Psychosis Recovery Orientation in Malawi by Improving Services and Engagement (PROMISE) protocol

Malawi has a population of around 20 million people and is one of the world's most economically deprived nations. Severe mental illness (largely comprising psychoses and severe mood disorders) is managed by a very small number of staff in four tertiary facilities, aided by clinical officers and nurses in general hospitals and clinics. Given these constraints, psychosis is largely undetected and untreated, with a median duration of untreated psychosis (DUP) of around six years. Our aim is to work with people with lived experience (PWLE), caregivers, local communities and health leaders to develop acceptable and sustainable psychosis detection and management systems to increase psychosis awareness, reduce DUP, and to improve the health and lives of people with psychosis in Malawi. We will use the UK Medical Research Council guidance for developing and evaluating complex interventions, including qualitative work to explore diverse perspectives around psychosis detection, management, and outcomes, augmented by co-design with PWLE, and underpinned by a Theory of Change. Planned deliverables include a readily usable management blueprint encompassing education and community supports, with an integrated care pathway that includes Primary Health Centre clinics and District Mental Health Teams. PWLE and caregivers will be closely involved throughout to ensure that the interventions are shaped by the communities concerned. The effect of the interventions will be assessed with a quasi-experimental sequential implementation in three regions, in terms of DUP reduction, symptom remission, functional recovery and PWLE / caregiver impact, with quality of life as the primary outcome. As the study team is focused on long-term impact, we recognise the importance of having embedded, robust evaluation of the programme as a whole. We will therefore evaluate implementation processes and outcomes, and cost-effectiveness, to demonstrate the value of this approach to the Ministry of Health, and to encourage longer-term adoption across Malawi.

Pathways to care for psychosis in Malawi

People with psychosis in Malawi have very limited access to timely assessment and evidence-based care, leading to a long duration of untreated psychosis and persistent disability. Most people with psychosis in the country consult traditional or religious healers. Stigmatising attitudes are common and services have limited capacity, particularly in rural areas. This paper, focusing on pathways to care for psychosis in Malawi, is based on the Wellcome Trust Psychosis Flagship Report on the Landscape of Mental Health Services for Psychosis in Malawi. Its purpose is to inform Psychosis Recovery Orientation in Malawi by Improving Services and Engagement (PROMISE), a longitudinal study that aims to build on existing services to develop sustainable psychosis detection systems and management pathways to promote recovery.

Views and experiences of traditional and Western medicine practitioners on potential collaboration in the care of people living with mental illness in Malawi

Introduction

Collaboration between traditional and biomedical medicine can lead to holistic care and improved health outcomes for people with mental illnesses. The current study aimed to explore the views and experiences of traditional and western medicine practitioners on potential collaboration in the care of people living with mental illness in Blantyre, Malawi.

Method

A phenomenological qualitative research design was used. Data were collected using both one-on-one in-depth interviews (IDIs) and focus group discussions (FGDs). Participants were traditional healers and western medicine practitioners in Blantyre, Malawi. We conducted 10 in-depth interviews with traditional healers, 4 focus group discussions (2 for traditional healers and 2 for western medicine practitioners) and 6 key informant interviews with leaders of the two groups. The sample was determined based on data saturation. Thematic analysis was used to analyse the data. We used a combination of deductive and inductive coding.

Results

Five broad themes were identified from the data: experiences with collaboration, views on collaboration, models of collaboration, barriers to collaboration, and factors that can facilitate collaboration. participants had no experience of formal collaboration between traditional healers and western healthcare workers in the management of mental illness. However, some reported experience of successful collaborations in other health areas such as safe motherhood, tuberculosis and HIV/AIDS. Many participants showed a positive attitude toward collaboration and were in support of it. Barriers to collaboration included negative attitudes and a lack of resources. Factors that can facilitate collaboration were dialogue, training and respect. Referral and training were the preferred forms of collaboration.

Conclusion

With proper structures and respectful dialogue, a collaboration between traditional and western medicine practitioners is possible in Blantyre, Malawi.

Developing Biopsychosocial Research on Maternal Mental Health in Malawi: Community Perspectives and Concerns

Interest in maternal mental health research is growing around the world. Maternal mental health research studies in Malawi have, for instance, sought to determine and establish the incidence and prevalence of depression and anxiety in pregnant people and the factors that contribute to experiences of these states. This article reports stakeholder perspectives on potential community concerns with biopsychosocial mental health research (which might include collecting blood samples) in Malawi. These perspectives were generated through a town hall event that featured five focus group discussions with various participants. In this article, we reflect on key themes from these discussions, demonstrating the endurance of long-standing concerns and practices around autonomy, consent, and the drawing of blood. We conclude by arguing that, while maternal mental health research conducted in Malawi could benefit Malawian women and children, consultation with community stakeholders is necessary to inform whether and how such research should be conducted.

Implementing an mhGAP-based training and supervision package to improve healthcare workers' competencies and access to mental health care in Malawi

Background

It is now well established that the integration of mental health care into primary care is one of the most effective ways of reducing the substantial treatment gap for mental disorders which exists in most low- and middle-income countries. This study set out to determine whether a Mental Health Gap Action Programme (mhGAP) training and supervision package could be contextualised and implemented within the existing health care system in five districts in Southern Malawi. In addition, the study assessed the feasibility of holding community awareness events and establishing peer support groups in each district to further improve the access of the population to evidence-based mental health care.

Methods

A lead training team of experienced Malawian mental health professionals was appointed and mhGAP training materials were contextualised for use in Malawi. The lead team delivered a 4-day training package to district mental health teams in five districts covering three core conditions: psychosis, moderate-severe depression, and alcohol and substance use disorders. District mental health teams then delivered a 2-day training package and provided monthly supervision for 3 months to 500 non-specialist healthcare workers. Paired sample t-tests were used to compare knowledge, confidence and attitude scores before and immediately after training, and after 6 months in two districts. Case detection rates measured pre- and post-training in the pilot district were compared using Wilcoxon Rank Sum Test. Community awareness events were held and peer support groups were established in each of the five districts. The acceptability of the package was assessed through focus group discussions involving specialist and non-specialist healthcare workers, users and carers.

Results

Non-specialist healthcare workers’ knowledge and confidence scores significantly increased immediately after training in comparison to pre-training. These scores were maintained at 6 months. However, no statistically significant change in attitude scores was detected. Case detection rates increased immediately after the training in comparison to pre-training. Responses from focus group discussion participants illustrated the programme’s acceptability.

Conclusions

This study demonstrated that, with minimal additional funding and working within existing structures, an mhGAP based training at primary and secondary health care levels is feasible in Southern Malawi.

Perceptions and experiences of caregivers of severely malnourished children receiving inpatient care in Malawi: An exploratory study

Background

Severe acute malnutrition (SAM) affects approximately 18 million children under the age of five and is associated with more than 500 thousand deaths per year. Existing research has indicated that a high number of caregivers of children admitted for inpatient treatment of SAM experience psychological distress, depressive symptoms, and suicidality. However, no published studies in Malawi have been undertaken to qualitatively explore caregivers' perceptions and experiences regarding their children's malnutrition and inpatient treatment.

Aim

To explore caregivers' perceptions and experiences surrounding childhood acute malnutrition and the experience of inpatient care in Malawi.

Methods

Interviews were conducted utilising a semi-structured topic guide and were coded using thematic analysis.

Results

Caregivers (N=30) gave informed consent to participate in interviews. Caregiver understanding and perceptions of their children's illness varied. Some caregivers identified a physical cause, with a minority identifying lack of dietary protein. Other narratives were around characteristics of the infant, other circumstantial events and religious and spiritual influences. One-third of caregivers described their own health difficulties and marital and relationship stressors. Challenges such as poverty, lack of access to food, poor food variability and competing demands for caregiver time were explained. Both positive and negative experiences of family and community support and hospital-based care were reported.

Conclusion

The themes identified contribute to a greater contextual understanding of the multifactorial and integrated approaches required to address malnutrition. This study indicates that healthcare providers need to take a multi-faceted view of malnutrition and be aware of the many factors that may influence healthcare experience and response to treatment. Acknowledging pluralistic belief systems may improve engagement with care. This demands a broader appreciation of perceptions and experiences of malnutrition, hospital-based care, sources of support and stressors within the caregiver, family and community environment as well as consideration of social determinants such as poverty and how these influences present within a clinical context.

Attitudes towards mental illness in Malawi: a cross-sectional survey

BACKGROUND

Stigma and discrimination associated with mental illness are strongly linked to suffering, disability and poverty. In order to protect the rights of those with mental disorders and to sensitively develop services, it is vital to gain a more accurate understanding of the frequency and nature of stigma against people with mental illness. Little research about this issue has been conducted in Sub- Saharan Africa. Our study aimed to describe levels of stigma in Malawi.

METHODS

A cross-sectional survey of patients and carers attending mental health and non-mental health related clinics in a general hospital in Blantyre, Malawi. Participants were interviewed using an adapted version of the questionnaire developed for the "World Psychiatric Association Program to Reduce Stigma and Discrimination Because of Schizophrenia".

RESULTS

210 participants participated in our study. Most attributed mental disorder to alcohol and illicit drug abuse (95.7%). This was closely followed by brain disease (92.8%), spirit possession (82.8%) and psychological trauma (76.1%). There were some associations found between demographic variables and single question responses, however no consistent trends were observed in stigmatising beliefs. These results should be interpreted with caution and in the context of existing research. Contrary to the international literature, having direct personal experience of mental illness seemed to have no positive effect on stigmatising beliefs in our sample.

CONCLUSIONS

Our study contributes to an emerging picture that individuals in Sub-Saharan Africa most commonly attribute mental illness to alcohol/ illicit drug use and spirit possession. Our work adds weight to the argument that stigma towards mental illness is an important global health and human rights issue.