Geographic distribution and determinants of mental health stigma in central Mozambique

Suicidal behavior, depression, generalized anxiety and associated factors among a national sample of adults in Mozambique in 2022 to 2023

BACKGROUND

The study's objective was to assess adult Mozambicans' past 12-month suicidal behavior (PSB), major depressive disorder (MDD), and generalized anxiety disorder (GAD).

METHODS

Data from 10,074 women (aged 20-49 years) and 3,941 men (aged 20-54 years) that participated in the 2022 to 2023 Mozambique Demographic and health Survey were analyzed.

RESULTS

The prevalence of PSB among women (attempt 1.0%, plan 1.8%, and ideation 4.2%) was 4.6% and among men (attempt 0.6%, plan 1.6%, and ideation 3.1%) was 3.4%. Among women and men, the prevalence of MDD was 10.6% and 2.3%, respectively, and the prevalence of GAD was 11.9% and 2.3%, respectively. In adjusted logistic regression analysis, among women and men, MDD was positively and being married or cohabiting was negatively associated with PSB, while among women being HIV positive and among men history of sexually transmitted infection (STI) were positively associated with PSB. Among women and men, having a history of STI was positively, and currently working was negatively associated with MDD. In addition, among women, low dietary diversity and 'big problem to get money for medical treatment' were positively, and among men, having hypertension, lung disease, and early sexual debut were associated with MDD. Among women, having a history of STI, low dietary diversity, 'big problem to get money for medical treatment', and the use of solid cooking fuel were positively, and currently working and early sexual debut were negatively associated with GAD. Among men, having hypertension and having been diagnosed with lung disease were positively associated with GAD.

CONCLUSION

Almost 4% of participants had PSB, among women more than 10% had MDD and GAD, respectively, and among men more than 2% had MDD and GAD, respectively. Public health interventions can be guided by a number of associated factors that have been identified.

Barriers and facilitators to accessing mental health services among young people living with HIV and healthcare professionals in Mozambique: a content and sentiment analysis using the capability, opportunity, motivation and behaviour (COM-B) framework

BACKGROUND

Ensuring timely and effective access to mental health (MH) services is crucial in Mozambique, where the suicide rate is 13.7/100.000, twice that of sub-Saharan Africa. This is particularly significant for a MH at-risk group, such as young adults (YA) living with HIV. This study aimed to assess barriers/facilitators to access MH services for YAs, comparing by HIV status, in Beira, Mozambique.

METHODS

A cross-sectional study using focus groups and key-informant interviews was conducted between July and August 2023, involving YAs (18-24 years) with (YALHIV) and without HIV (YAHIV-) and MH staff of five health centres (HCs). A deductive approach was adopted using the COM-B framework to classify themes referring to barriers/facilitators to access MH services. Two researchers carried out the content analysis independently, assessing the inter-rater agreement through Cohen's K.

RESULTS

A total of 48 YAs (half with HIV), and 15 MH providers were involved. Of the 650 themes identified, 347 (53.4%) were labelled as barriers. Opportunities were the most frequent barrier (57.7%): social ones were related to community stigma, while physical ones to staff shortage, lack of community services, and distance from HCs. Physical opportunities were a more frequent barrier in YAHIV- (p < 0.001) and females (p = 0.013). Automatic motivation was related to self-stigma and preconceived distrust. It was more common as a barrier among YAHIV- (65.6% vs. 35.5%, p = 0.032). Reflective motivation was the most frequent facilitator (33.1%): YALHIV reported good knowledge of their MH risk factors, and YAHIV- had previous positive experiences with MH services for people close to them. Psychological capability was a barrier for both YAs and MH staff, related to a lack of knowledge of health services and MH in general.

CONCLUSIONS

Addressing community and self-stigma and scaling up community MH services, increasing MH staff, are the two main action points that emerged to improve access to MH services. More attention should be paid to YAHIV-, which showed significant access barriers.

Providers' perspectives of barriers and facilitators to scale-up of mental health care in the public health delivery system of Mozambique: a qualitative inquiry

BACKGROUND

A central challenge to closing the mental health treatment gap in low- and middle-income countries (LMICs) is determining the most effective pathway for delivering evidence-based mental health services. We are conducting a cluster-randomized, Type 2 hybrid implementation-effectiveness trial across 20 districts of Mozambique called the Partnerships in Research to Implement and Disseminate Sustainable and Scalable EBPs (PRIDE) program. Following training of nonspecialized providers in facilitation of evidence-based treatments for mental health and informed by the Consolidated Framework for Implementation Research (CFIR), we identified how PRIDE compares to care as usual and the perceived barriers and facilitators of implementation and modifications needed for widescale service delivery and scale-up.

METHODS

We conducted rapid ethnographic assessment using freelisting among 34 providers, followed by four focus group discussions (n = 29 participants) with a subsample of psychiatric technicians and primary care providers from 14 districts in Nampula Province. We used Thematic Analysis to inductively apply open codes to transcripts and then deductively applied the CFIR domains and constructs to organize open codes.

RESULTS

The main Outer Setting constructs relevant to implementation were recognition that patient mental health needs were significant. Additionally, numerous community-level characteristics were identified as barriers, including distance between clinics; shortage of providers; and low awareness of mental health problems, stigma, and discrimination among community members towards those with mental health struggles. The PRIDE program was perceived to offer a relative advantage over usual care because of its use of task-sharing and treating mental illness in the community. PRIDE addressed Inner Setting barriers of having available resources and training and provider low self-efficacy and limited knowledge of mental illness. Providers recommended leadership engagement to give support for supervision of other task-shared professionals delivering mental healthcare.

CONCLUSIONS

Primary care providers and psychiatric technicians in Mozambique perceived the relative advantage of the PRIDE program to address mental health treatment access barriers and offered recommendations for successful sustainment and scale up of integrated mental health care.

Association between socioeconomic position of the household head, food insecurity and psychological health: an application of propensity score matching

BACKGROUND

Mental health outcomes can be influenced by various factors, one of which has recently gained attention, namely food security. Food security is paramount to maintaining not only physical, but also mental health. There is an increasing need to understand the interplay between food insecurity (FI) and mental health outcomes, especially among vulnerable populations. The objective of this study was to investigate the effect of FI on psychological health (anxiety and depression) as well as to examine the modifying effect of socioeconomic position on this relationship.

METHODS

A cross-sectional study was conducted in Maputo City, Mozambique, in 1,842 participants. Data were collected through structured interviews using a modified version of the US Department of Agriculture Household Food Security Module to measure FI, and the Hospital Anxiety and Depression Scale to measure anxiety and depression. A composite variable for psychological health was created. Propensity score matching and interaction effect analyses were employed to examine the effects of FI on psychological health and the moderating role of socioeconomic position.

RESULTS

Of the 1,174 participants randomly assigned to propensity score matching, 787 were exposed to FI while 387 were unexposed. The analysis revealed stark disparities in psychological health outcomes associated with FI. The risk of poor psychological health among those exposed to FI was 25.79%, which was significantly higher than the 0.26% in unexposed individuals. The risk difference was 25.54% points (95% CI: 22.44-28.63), with a risk ratio of 99.82. Our assessment of population attributable fractions indicated that nearly all the risk for poor psychological health in the exposed group could be ascribed to FI. The interaction effects analysis revealed that socioeconomic status modifies this relationship. Specifically, heads of food-insecure households with a lower socioeconomic position tended to report poor mental health compared to their food-secure counterparts with a higher position.

CONCLUSIONS

The findings underscore the profound impact of FI on the mental health of household heads in Maputo City, socioeconomic position being a significant modifier. Addressing household FI along with the socioeconomic position of household heads could be pivotal to mental health promotion, especially among vulnerable populations.

Mental illness stigma in Bangladesh: Findings from a cross-sectional survey

Background

Mental illness stigma is universally prevalent and a significant barrier to achieving global mental health goals. Mental illness stigma in Bangladesh has gained little attention despite its widespread impact on seeking mental health care in rural and urban areas. This study aimed to investigate mental illness stigma and the associated factors in rural and urban areas of Bangladesh.

Methods

The study areas were divided into several clusters from which 325 participants (≥18 years) were recruited with systematic random sampling. The Bangla version of the Days' Mental Illness Stigma Scale was used to collect data. Independent-samples t-test, ANOVA, and multiple regression were performed.

Results

Results suggest that gender, age, geographical location, socioeconomic status, and occupation significantly differed across subscales of stigma. Age, gender, seeking treatment of mental illness, having knowledge on mental health, and socioeconomic status were predictive factors of mental illness stigma. The results also showed a high treatment gap in both rural and urban areas.

Conclusion

This study supports that mental illness stigma is prevalent in Bangladesh, requiring coordinated efforts. Results can inform the development of contextually tailored mental health strategies to reduce stigma and contribute to the promotion of mental health of individuals and communities across Bangladesh.

Public attitudes towards protecting the human rights of people with mental illness: a scoping review and data from a population trend study in Germany

The human rights of people with mental illness are constantly threatened. We conduct a scoping review showing how public attitudes towards protecting human rights have so far been examined and providing an overview of our present knowledge of these attitudes, and present novel findings from a trend study in Germany over nine years, reporting attitudes elicited in 2020 and examining whether these attitudes have changed since 2011. Few studies address attitudes towards human rights explicitly, but several studies contain single items on either first generation human rights, mainly concerning involuntary admission, or civil liberties like the right to vote, or second generation human rights, mainly with regard to funding for healthcare, but also for example regarding career choice. Recent data from Germany showed little improvement in attitudes towards protecting human rights over the last decade and particularly high support for restricting job opportunities for people with mental illness. Although generally, most restrictions were supported by a minority of respondents only, both our data and our scoping review indicate substantial support for several restrictions in several countries, showing that public attitudes pose a challenge to the human rights of persons with mental illness. We discuss possible lines of future research.

Prevalence and associated factors of common mental disorders in primary care settings in Sofala Province, Mozambique

BACKGROUND

In Mozambique, the prevalence of common mental illness in primary care is not well established.

AIMS

This study aimed to assess the prevalence of, and associated factors for, common mental illness in patients accessing primary care services in three Ministry of Health clinics in Mozambique.

METHOD

Adult patients were recruited from the waiting rooms of prenatal, postpartum and general out-patient consultations. A mental health professional administered a diagnostic interview to examine prevalence of major depressive disorder (MDD), generalised anxiety disorder (GAD), post-traumatic stress disorder (PTSD) and any substance misuse or dependence. Generalised linear mixed models were used to examine the odds of each disorder and sociodemographic associations.

RESULTS

Of 502 patients interviewed, 74.1% were female (n = 372) and the average age was 27.8 years (s.d. = 7.4). Of all participants, 23.9% (n = 120) met diagnostic criteria for at least one common mental disorder; 8.6% were positive for MDD (n = 43), 13.3% were positive for GAD (n = 67), 4.8% were positive for PTSD (n = 24) and 4.0% were positive for any substance misuse or dependence (n = 20). Patients attending prenatal or postpartum consultations had significantly lower odds of any common mental disorder than patients attending out-patient primary care. Age was negatively associated with MDD, but positively associated with substance misuse or dependence.

CONCLUSIONS

Over 20% of patients attending primary care in Mozambique may have common mental disorders. A specific focus on patients attending general out-patient visits, young people for depression, and older people and men for substance misuse/dependence would provide a targeted response to high-risk demographics.

Implementation Planning for Integrating Depression Screening in Diabetes Mellitus and HIV Clinics in Botswana

Depression is highly prevalent and, when comorbid with other medical conditions, can worsen health outcomes. Implementing routine depression screening within medical clinics can ensure that patients receive suitable treatment and improve overall health outcomes. Unfortunately, depression screening within medical settings is rare, particularly in low- and middle-income countries. This qualitative study evaluated patient and clinician perspectives on implementing depression screening within HIV and diabetes clinics in Botswana. Seven clinicians and 23 patients within these clinics were purposively selected and interviewed using a guide informed by the Consolidated Framework for Implementation Research (CFIR) to understand barriers and facilitators to depression screening in medical clinics in Botswana. Interviews were recorded, transcribed, and analyzed using NVivo. Three general themes emerged: (1) Appropriateness and Acceptability: attitudes and beliefs from clinicians and patients about whether depression screening should occur in this setting; (2) Stigma as an important barrier: the need to address the negative associations with depression to facilitate screening; and (3) Recommendations to facilitate screening including improving knowledge and awareness about depression, offering incentives to complete the screening, providing staff training, ensuring resources for treatment, the need to preserve confidentiality, and utilizing leadership endorsement. These results offer insights into how to implement depression screening within medical clinics in Botswana. These results can help design implementation strategies to increase depression screening in these clinics, which can be tested in future studies.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43477-022-00062-3.

Systems analysis and improvement approach to optimize outpatient mental health treatment cascades in Mozambique (SAIA-MH): study protocol for a cluster randomized trial

BACKGROUND

Significant investments are being made to close the mental health (MH) treatment gap, which often exceeds 90% in many low- and middle-income countries (LMICs). However, limited attention has been paid to patient quality of care in nascent and evolving LMIC MH systems. In system assessments across sub-Saharan Africa, MH loss-to-follow-up often exceeds 50% and sub-optimal medication adherence often exceeds 60%. This study aims to fill a gap of evidence-based implementation strategies targeting the optimization of MH treatment cascades in LMICs by testing a low-cost multicomponent implementation strategy integrated into routine government MH care in Mozambique.

METHODS

Using a cluster-randomized trial design, 16 clinics (8 intervention and 8 control) providing primary MH care will be randomized to the Systems Analysis and Improvement Approach for Mental Health (SAIA-MH) or an attentional placebo control. SAIA-MH is a multicomponent implementation strategy blending external facilitation, clinical consultation, and provider team meetings with system-engineering tools in an overall continuous quality improvement framework. Following a 6-month baseline period, intervention facilities will implement the SAIA-MH strategy for a 2-year intensive implementation period, followed by a 1-year sustainment phase. Primary outcomes will be the proportion of all patients diagnosed with a MH condition and receiving pharmaceutical-based treatment who achieve functional improvement, adherence to medication, and retention in MH care. The Consolidated Framework for Implementation Research (CFIR) will be used to assess determinants of implementation success. Specific Aim 1b will include the evaluation of mechanisms of the SAIA-MH strategy using longitudinal structural equation modeling as well as specific aim 2 estimating cost and cost-effectiveness of scaling-up SAIA-MH in Mozambique to provincial and national levels.

DISCUSSION

This study is innovative in being the first, to our knowledge, to test a multicomponent implementation strategy for MH care cascade optimization in LMICs. By design, SAIA-MH is a low-cost strategy to generate contextually relevant solutions to barriers to effective primary MH care, and thus focuses on system improvements that can be sustained over the long term. Since SAIA-MH is integrated into routine government MH service delivery, this pragmatic trial has the potential to inform potential SAIA-MH scale-up in Mozambique and other similar LMICs.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT05103033 ; 11/2/2021.

Leveraging Neuroscience to Fight Stigma Around Mental Health

Labels serve as identifiers and convenient descriptors of inanimate and animate objects. In humans, given labels can easily become part of an individual's self-perceived identity. Negative labels ascribed to a person can result in internalized stigma, a state that will shape the subject's biography. This can ultimately impact the person's mental and physical health since perceived and/or anticipated stigma discourages the use of social and health services. Per definition, stigma involves labeling of persons with physical, mental, or social characteristics that do not match the observer's arbitrarily conditioned and calibrated sense of norms (public stigma); such labeling may eventually become embedded in rules, regulations, and laws (structural stigma). Internalized stigma projects onto a person's emotions and actions. Public (enacted) stigma results from stereotyping (collectively agreed-upon notions about a group of persons that are used to categorize these people) and devaluation, which subsequently leads to social distancing, discrimination, and blatant abuse of human rights. Much of what we know about stigma results from research in the psychosocial sciences and, more recently, from social neuroscience. The stigma around mental health has generated much attention in the field of psychiatry where, to date, most research has focussed on epidemiology and anti-stigma interventions. This essay intends to stimulate thought, debate, and research within the behavioral neuroscience community and, therefore, to inform evidence-based design and implementation of neuroscience-based approaches by other professionals working towards the elimination of the stigma attached to mental illness. The article starts by considering the concept of stigma and the psychological processes that give rise to the phenomenon; it also considers how projected and perceived stigma are multiplied. Finally, after a brief review of the few existing neuroscientific explorations of stigma, gaps in our knowledge of the neurobiological basis of stigma are identified and discussed.

Post-traumatic stress disorder psychological interventions in sub-Saharan Africa: protocol for a systematic review of the literature

INTRODUCTION

Untreated post-traumatic stress disorder (PTSD) results in considerable morbidity and higher risk of mortality. However, little is being done to treat PTSD in sub-Saharan Africa (SSA) settings where rates of PTSD are likely to be elevated due to mass exposure of the population to traumatic events. This systematic review aims to summarise available evidence on the efficacy of psychological therapies for PTSD in SSA.

METHODS AND ANALYSIS

A systematic search of the literature will be conducted in four electronic databases: PubMed, PsychInfo, EMBASE and Cochrane Register of Controlled Trials using keywords and synonyms related to 'PTSD', 'psychological therapies' and 'SSA'. Studies will be included if they were conducted in SSA and used a randomised controlled trial design. Two researchers will screen the studies for eligibility to be included, and data on intervention types, population, comorbidities, comparison group intervention and PTSD outcomes will be extracted from those included. Risk of bias will be assessed using Cochrane risk-of-bias tool for randomised trials (version 2). Narrative synthesis of data will be conducted and pooled effect estimates calculated.

ETHICS AND DISSEMINATION

Ethical approval is not required as this is a protocol of a systematic review of available data. Findings will be disseminated to the scientific community through peer-reviewed publications and presentation at conferences.

PROSPERO REGISTRATION

CRD42020181638.

Stigmatizing attitudes toward psychiatric disorders: A cross-sectional population-based survey

BACKGROUND

Stigmatizing attitudes against individuals diagnosed with mental illness could increase the severity of psychiatric symptoms, lead to delay in getting medical support, and decrease adherence to treatments. Identifying the groups most associated with stigmatization could orientate actions to reduce this prejudice and improve patients' prognosis.

OBJECTIVE

To investigate variables associated with stigmatization toward psychiatric disorders in Brazil.

METHODS

A Web-based survey was sent out to assess the sociodemographic characteristics of the respondents and their perception of mental illness. Included participants were composed of Brazilians aged 18 years or over, with access to the internet and social networks. The questionnaire was available from June to August 2018 on Facebook.

RESULTS

A total of 2414 respondents were included. The majority were female, white, aged between 18 and 29 years, and had more than 10 years of study. The variables associated with stigma were male sex, fewer years of education, lower household income, the presence of a psychiatric disorder in a first-degree relative, and internalized stigma.

CONCLUSIONS

The present study identified variables associated with the stigma against psychiatric disorders. Future studies should propose intervention strategies, such as to foster education about mental illness and to promote the importance of seeking help from a mental health professional, to address this problem in Brazil.

Validity and item response theory properties of the Patient Health Questionnaire-9 for primary care depression screening in Mozambique (PHQ-9-MZ)

BACKGROUND

Depression is one of the leading causes of disability in Mozambique; however, few patients with depression are identified in primary care. To our knowledge, there are no validated tools for depression screening in Mozambique. The aim of this study was to validate the Patient Health Questionnaire-9 (PHQ-9) for use in primary care settings in Mozambique.

METHODS

The PHQ-9 was adapted using a structured multi-phase process led by a team of bilingual experts followed by a review by lay individuals and pilot-testing including cognitive interviews. The final Mozambican PHQ-9 (PHQ-9-MZ) was applied among 502 individuals randomly selected from antenatal, postpartum, and general outpatient consultations in three Ministry of Health primary healthcare clinics in Sofala Province, Mozambique. The PHQ-9-MZ was evaluated against the MINI 5.0-MZ as a gold standard diagnostic tool.

RESULTS

The majority of participants were female (74%), with a mean age of 28. Using the MINI 5.0-MZ, 43 (9%) of the sample tested positive for major depressive disorder. Items of the PHQ-9-MZ showed good discrimination and factor loadings. One latent factor of depression explained 54% of the variance in scores. Questions 3 (sleep) and 5 (appetite) had the lowest item discrimination and factor loadings. The PHQ-9-MZ showed good internal consistency, with a Cronbach's alpha of 0.84, and an area under the receiver operating characteristic curve (AUROC) of 0.81 (95% CI: 0.73, 0.89). The PHQ-2-MZ had an AUROC of 0.78 (95% CI: 0.70, 0.85). Using a cut-point of ≥9, the PHQ-9-MZ had a sensitivity of 46.5% and a specificity of 93.5%. Using a cut-point of ≥2, the PHQ-2-MZ had a sensitivity of 74.4% and a specificity of 71.7%. Increasing the cut-point to ≥3, the PHQ-2-MZ has a sensitivity of 32.6% and a specificity of 94.6%.

CONCLUSIONS

The PHQ-9-MZ and PHQ-2-MZ emerge as two valid alternatives for screening for depression in primary health care settings in Mozambique. Depending on program needs and weighing the value of minimizing false positives and false negatives, the PHQ-9-MZ can be employed with cut-points ranging from ≥8 to ≥11, and the PHQ-2-MZ with cut-points ranging from ≥2 to ≥3.