Mental health training for primary health care workers and implication for success of integration of mental health into primary care: evaluation of effect on knowledge, attitude and practices (KAP)

Effects of an intervention program to improve mental health and epilepsy care in Madagascar

BACKGROUND

Despite the high prevalence of mental disorders and epilepsy in low- and middle-income countries, nearly 80% of patients are not treated. In Madagascar, initiatives to improve access to epilepsy and mental health care, including public awareness and training of general practitioners (GPs), were carried out between 2013 and 2018. Our study's main objective was to assess the effectiveness of these initiatives, two to five years post-intervention.

METHODS

This quasi-experimental study (intervention vs. control areas) included five surveys assessing: general population's Knowledge Attitudes and Practices (KAP), GPs' KAP , number of epilepsy and mental health consultations at different levels of the healthcare system, diagnostic accuracy, and treatments' availability.

OUTCOMES

In the general population, KAP scores were higher in intervention areas for epilepsy (11.4/20 vs. 10.3/20; p = 0.003). For mental disorders, regardless of the area, KAP scores were low, especially for schizophrenia (1.1/20 and 0.1/20). Among GPs, KAP scores were higher in intervention areas for schizophrenia (6.0/10 vs. 4.5/10; p = 0.008) and epilepsy (6.9/10 vs. 6.2/10; p = 0.044). Overall, there was a greater proportion of mental health and epilepsy consultations in intervention areas (4.5% vs 2.3%). Although low, concordance between GPs' and psychiatrists' diagnoses was higher in intervention areas. There was a greater variety of anti-epileptic and psychotropic medications available in intervention areas.

INTERPRETATION

This research has helped to better understand the effectiveness of initiatives implemented in Madagascar to improve epilepsy and mental health care and to identify barriers which will need to be addressed.

FUNDING

Sanofi Global Health, as part of the Fight Against STigma Program.

Lessons from integrating mental health as part of lymphatic filariasis morbidity management and disability prevention services in Jigawa State, Nigeria

Lymphatic filariasis (LF) is a neglected tropical disease affecting >120 million people worldwide. LF has debilitating effects on humans and leads to morbidity and sometimes irreversible disability. A significant proportion of persons affected by LF morbidity also suffer from ill health, such as depression, anxiety, pain, stigma and social isolation due to disfigurement, as well as loss of mobility, livelihood and income. Mental health is often overlooked as a component of morbidity management and disability prevention (MMDP) services, despite the high prevalence of depression and anxiety among people affected by LF. To address this gap, Christian Blind Mission (CBM) piloted a comprehensive approach providing morbidity management and disability prevention by integrating mental health as part of the MMDP care package. The participatory evaluation of the project reviewed the project documents and a review meeting, small group discussions and in-depth interviews with project stakeholders. Findings suggest that project training and service delivery targets were exceeded in most cases. In addition, the disability and gender disaggregated data highlights the interplay of gender and disability in accessing care and the existence of unmet mental health needs. The financial cost of transportation to utilise referrals or access other MMDP services, such as replenishing treatment supplies, was a major constraint in accessing services for LF morbidity patients and low levels of awareness, fear of hydrocoele surgery and social stigmatisation were reported. The project outcomes demonstrate the feasibility and effectiveness of integrating mental health as part of a comprehensive MMDP package of care. Integration strategies should target training of MMDP providers in basic mental health skills, screening for mental health issues and the provision of mental health services and other MMDP services within the same facilities. Integration is an important step towards comprehensive care for people affected by LF and other NTD morbidities and disabilities.

Primary care physicians' experience of caring for children with parents with mental health illness: a qualitative study among French general practitioners and paediatricians

BACKGROUND

Parental psychiatric disorders can have a significant impact on child development and the parent-infant bond, with a high risk of attachment disorders. Early identification of difficulties in the parent-child relationship is essential to prevent consequences for the child. Childcare practitioners have a major role to play in this early detection process, through regular mandatory consultations during the first two years of a child's life. Thus, the aim of this study was to collect the experience of private practitioners in their care of children of parents with a mental health illness.

METHOD

This is a cross-sectional, observational, qualitative study. Data were collected by means of semi-structured interviews with eleven general practitioners and private paediatricians between February and July 2021 in Toulouse and its suburbs. We only included practitioners who had followed children of parents with a mental health illness. The interviews were recorded with the agreement of the participants, before being transcribed anonymously. The data were analysed with NVivo software using interpretative phenomenological analysis.

RESULTS

Three main themes emerged from the results, which were further divided into several sub-themes. Addressing psychiatric disorders presents a risk for the therapeutic relationship. Practitioners express a need to preserve this relationship with the parent in joint care. Care is difficult and is permeated by the parents' emotional issues. Furthermore, practitioners face a conflict between their concerns for the parent-child bond and their desire not to stigmatise these families. They express a feeling of isolation in these follow-ups. This stressful care has a significant emotional impact on the doctors. Access to psychiatric training and multidisciplinary collaboration seem to be essential to improve the follow-up experience for practitioners, as these factors strengthen inter-professional connections.

CONCLUSION

Practitioners describe a parent-doctor relationship at risk, which is underpinned by the fear of care placement. This study illustrates the need to strengthen multidisciplinary work by promoting interprofessional exchanges, in order to improve the experience of practitioners in this care process. Addressing practitioners' fear of discussing parental psychiatric illness is very important, so as not to delay the implementation of preventive actions that are likely to improve the developmental prognosis for children.

Prevalence of mental distress and associated factors among university students in Ethiopia: a meta-analysis

BACKGROUND

Mental distress is an important public health problem and is becoming common health problems among university students.

AIMS

This study aimed to provide a pooled prevalence of mental distress and associated factors among university students in Ethiopia.

METHOD

We systematically searched PubMed, EMBASE and PsycINFO databases. A further search was performed at Google Scholar search engine for additional studies. All observational studies reporting the prevalence of mental distress and/or associated factors among university students in Ethiopia were included. Pooled prevalence with 95% confidence interval (95% CI) were calculated using random effects and quality effects models. Subgroup and sensitivity analyses were performed. Heterogeneity between studies and evidence of publication bias were assessed.

RESULTS

The pooled prevalence of mental distress was 35% (95% CI; 28%-43%). Being female, participating in religious programmes, having close friends, experiencing financial distress, alcohol use, khat use, conflict with friends, lack of interest in their field of study and a family history of mental illness were factors associated with mental distress among students. We found significant heterogeneity, but no evidence of publication bias.

CONCLUSIONS

More than one third of university students in Ethiopia have suffered with mental distress. The finding provides evidence that university students are at risk population for mental health problems and suggests the need for early intervention to prevent severe mental illness.

Enabling mental health task-sharing: a collective case study of undergraduate clinical associate training programmes in South Africa

BACKGROUND

There is a shortage of the human resources needed to deliver mental health services which is likely to be exacerbated by COVID-19. Due to mental health workforce shortages, task-shifting and task-sharing approaches have been implemented in a number of countries. Clinical associates, a mid-level cadre working under the supervision of medical practitioners, could play a role in delivering mental health services but it is not clear if they are adequately prepared. This study explored the mental health curriculum content of the undergraduate clinical associate training programmes in South Africa and the views of key informants of the adequacy of training in mental health.

METHODS

A qualitative collective case study approach was utilised for this multisite study at the three universities in South Africa offering clinical associate degrees. The study consisted of in-depth interviews utilising videoconferencing of individuals involved in each programme and a document review. Thematic analysis of the data was conducted.

RESULTS

Nineteen interviews were conducted. Mental health formed part of the curriculum in all three programmes with the bulk of the training taking place in the final year of the three-year degree. Facility-based training ranged from two weeks to four weeks with one university only using hospitals with mental health units while two universities used hospitals at which the students were based for the year regardless of potential mental health exposure they would receive. The list of curricula inclusions extended to seldom-seen conditions. The quality of training and supervision appeared site-dependant and only one university set minimum experiential targets.

CONCLUSION

There is a basis on which to build the competencies and skills regarding mental health in this cadre. A training model that integrates mental health early in the undergraduate curriculum, focuses on common conditions and those with high disease burden, includes time in a mental health unit, provides facility-based trainers with detailed guidance to improve standardisation, and includes specific experiential targets that are monitored will enhance the potential utility of this cadre.

Training types associated with knowledge and experience in public health workers

BACKGROUND

Training non-specialist workers in mental healthcare improves knowledge, attitude, confidence, and recognition of mental illnesses. However, still little information is available on which type of mental health training is important in the improvement of these capacities.

METHODS

We studied web-based survey data of 495 public health workers to examine training types associated with knowledge and experience in supporting individuals with mental illness. Multivariable logistic regression analysis was conducted to evaluate the association between a lack of knowledge and experience (outcome) and mental health training (exposure). We fitted three regression models. Model 1 evaluated unadjusted associations. Model 2 adjusted for age and sex. Model 3 adjusted for age, sex, years of experience, mental health full-time worker status, and community population. Bias-corrected and accelerated bootstrap confidence intervals (CIs) were used.

RESULTS

For all training types, the association between a lack of knowledge and experience and mental health training attenuated as the model developed. In Model 3, a lack of knowledge and experience was significantly associated with training in specific illness (OR, 0.54; 95% CI, 0.32-0.93) and screening and assessment (OR, 0.63; 95% CI, 0.39-0.99). Non-significant results were produced for training in counseling, psychosocial support, collaborative work, and law and regulation in Model 3.

CONCLUSIONS

We believe that the present study provides meaningful information that training in specific illness and screening and assessment may lead to knowledge and experience of public health workers. Further studies should employ a longitudinal design and validated measurements.

Can a brief training intervention help improve mental health service delivery in South Africa?

BACKGROUND

South Africa faces a number of significant challenges apropos mental health service delivery, including a large treatment gap, a high rate of readmission, over-burdened specialist tertiary facilities, and slow integration of mental health into general health services. The South African National Mental Health Education Programme implemented between February 2019 and December 2019, aimed to upskill health workers to diagnose and manage mental disorders at primary and secondary levels of care.

AIM

This study aimed to assess the evolution of training participants' self-reported competency in mental health care and the number of referrals made to higher levels of care as well as to reflect on the possible broader effects of the training.

SETTING

The programme and study were conducted in South Africa with Medical Officers and Professional Nurses working at public sector primary and secondary level health care facilities.

METHODS

A descriptive observational study collected data from training participants through a pre- and post-course, and 3-month follow-up survey.

RESULTS

The average confidence ratings for performing mental health care activities and managing mental health conditions increased from pre- to post-course, and was either maintained or increased further at 3-month follow-up. A decrease in the self-reported percentage of patients being referred to a higher level of care was observed 3-months after the training.

CONCLUSION

The evaluation suggests that a brief training intervention such this can go a long way in increasing the confidence of primary and secondary level health care workers in managing common mental health conditions and adhering to the provisions of legislation.

Community Perception and Attitude towards people with Depression among Adults Residing in Arba Minch Health and Demographic Surveillance Site (AM-HDSS), Southern Ethiopia

Background:

Negative perception and attitude of community prevents many people with depression and their caregivers from seeking help and receiving adequate treatment due to fear of social reaction and may try to hide the illness. The reasons for negative attitudes are not consistent across communities or cultures. Therefore, understanding the level of community perception and attitude towards people with depression is important to develop an intervention to reduce the impact of mental illness.

Methods:

A community-based cross-sectional study was conducted among 617 randomly selected adults. The data was collected using structured, pre-tested, and interviewer-administered questionnaires. Descriptive statistics like frequency, mean, and median were performed. Bi-variable and multivariable logistic regression analyses were performed to identify the factors that affect the community attitude towards people with depression.

Results:

Of the study population, 325(52.7%) had a good perception and 246(39.9%) had a positive attitude towards people with depression. The majority of study participants frequently identified as the perceived cause of depression was substance misuse, loss of loved one, and conflict within a family. In addition, psychosocial treatment was the most preferred treatment for people with depression in the study area. Marital status and educational status were significantly associated with the community attitude towards people with depression

Conclusion:

Giving special attention to people with substance misuse, loss of loved one, and conflict within a family is very vital for the prevention of depression. In addition, future mental health promotion activities should focus on cause and common manifestation of depression to improve the attitude toward people with depression.

Misdiagnosis, detection rate, and associated factors of severe psychiatric disorders in specialized psychiatry centers in Ethiopia

BACKGROUND

There are limited studies on the prevalence of misdiagnosis as well as detection rates of severe psychiatric disorders in specialized and non-specialized healthcare settings. To the best of our knowledge, this is the first study to determine the prevalence of misdiagnosis and detection rates of severe psychiatric disorders including schizophrenia, schizoaffective, bipolar, and depressive disorders in a specialized psychiatric setting.

METHOD

In this cross-sectional study, a random sample of 309 patients with severe psychiatric disorders was selected by systematic sampling technique. Severe psychiatric disorders were assessed using the Structured Clinical Interview for DSM-IV (SCID). The potential determinates of misdiagnosis were explored using univariable and multivariable logistic regression models, adjusting for the potential confounding factors.

RESULT

This study revealed that more than a third of patients with severe psychiatric disorders were misdiagnosed (39.16%). The commonly misdiagnosed disorder was found to be a schizoaffective disorder (75%) followed by major depressive disorder (54.72%), schizophrenia (23.71%), and bipolar disorder (17.78%). Among the patients detected with the interview by SCID criteria, the highest level of the correct diagnosis was recorded in the medical record for schizophrenia (76.29%) followed by bipolar (72.22%), depressive (42.40%), and schizoaffective (25%) disorders with detection rate (sensitivity) of 0.76 (95% CI 0.69-0.84), 0.42 (95% CI 0.32-0.53), 0.72 (95% CI 0.60-0.84), and 0.25 (95% CI 0.09-0.41), respectively for schizophrenia, depressive, bipolar, and schizoaffective disorders. Patients with bipolar disorder were more likely to be misdiagnosed as having schizophrenia (60%), whereas schizophrenic patients were more likely to be misdiagnosed as having bipolar disorder (56.25%) and patients with depressive disorders were more likely to be misdiagnosed as having schizophrenia (54.72%). Having a diagnosis of schizoaffective and depressive disorders, as well as suicidal ideation, was found to be significant predictors of misdiagnosis.

CONCLUSION

This study showed that roughly four out of ten patients with severe psychiatric disorders had been misdiagnosed in a specialized psychiatric setting in Ethiopia. The highest rate of misdiagnosis was observed for schizoaffective disorder (3 out of 4), followed by major depressive disorder (1 out of 2), schizophrenia (1 out of 4), and bipolar disorders (1 in 5). The detection rates were highest for schizophrenia, followed by bipolar, depressive, and schizoaffective disorders. Having a diagnosis of schizoaffective and depressive disorders as well as suicidal ideation was found to be significant predictors of misdiagnosis.

Primary care mental health services in Qatar

With rapid growth and development in recent decades, the State of Qatar has been redefining strategies and policies towards building a world-class healthcare system. Mental health has emerged as a priority area for development. As a result, mental health services in the region are being redefined and expanded, and this was realised with the launching of the ambitious National Mental Health Strategy in 2013. Traditionally, mental healthcare in Qatar had been considered to be the remit of psychiatrists within secondary care. The new strategy supported the transition towards community-based care. It outlined a plan to design and build a comprehensive and integrated mental health system, offering treatment in a range of settings. In this article, we provide an overview of the advent of primary care mental health services in Qatar. We discuss the historical aspects of psychiatric care and development of primary care mental health services in Qatar.

Factors supporting the implementation of integrated care between physical and mental health services: an integrative review

In Australia and internationally there is a strong policy commitment to the redesign of health services toward integrated physical and mental health care. When executed well, integrated care has been demonstrated to improve the access to, clinical outcomes from, and quality of care while reducing overtreatment and duplication. Despite the demonstrated effectiveness and promise of integrated care, exactly how integrated care is best achieved remains less clear. The aim of this review study was to identify factors that support the implementation of integrated care between physical and mental health services. An integrative review was conducted following the framework developed by Whittemore and Knafl, with quantitative and qualitative evidence systematically considered. To identify studies, Medline, PubMed, PsychINFO, CINAHL were searched for the period from 2003 to 2018, and reference lists of included studies and review articles were examined. Nineteen studies were included. Synthesis of study findings identified seven key factors supporting the implementation of integrated care between physical and mental health services: (a) adequate resourcing, (b) shared values, (c) effective communication, (d) information technology (IT) infrastructure, (e) flexible administrative organizations, (f) role clarity and accountability, and (g) staff engagement and training. There was little theoretical development in included studies, with little insight into the contextual factors or underlying mechanism required to support the implementation of integrated care initiatives. This review identified a set of inter-related barriers and facilitators which, if addressed, can improve the implementation and sustainability of truly integrated care.

The APEC Digital Hub-WONCA Collaborative Framework on Integration of Mental Health into Primary Care in the Asia Pacific

Mental ill health affects individual well-being and national economic prosperity and makes up a substantial portion of the burden of disease globally, especially in the Asia-Pacific region. Integrating mental health into primary care is widely considered a key strategy to improve access to mental health care. Integration, however, is a complex process that needs to be addressed at multiple levels. A collaboration between the Asia-Pacific Economic Cooperation (APEC) Digital Hub for Mental Health and the World Organization of Family Doctors (WONCA) is described in this paper, which outlines a framework and next steps to improve the mental health of communities in APEC economies. This paper notes gaps related to the integration of mental health into primary care across the region and identifies enablers and current best practices from several APEC economies. The potential of digital technology to benefit primary mental health care for populations in the APEC region, including delivery of training programs for healthcare staff and access to resources for patients, is described. Finally, key next steps are proposed to promote enhanced integration into primary care and improve mental health care throughout the APEC region.

Community Perception and Attitude Towards People with Schizophrenia Among Residents of Arba Minch Zuria District, Arba Minch Health and Demographic Surveillance Sites System (AM-HDSS), Ethiopia: Cross-Section Study

Background

Mental health disorders have identified as being one of the public health issues throughout the world. Recent evidence reveals that more than 21 million people diagnosed with schizophrenia. However, there is little information about community perception and attitude towards people with Schizophrenia in Ethiopia.

Objective

The aim of this study was to assess the community perception and attitude towards people with Schizophrenia among residents of Arba Minch Zuria Districts, Southern Ethiopia.

Methods

A community-based cross-sectional study was conducted among 617 randomly selected adults. Interviewer-administered standard tool was used to collect the data. Descriptive statistics like frequency, mean, and median computed. A binary logistic regression model used to identify factors affecting community perception and attitude towards people with schizophrenia.

Results

Of the study population, 469 (76%) of respondents had good perception and 390 (63.2%) had positive attitudes towards people with schizophrenia. The study participants identified talkativeness and self-neglect behaviors as the most common manifestations of schizophrenia. Besides, this study identified substance misuse and head injury as the perceived cause and spiritual or traditional methods as a preferred treatment for people with schizophrenia. Moreover, the study participants preferred spiritual or traditional methods for the treatment of schizophrenia. Young age [AOR=2.03, 95% CI: 1.21, 3.40], females [AOR=2.32, 95% CI: 1.58, 3.41], good perception towards people with schizophrenia [AOR=4.95, 95% CI: 3.25, 7.54] and no formal educational status [AOR=2.75, 95% CI: 1.33, 5.70], and primary education [AOR=3.72, 95% CI: 1.87, 7.39] were significantly associated with the attitude towards people with schizophrenia.

Conclusion

The findings of this study indicate that approximately one-third of the residents had unfavorable attitudes towards people with schizophrenia. Therefore, giving special attention to male, elders and those who were educated, and individuals who have poor perceptions of people with schizophrenia is crucial.

Core components of mental health stigma reduction interventions in low- and middle-income countries: a systematic review

AIMS

To identify and categorise core components of effective stigma reduction interventions in the field of mental health in low- and middle-income countries (LMICs) and compare these components across cultural contexts and between intervention characteristics.

METHODS

Seven databases were searched with a strategy including four categories of terms ('stigma', 'mental health', 'intervention' and 'low- and middle-income countries'). Additional methods included citation chaining of all papers identified for inclusion, consultation with experts and hand searching reference lists from other related reviews. Studies on interventions in LMICs aiming to reduce stigma related to mental health with a stigma-related outcome measure were included. All relevant intervention characteristics and components were extracted and a quality assessment was undertaken. A 'best fit' framework synthesis was used to organise data, followed by a narrative synthesis.

RESULTS

Fifty-six studies were included in this review, of which four were ineffective and analysed separately. A framework was developed which presents a new categorisation of stigma intervention components based on the included studies. Most interventions utilised multiple methods and of the 52 effective studies educational methods were used most frequently (n = 83), and both social contact (n = 8) and therapeutic methods (n = 3) were used infrequently. Most interventions (n = 42) based their intervention on medical knowledge, but a variety of other themes were addressed. All regions with LMICs were represented, but every region was dominated by studies from one country. Components varied between regions for most categories indicating variation between cultures, but only a minority of studies were developed in the local setting or culturally adapted.

CONCLUSIONS

Our study suggests effective mental health stigma reduction interventions in LMICs have increased in quantity and quality over the past five years, and a wide variety of components have been utilised successfully - from creative methods to emphasis on recovery and strength of people with mental illness. Yet there is minimal mention of social contact, despite existing strong evidence for it. There is also a lack of robust research designs, a high number of short-term interventions and follow-up, nominal use of local expertise and the research is limited to a small number of LMICs. More research is needed to address these issues. Some congruity exists in components between cultures, but generally they vary widely. The review gives an in-depth overview of mental health stigma reduction core components, providing researchers in varied resource-poor settings additional knowledge to help with planning mental health stigma reduction interventions.

A qualitative study exploring the barriers and facilitators of implementing a cardiovascular disease risk reducing intervention for people with severe mental illness into primary care contexts across England: the 'PRIMROSE' trial

BACKGROUND

People with severe mental illness (SMI) are at greater risk of earlier mortality due to physical health problems including cardiovascular disease (CVD). There is limited work exploring whether physical health interventions for people with SMI can be embedded and/or adopted within specific healthcare settings. This information is necessary to optimise the development of services and interventions within healthcare settings. This study explores the barriers and facilitators of implementing a nurse-delivered intervention ('PRIMROSE') designed to reduce CVD risk in people with SMI in primary care, using Normalisation Process Theory (NPT), a theory that explains the dynamics of embedding or 'normalising' a complex intervention within healthcare settings.

METHODS

Semi-structured interviews were conducted between April-December 2016 with patients with SMI at risk of CVD who received the PRIMROSE intervention, and practice nurses and healthcare assistants who delivered it in primary care in England. Interviews were audio recorded, transcribed and analysed using thematic analysis. Emergent themes were then mapped on to constructs of NPT.

RESULTS

Fifteen patients and 15 staff participated. The implementation of PRIMROSE was affected by the following as categorised by the NPT domains: 1) Coherence, where both staff and patients expressed an understanding of the purpose and value of the intervention, 2) Cognitive participation, including mental health stigma and staff perceptions of the compatibility of the intervention to primary care contexts, 3) Collective action, including 3.1. Interactional workability in terms of lack of patient engagement despite flexible appointment scheduling. The structured nature of the intervention and the need for additional nurse time were considered barriers, 3.2. Relational integration i.e. whereby positive relationships between staff and patients facilitated implementation, and access to 'in-house' staff support was considered important, 3.3. Skill-set workability in terms of staff skills, knowledge and training facilitated implementation, 3.4. Contextual integration regarding the accessibility of resources sometimes prevented collective action. 4) Reflexive monitoring, where the staff commonly appraised the intervention by suggesting designated timeslots and technology may improve the intervention.

CONCLUSIONS

Future interventions for physical health in people with SMI could consider the following items to improve implementation: 1) training for practitioners in CVD risk prevention to increase practitioners knowledge of physical interventions 2) training in SMI to increase practitioner confidence to engage with people with SMI and reduce mental health stigma and 3) access to resources including specialist services, additional staff and time. Access to specialist behaviour change services may be beneficial for patients with specific health goals. Additional staff to support workload and share knowledge may also be valuable. More time for appointments with people with SMI may allow practitioners to better meet patient needs.

Effectiveness of mental health community training on depression and anxiety to the health care profession working in rural centers of eastern Nepal

Background:

Depression and anxiety is the leading cause of disease burden in low- and middle-income countries. It is associated with a worse clinical course over the lifespan. This study aims the post-effect on the approach of managing depression and anxiety after the training on diagnosis and management of depression and anxiety.

Methods:

This is a prospective observational study done in the health care professionals who had done training on diagnosis and management of depression and anxiety from me. The participants were evaluated with the questionnaire.

Results:

The training was given in three parts in three different places of eastern Nepal with the health care professionals working near to those centers. There were total of 49 participants from 17 different primary health care centers. The referral rate of patients with depression and anxiety was decreased by 27% as stated by the participants as they can give psychoeducation and counseling in a very well manner after training which was lacking before training.

Conclusions:

Overall, the findings from the current data suggest that there is merit in continuing to evaluate and deliver community health training programs for depression and anxiety. While prevention type and personnel delivering the intervention account for aspects of the heterogeneity observed, more research is needed to identify how program completion and fidelity impact outcomes.

Assessment of the knowledge, attitudes, and practices (KAP) among UNRWA* health staff in Jordan concerning mental health programme pre-implementation: a cross-sectional study

BACKGROUND

Mental health is a major public health priority, especially among refugees. The United Nations Relief and Works Agency for Palestine Refugees (UNRWA) started to integrate mental health and psychosocial support (MHPSS) into its primary healthcare services in Jordan in late 2017. In this study, we aimed to assess of the knowledge, attitudes, and practices (KAP) among UNRWA health staff (HS) in Jordan concerning mental health programme pre-implementation, and their perceived barriers about this MHPSS programme.

METHODS

A cross-sectional study was conducted among doctors, dentists, nurses, and midwives who work at 16 of the 25 UNRWA health centres in Jordan. The assessment was made using a validated self-administered questionnaire. Data analysis was performed using SPSS (version 22).

RESULTS

Of the participants, 73% (161 of 220) believed that their knowledge of MHPSS programmes was insufficient, with no significant difference (p = 0·116) between different categories of staff. Furthermore, 88% (194 of 220) said that they needed more training, 67% (147 of 220) reported that the number of mental health cases is increasing, and 50% (110 of 220) that dealing with these cases is difficult. Reflecting on the past 12 months, 31% of staff (69 out of 220) reported meeting between one and ten children, and 45% (100 out of 220) reported meeting between one and ten adults suspected of having mental illnesses. The most suspected condition was depression (84%; 150 of 220), followed by epilepsy (64%; 140 of 220). The main perceived barriers to implementation included the limited availability of MHPSS policies (87%; 192 of 220), MH professionals (86%; 190 of 220), resources (86%; 189 out of 220), and lack of privacy (14%; 31 out of 220).

CONCLUSIONS

Most health staff had positive attitudes towards MHPSS programme implementation but felt they lacked the required knowledge. There is a need for training and clear technical guidelines. Perceived barriers to MHPSS programme implementation were consistent with the previous studies and need to be tackled with a structured plan of action.

Integrating mental health services into human immunodeficiency virus clinics: Lessons from task-sharing between clinical and lay healthcare providers in Ethiopia

Background

Globally, mental health problems are more common among people living with human immunodeficiency virus (PLHIV) than among the general population. Mental health problems affect human immunodeficiency virus (HIV) treatment adherence and retention. To address this challenge, partners used a task-sharing approach among lay healthcare works and clinicians to integrate mental health services into HIV services at pilot hospitals in the Amhara and Tigray regions of Ethiopia. In this model, trained lay healthcare workers proactively screened patients using a mental health screening tool and subsequently linked potential clients with trained clinicians working at HIV clinics for further diagnosis and treatment.

Methods

We retrospectively gathered secondary data, including demographic characteristics and diagnosis information, from mental health clinicians' and case managers' quarterly reports from HIV clinics during the implementation period (January 1, 2013 to March 31, 2014).

Results

During the initial three-month implementation period of the project (January to March 2013), case managers screened 5,862 PLHIV for mental health disorders. Case managers referred 687 (11.7%) patients with suspected mental health disorders to clinicians for further evaluation and management. Of the total patients screened by case managers in this period, clinicians confirmed that 454 (7.7%) had a mental health disorder. Overall, the concordance between the case managers' screening results and the clinicians' diagnoses was 67.8% over the 15-month pilot implementation period.

Conclusions

Routine screening of PLHIV for mental health disorders helps to proactively identify and manage patients with co-morbidities. The integration of mental health services into HIV care through a task-sharing approach is a feasible strategy that could increase access to mental health services among PLHIV.

Can General Practitioners manage mental disorders in primary care? A partially randomised, pragmatic, cluster trial

Background

For a decade, experts have suggested integrating mental health care into primary care to help bridge mental health Treatment Gap. General Practitioners (GPs) are the first port-of-call for many patients with mental ill-health. In Indonesia, the WHO mhGAP is being systematically introduced to its network of 10,000 primary care clinics as an add-on mental health training for pairs of GPs and Nurses, since the end of 2015. In one of 34 provinces, there exists an integrated care model: the co-location of clinical psychologists in primary care clinics. This trial evaluates patient outcomes among those provided mental health care by GPs with those treated by clinical psychologists in primary care.

Methods

In this partially-randomised, pragmatic, two-arm cluster non-inferiority trial, 14 primary care clinics were assigned to receive the WHO mhGAP training and 14 clinics with the co-location framework were assigned to the Specialist arm. Participants (patients) were blinded to the existence of the other pathway, and outcome assessors were blinded to group assignment.

All adult primary care patients who screened positive for psychiatric morbidity were eligible. GPs offered psychosocial and/or pharmacological interventions and Clinical Psychologists offered psychosocial interventions. The primary outcome was health and social functioning as measured by the HoNOS and secondary outcomes include disability measured by WHODAS 2.0, health-related quality of life measured by EQ‐5D-3L, and resource use and costs evaluated from a health services perspective, at six months.

Results

153 patients completed the outcome assessment following GP care alongside 141 patients following Clinical Psychologists care. Outcomes of GP care were proven to be statistically not inferior to Clinical Psychologists in reducing symptoms of social and physical impairment, reducing disability, and improving health-related quality of life at six months. Economic analyses indicate lower costs and better outcomes in the Specialist arm and suggest a 50% probability of WHO mhGAP framework being cost-effective at the Indonesian willingness to pay threshold per QALY.

Conclusion

General Practitioners supported by nurses in primary care clinics could effectively manage mild to moderate mental health issues commonly found among primary care patients. They provide non-stigmatising mental health care within community context, helping to reduce the mental health Treatment Gap.

Trial registration

ClinicalTrials.gov NCT02700490

Considering culture, context and community in mhGAP implementation and training: challenges and recommendations from the field

BACKGROUND

Major efforts are underway to improve access to mental health care in low- and middle-income countries (LMIC) including systematic training of non-specialized health professionals and other care providers to identify and help individuals with mental disorders. In many LMIC, this effort is guided by the mental health Gap Action Programme (mhGAP) established by the World Health Organization, and commonly centres around one tool in this program: the mhGAP-Intervention Guide.

OBJECTIVE

To identify cultural and contextual challenges in mhGAP training and implementation and potential strategies for mitigation.

METHOD

An informal consultative approach was used to analyze the authors' combined field experience in the practice of mhGAP implementation and training. We employed iterative thematic analysis to consolidate and refine lessons, challenges and recommendations through multiple drafts. Findings were organized into categories according to specific challenges, lessons learned and recommendations for future practice. We aimed to identify cross-cutting and recurrent issues.

RESULTS

Based on intensive fieldwork experience with a focus on capacity building, we identify six major sets of challenges: (i) cultural differences in explanations of and attitudes toward mental disorder; (ii) the structure of the local health-care system; (iii) the level of supervision and support available post-training; (iv) the level of previous education, knowledge and skills of trainees; (v) the process of recruitment of trainees; and (vi) the larger socio-political context. Approaches to addressing these problems include: (1) cultural and contextual adaptation of training activities, (2) meaningful stakeholder and community engagement, and (3) processes that provide support to trainees, such as ongoing supervision and Communities of Practice.

CONCLUSION

Contextual and cultural factors present major barriers to mhGAP implementation and sustainability of improved services. To enable trainees to effectively apply their local cultural knowledge, mhGAP training needs to: (1) address assumptions, biases and stigma associated with mental health symptoms and problems; (2) provide an explicit framework to guide the integration of cultural knowledge into assessment, treatment negotiation, and delivery; and (3) address the specific kinds of problems, modes of clinical presentations and social predicaments seen in the local population. Continued research is needed to assess the effectiveness these strategies.

Percepção da equipe multidisciplinar sobre a estrutura dos serviços de saúde mental: estudo fenomenológico

Resumo OBJETIVO Compreender a percepção da equipe multidisciplinar em relação à estrutura organizacional dos serviços de saúde mental no município de Cascavel-Paraná. MÉTODOS Trata-se de estudo exploratório, descritivo, qualitativo com a abordagem da Fenomenologia Social de Alfred Schütz. As informações foram coletadas por meio de entrevista semiestruturada com profissionais dos referidos serviços, entre os meses de maio a julho de 2016 e analisadas a partir dos pressupostos da fenomenologia social. RESULTADOS A partir da análise foram identificadas as seguintes categorias: a estrutura organizacional da rede de atenção à saúde mental; ações de cuidado no contexto da estrutura organizacional dos serviços de saúde mental e; expectativas em relação à rede de atenção à saúde mental. CONCLUSÕES A equipe multidisciplinar tem conhecimento sobre o formato estrutural e organizacional dos serviços de saúde mental e, tem expectativas de melhorias em relação ao futuro da atenção à saúde mental no município.

Perceptions of the causes of schizophrenia and associated factors by the Holy Trinity Theological College students in Ethiopia

INTRODUCTION

There is a cultural variability around the perception of what causes the syndrome of schizophrenia. As far as the cause of schizophrenia by the general public concerned, people living in western countries focus mainly on biological and social risk factors such as genetic vulnerability, disease of the brain, infection or stressful social conditions or personal weakness, but the predominant views held by people living in non-western countries focus mainly on supernatural and religious factors. Awareness and beliefs about the causes of mental illnesses influence the preferred treatments. The aim of this study was to determine the perceptions regarding the etiology of schizophrenia and the associated factors by theology students.

METHODS

An institution-based cross-sectional study was conducted among Holy Trinity Theological College students from May to June 2016. Self-administered Short Explanatory Model Interview was used to assess the perception of what causes the syndrome of schizophrenia. Data entry was performed by Epi-info version 3.5.3 and the Statistical Program for Social Science (SPSS version 20) was used for data clearance, and analyses.

RESULTS

A total of 409 students were involved in the survey. The mean age of the participants was 33.3 years (standard deviation ± 8.3) and almost all 94.4% of them were males. The majority (81.7%) of the participant recognized schizophrenia as a mental illness. Only 16.9% of the participants attributed supernatural phenomenon as a cause of schizophrenia and most of them 76.5% (313) thought of psychosocial problems as the cause of schizophrenia. About 40.1% of the participant endorsed biological factors as a cause of schizophrenia. About two-thirds (68.2%) of the participant thought schizophrenia as severe but not fatal illness and about 22.2% of them thought both severe and fatal illness. As far as the course concerned majority (88.5%) of the participants thought schizophrenia as a chronic illness and about 11.5% thought acute illness. Regarding the treatment, almost all (99.8%) of reported schizophrenia is treatable. Moreover, concerning the consequences of the illness about 18.8% reported the death as a consequence and about 66.7, 34.7 and 7.8% reported madness, family disintegration and losing a job, respectively. Urban residency and holding other degree were significantly associated with biological factors as a cause of schizophrenia (p < 0.05). Whereas getting information from mass media and health professional, marital status (married) and urban residence were significantly associated with psychosocial factors as the cause of schizophrenia. Furthermore, rural residency was significantly associated with the supernatural phenomenon as the cause of schizophrenia.

CONCLUSION

In the current study, the majority of the participant recognized schizophrenia as a mental illness and a treatable syndrome. A vast majority of the participant thought of psychosocial problems as the cause of schizophrenia about two-thirds of the participant thought schizophrenia as a severe but not fatal illness. As far as the course concerned majority (88.5%) of the participants thought schizophrenia as a chronic illness. Concerning the consequences of the illness, about 18.8% reported the death as a consequence and about 66.7, 34.7, and 7.8% reported madness, family disintegration and losing a job, respectively. Residency, marital status, and source of information were significantly associated with perceived causes of schizophrenia. Linking mental health service with spiritual care to address community mental health care needs and for early detection as well as referral linkage of mentally ill patients is warranted.