integration process and attitudinal problems emerged as the most pressing challenges for integration of mental health into primary health care.Conclusion Irrespective of the various opportunities in place, the integration of mental health into primary health care has not yet been fully realised, as it faces a number of challenges within and outside the health sector. This calls for more concerted efforts to scale up activities for effective integration of mental health care into primary health care.