Geographic mobility and treatment outcomes among people in care for tuberculosis in the Lake Victoria region of East Africa: A multi-site prospective cohort study

Geographic mobility may disrupt continuity of care and contribute to poor clinical outcomes among people receiving treatment for tuberculosis (TB). This may occur especially where health services are not well coordinated across international borders, particularly in lower and middle income country settings. In this work, we describe mobility and the relationship between mobility and unfavorable TB treatment outcomes (i.e., death, loss to follow-up, or treatment failure) among a cohort of adults who initiated TB treatment at one of 12 health facilities near Lake Victoria. We abstracted data from health facility records for all 776 adults initiating TB treatment during a 6-month period at the selected facilities in Kenya, Tanzania, and Uganda. We interviewed 301 cohort members to assess overnight travel outside one's residential district/sub-county. In our analyses, we estimated the proportion of cohort members traveling in 2 and 6 months following initiation of TB treatment, explored correlates of mobility, and examined the association between mobility and an unfavorable TB treatment outcome. We estimated that 40.7% (95% CI: 33.3%, 49.6%) of people on treatment for TB traveled overnight at least once in the 6 months following treatment initiation. Mobility was more common among people who worked in the fishing industry and among those with extra-pulmonary TB. Mobility was not strongly associated with other characteristics examined, however, suggesting that efforts to improve TB care for mobile populations should be broad ranging. We found that in this cohort, people who were mobile were not at increased risk of an unfavorable TB treatment outcome. Findings from this study can help inform development and implementation of mobility-competent health services for people with TB in East Africa.

Social networks, mobility, and HIV risk among women in the fishing communities of Lake Victoria

BACKGROUND

Population mobility is a demonstrated barrier to reducing HIV incidence. A clear understanding of social networks and their influence on mobility among women in the fishing communities of Lake Victoria may contribute to tailoring effective interventions that suit the needs of these mobile women.

METHODS

A cross-sectional qualitative methods study was conducted to understand mobility patterns among women resident and or working in fishing communities of Lake Victoria in Kenya, Tanzania, and Uganda. The study was conducted in six fishing communities from March 2018 to June 2019. The communities were purposively selected, based on population size (1000 people or more) and HIV prevalence of > 15% among women aged 18 years or older who had lived in the fishing community for at least six months. In-depth interviews were conducted with 24 key informants and 72 women from the sites in the three countries. Questions focused on women's social networks and other factors that fuelled or facilitated women's mobility as well as challenges they faced due to mobility. Data analysis followed a thematic framework approach.

RESULTS

Different social groupings/networks existed among women in the fishing communities of Lake Victoria. These included female sex workers, women fish processors/traders, women bar workers/owners, restaurant workers, and family networks. Networks encouraged mobility, supporting finding work opportunities, but also increased sexual risks through partner changes. The benefits of networks included information sharing, financial support, and group protection, especially against violence.

CONCLUSION

Social networks and groupings among women in the fishing communities of Lake Victoria could be useful in tailoring HIV prevention and HIV care interventions to suit the needs of these highly mobile populations.

Understanding barriers and facilitators to clinic attendance and medication adherence among adults with hypertensive urgency in Tanzania

Hypertensive urgency is a major risk factor for cardiovascular events and premature deaths. Lack of medication adherence is associated with poor health outcomes among patients with hypertensive urgency in resource-limited settings. To inform the development of tailored interventions to improve health outcomes in this population, this study aimed at understanding facilitators and barriers to clinic attendance and medication adherence among Tanzanian adults with hypertensive urgency. We conducted in-depth interviews with 38 purposively selected participants from three groups: 1) patients with hypertension attending hypertension clinic, 2) patients with hypertension not attending hypertension clinic, and 3) clinic health workers. Interviews were conducted using a semi-structured guide which included open-ended questions with prompts to encourage detailed responses. In their narrative, patients and healthcare workers discussed 21 types of barriers/facilitators to clinic attendance and medication adherence: 12 common to both behaviors (traditional medicine, knowledge and awareness, stigma, social support, insurance, reminder cues, symptoms, self-efficacy, peer support, specialized care, social services, religious beliefs); 6 distinct to clinic attendance (transport, clinic location, appointment, patient-provider interaction, service fragmentation, quality of care); and 3 distinct to medication adherence (drug stock, side effects, medicine beliefs). The majority of identified barriers/facilitators overlap between clinic attendance and medication adherence. The identified barriers may be surmountable using tailored supportive intervention approaches, such as peer counselors, to help patients overcome social challenges of clinic attendance and medication adherence.

'There is nowhere to take the child': a qualitative study of community members' views on managing early childhood substance use in Mbale, Uganda

Background

Harmful alcohol use by 5–8-year-old children has been identified in Mbale District, Uganda. To further examine this finding, the present study explores the experiences and perceptions of community members regarding how childhood substance use (before age 10) is managed in this area.

Methods

We conducted eight focus group discussions with 48 parents of children aged < 10 years and 26 key informant interviews with teachers, health workers, child protection workers, police, local stakeholders, brewers, and others. Thematic content analysis was performed.

Results

Three main themes were identified:

‘We don’t talk about it’: Despite concern, childhood substance use was not addressed in the community. Participants attributed this to three main factors related to a lack of leadership in addressing it, changing acceptability for peer parental interference, and uncertainty about repercussions related to children’s rights.

‘There is nowhere to take the child’: Schools, police, and remand homes were intuitively considered appropriate arenas for managing childhood substance use but were considered inaccessible, unresponsive, and inadequate due to insufficient resources, competence, and training. Since substance use was not considered a medical problem, help from the health sector was only sought for adverse consequences, such as injury. This left the participants with the experience that there was in effect nowhere to take the child.

‘The government has not done so much’: The participants called for government action and clear laws that would regulate the availability of alcohol and other substances to children, but they had limited trust in the capacity and commitment of the government to act.

Conclusions

The participants were concerned about childhood alcohol and substance use, but the complexity and magnitude of the problem left them feeling incapacitated in responding. Relevant factors were identified on the community, institutional, and the government level, such as a lack of leadership in addressing it, a loss of mandate to interfere in child-rearing, inadequate services, weak legal structures, and missing government action. A strengthening of collective agency and public policy is necessary to prevent and address childhood alcohol and substance use.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13548-4.

'As soon as they can hold a glass, they begin taking alcohol': a qualitative study on early childhood substance use in Mbale District, Uganda

Background

Globally, substance use is a leading contributor to the burden of disease among young people, with far reaching social, economic and health effects. Following a finding of harmful alcohol use among 5-8-year-old children in Mbale District, Uganda, this study aims to investigate community members’ views on early childhood substance use among children below the age of 10 years.

Methods

In 2016, we conducted eight focus group discussions with 48 parents and 26 key informant interviews with teachers, health workers, alcohol distributors, traditional healers, religious leaders, community leaders and youth workers. We used thematic content analysis. Four participants and two research assistants reviewed and confirmed the findings.

Results

Alcohol in everyday life: ‘Even children on laps taste alcohol’: Almost all participants confirmed the existence of and concern for substance use before age 10. They described a context where substance use was widespread in the community, especially intake of local alcoholic brews. Children would access substances in the home or buy it themselves. Those living in poor neighbourhoods or slums and children of brewers were described as particularly exposed.

Using substances to cope: ‘We don’t want them to drink’: Participants explained that some used substances to cope with a lack of food and resources for childcare, as well as traumatic experiences. This made children in deprived families and street-connected children especially vulnerable to substance use. Participants believed this was a result of seeing no alternative solution.

Conclusions

To our knowledge, this is the first study to describe the context and conditions of childhood substance use before age 10 in Mbale District, Uganda. The study shows that community members attributed early childhood substance use to a social context of widespread use in the community, which was exacerbated by conditions of material and emotional deprivation. These social determinants for this practice deserve public health attention and intervention.

A social worker intervention to reduce post-hospital mortality in HIV-infected adults in Tanzania (Daraja): Study protocol for a randomized controlled trial

BACKGROUND

In sub-Saharan Africa (SSA), hospitalized HIV-infected patients who are discharged home have been shown to experience extremely high mortality rate. Daraja is an individual-level, time-limited, five-session case management intervention aiming to link hospitalized HIV-infected patients to outpatient HIV care upon discharge.

METHODS

A randomized control trial will aim at evaluating the efficacy of Daraja intervention on reducing mortality in hospitalized HIV-infected patients upon discharge from hospital. The study will recruit 500 hospitalized HIV-infected adults who are ART naïve or defaulted for >7 days from hospitals in Mwanza region, Tanzania. Participants will be enrolled during hospitalization and a baseline assessment will be done. Participants will be randomized to receive either the standard of care HIV linkage, or the Daraja intervention a day before the expected hospital discharge date. The Daraja intervention includes five sessions delivered by a social worker over a 3-month period. All participants will complete follow-up assessment at month 12 and 24. Measures will include 1-year survival, HIV care continuum outcomes (linkage, retention, antiretroviral adherence, and viral suppression), and cost (incremental cost of the intervention and cost per life saved). Quality assurance data will be collected, and the feasibility and acceptability of the intervention will be described. Statistical analysis will assess the effectiveness of the Daraja intervention on improving survival and HIV care continuum outcomes.

DISCUSSION

Hospitalized HIV-infected patients who are being discharged home have higher mortality due to poor linkage to primary HIV care. The Daraja intervention has the potential to address barriers that prevent successful transition from hospital to primary HIV care.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03858998. Registered on 01 March 2019.

Religious Leaders as Trusted Messengers in Combatting Hypertension in Rural Tanzanian Communities

BACKGROUND

Hypertension is a growing public health emergency in rural sub-Saharan Africa. Based on the known influence of religious leaders in rural sub-Saharan Africa and our prior research, we explored perspectives of religious leaders on hypertension and potential strategies to improve hypertension control in their communities.

METHODS

We conducted 31 in-depth interviews with Christian (n = 17) and Muslim (n = 14) religious leaders in rural Tanzania. Interviews focused on religious leaders' perceptions of hypertension and how they could play a role in promoting blood pressure reduction. We used interpretative phenomenological analysis, a qualitative research method, to understand religious leaders' perspectives on, and experiences with, hypertension.

RESULTS

Three main themes emerged during analysis. First, we found that perceptions about causes, treatment, and complications of hypertension are influenced by religious beliefs. Second, religious beliefs can enable engagement with hypertension care through religious texts that support the use of biomedical care. Third, religious leaders are enthusiastic potential partners for promoting hypertension control in their communities. These themes were consistent between religion and gender of the religious leaders.

CONCLUSIONS

Religious leaders are eager to learn about hypertension, to share this knowledge with others and to contribute to improved health in their communities.

Adherence to clinical guidelines in integration of mental health services into primary health care in Mbarara, southwestern Uganda: a medical records review

Background

The Ugandan Ministry of Health decentralized mental healthcare to the district level; developed the Uganda Clinical Guidelines (UCG); and trained primary health care (PHC) providers in identification, management, and referral of individuals with common mental disorders. This was intended to promote integration of mental health services into PHC in the country. ‘Common mental disorders’ here refers to mental, neurological and substance use conditions as indicated in the UCG. However, the extent of integration of mental health into general healthcare remains unknown. This study aimed to establish the level of adherence of PHC providers to the UCG in the identification and management of mental disorders.

Methods

This was a prospective medical record review of patient information collected in November and December 2018, and March and April 2019 at two health centers (III and IV) in southwestern Uganda. Data (health facility level; sex and age of the patient; and mental disorder diagnosis, management) was collected using a checklist. Continuous data was analyzed using means and standard deviation while categorical data was analyzed using Chi-square. Multivariable logistic regression analysis was performed to establish predictors of PHC provider adherence to the clinical guidelines on integration of mental health services into PHC. The analysis was conducted at a 95% level of significance.

Results

Of the 6093 records of patients at the study health facilities during the study period, 146 (2.4%) had a mental or neurological disorder diagnosis. The commonly diagnosed disorders were epilepsy 91 (1.5%) and bipolar 25 (0.4%). The most prescribed medications were carbamazepine 65 (44.5%), and phenobarbital 26 (17.8%). The medicines inappropriately prescribed at health center III for a mental diagnosis included chlorpromazine for epilepsy 3 (2.1%) and haloperidol for epilepsy 1 (0.7%). Female gender (aOR: 0.52, 95% CI 0.39–0.69) and age 61+ years (aOR: 3.02, 95% CI 1.40–6.49) were predictors of a mental disorder entry into the HMIS register.

Conclusion

There was a noticeable change of practice by PHC providers in integrating mental health services in routine care as reflected by the rise in the number of mental disorders diagnosed and treated and entered into the modified paper based HMIS registers.

Assessment of the relationship between life events with psychosocial competence of students in selected secondary schools in Northern and Central Uganda

Introduction

As they grow, young people transit through adolescence; a particularly challenging phase. Many go through without difficulties but some experience maladaptive responses in form of conduct and adjustment problems, pubertal challenges and life stress. Published research from the developed societies demonstrates consistent associations between young people's exposure to life events, psychosocial competence (PSC) and mental health problems. However, comparable research from income-constrained societies remains scarce. The purpose of this study was to determine the prevalence of life events in secondary school students and describe the relationship between life events and PSC in the same population.

Methods

This was a cross-sectional study. Participants were 2,902 randomly selected in Central and Northern Uganda. They responded to self-administered questionnaires on socio-demographics, life events and PSC.

Results

Northern Ugandan students were more likely to be susceptible to stress-related illness associated with major life events (p = < 0.01). Among students with a high susceptibility to stress related illness, those with low scores on self-efficacy (p = < 0.001), accurate self-assessment (p = < 0.001) and self-confidence (p = < 0.001) were mostly from the North. Students from Northern Uganda had experienced more negative events. Students with higher scores on empathy, emotional awareness, accurate self- assessment and self-confidence tended to have low distress. Students that had a low susceptibility to stress related illness (AOR = 1.97; 95% CI: 1.57 – 2.48); high scores on self-efficacy (AOR 1.37; 95% CI: 1.09 – 1.74), self-confidence (AOR 1.32; 95% CI: 1.02 – 1.72), and accurate self-assessment (AOR 2.19; 95% CI: 1.70 – 2.80) were mostly from northern Uganda.

Conclusion

It is important to help students to cope with negative life events since an association exists between negative life events and PSC domains. PSC domains of empathy, emotional awareness, accurate self-assessment and self-confidence seem to be associated with lower distress levels, implying that these should be reinforced.

Exploring pathways to Hospital Care for Patients with Alzheimer's disease and related dementias in rural South Western Uganda

BACKGROUND

In order to analyze use of health services and identify sources of delays in accessing the right care for patients with Alzheimer's disease and related dementias (AD/ADRD), understanding of care seeking pathways is needed. The objectives of this study were: (i) to explore pathways to hospital care for patients with AD/ADRD and (ii) to describe challenges experienced by the patients and their families while seeking health care.

METHODS

Using purposive sampling, 30-in-depth, semi-structured interviews were conducted among caregivers of older adults diagnosed with dementia from rural Southwestern, Uganda. Data was analyzed using ATLAS. Ti software.

RESULTS

There was variability in pathways to care from individual to individual. There was one broader theme captured: points of care choice with four broader categories: hospitals, clinics, places of religious worship and traditional healers' shrines, each with its facilitating factors, outcomes and challenges encountered. Most of the respondents reported use of hospitals at first and second visit to the health care point but places of religious worship became more common from third to sixth health care encounter. Major improvements (58.1%) were observed on hospital use but little or no help with prayers, clinics and traditional healers. The challenges experienced with formal points of care focused on lack and cost of prescribed drugs, weakening effect of the drugs, lack of skills to manage the condition, and lack of improvement in quality of life. These challenges together with knowledge gap about the disease and belief in spiritual healing facilitated the shift from formal to informal health care pathways, more particularly the places of religious worship.

CONCLUSIONS

Our study findings indicate that caregivers/families of patients with dementia went to different places both formal and informal care settings while seeking health care. However, hospital point of care was more frequent at initial health care visits while places of worship took the lead at subsequent visits. Although no specific pathway reported, most of them begin with hospital (formal) and end with non-formal. We recommend that health systems carry out public awareness on dementia.

The development and tailoring of a peer support program for patients with diabetes mellitus and depression in a primary health care setting in Central Uganda

BACKGROUND

About 20-40% of patients with diabetes mellitus (DM) suffer from depressive disorders (DD) during the course of their illness. Despite the high burden of DD among patients with DM, it is rarely identified and adequately treated at the majority of primary health care clinics in sub-Saharan Africa (SSA). The use of peer support to deliver components of mental health care have been suggested in resource constrained SSA, even though its acceptability have not been fully examined.

METHODS

We conducted qualitative interviews (QI) to assess the perceptions of DM patients with an experience of suffering from a DD about the acceptability of delivering peer support to patients with comorbid DM and DD. We then trained them to deliver peer support to DM patients who were newly diagnosed with DD. We identified challenges and potential barriers to a successful implementation of peer support, and generated solutions to these barriers.

RESULTS

Participants reported that for one to be a peer, they need to be mature in age, consistently attend the clinics/keep appointments, and not to be suffering from any active physical or co-morbid mental or substance abuse disorder. Participants anticipated that the major barrier to the delivery of peer support would be high attrition rates as a result of the difficulty by DM patients in accessing the health care facility due to financial constraints. A potential solution to this barrier was having peer support sessions coinciding with the return date to hospital. Peers reported that the content of the intervention should mainly be about the fact that DM was a chronic medical condition for which there was need to adhere to lifelong treatment. There was consensus that peer support would be acceptable to the patients.

CONCLUSION

Our study indicates that a peer support program is an acceptable means of delivering adjunct care to support treatment adherence and management, especially in settings where there are severe staff shortages and psycho-education may not be routinely delivered.

Informal support for people with Alzheimer's disease and related dementias in rural Uganda: a qualitative study

Background

The generation of people getting older has become a public health concern worldwide. People aged 65 and above are the most at risk for Alzheimer's disease which is associated with physical and behavioral changes. This nurtures informal support needs for people living with dementia where their families together with other community members are the core providers of day to day care for them in the rural setting. Despite global concern around this issue, information is still lacking on informal support delivered to these people with dementia.

Objective

Our study aimed at establishing the nature of informal support provided for people with dementia (PWDs) and its perceived usefulness in rural communities in South Western Uganda.

Methods

This was a qualitative study that adopted a descriptive design and conducted among 22 caregivers and 8 opinion leaders in rural communities of Kabale, Mbarara and Ibanda districts in South Western Uganda. The study included dementia caregivers who had been in that role for a period of at least 6 months and opinion leaders in the community. We excluded trained health workers.

Results

The study highlights important forms of informal support offered to PWDs such as support in activities of daily living, enabling access to medical attention, recovering misplaced items, provision of herbal remedy, informal counseling, and sourcing carers from other families to offer presence and support in the hope to impact positively on behavioral outbursts and the frustration of living with dementia.

Conclusion

The study revealed various forms of informal support that are available for PWDs in South Western Uganda and stressed the role of caregivers and the perceived usefulness of the care provided.

Implementing clinical guidelines to promote integration of mental health services in primary health care: a qualitative study of a systems policy intervention in Uganda

Background

Clinical practice guidelines (CPG) are developed based on a synthesis of evidence regarding the best options for the assessment, diagnosis and treatment of diseases and are recognized as essential quality improvement tools. However, despite growing availability of CPG, research evaluating their use for mental disorders in Uganda is lacking. For a successful implementation of CPG to be achieved, a number of considerations need to be put in place.

Objective

This study aimed to assess the feasibility and acceptability of the educational intervention that we developed towards improvement of the primary health care providers (PHCPs) uptake of the Uganda Clinical Guidelines (UCG) in integrating mental health services into PHC in Mbarara district, southwestern Uganda.

Methods

This was a descriptive cross-sectional qualitative study with a semi-structured in-depth interview guide. The educational intervention we were assessing had four components: (i) summarized UCG on common mental disorders; (ii) modified Health Management Information System (HMIS) registers to include mental health; (iii) clinician's checklist outlining the steps to be followed; and iv) support supervision/training.

Results

Six themes emerged from the study while the components of the intervention formed the apriori subthemes. Key results based on the subthemes show: (i) summarized UCG: the participants liked the packaging stating that it eased their work, was time saving and user friendly; (ii) modified register: participants appreciated the modifications made to the register updating the existing record in the Health Management Information System (HMIS) registers to include mental health disorders; (iii) TRAINING and support supervision: the PHCPs attributed the success in using the summarized UCG to the training they received, and they further expressed the need to regularize the training in assessment for mental health and support by the mental health specialists.

Conclusion

Our study demonstrates that the use of summarized UCG, modified HMIS registers to include mental health, training and support supervision by mental health specialists in implementing the UCG in integrating mental health at PHC settings is feasible and acceptable by the PHCPs in Mbarara district, southwestern Uganda. Given the need for improved mental health care in Uganda, this intervention could be rigorously evaluated for effectiveness, scalability and generalizability.

Health system constraints in integrating mental health services into primary healthcare in rural Uganda: perspectives of primary care providers

Background

The World Health Organization issued recommendations to guide the process of integrating mental health services into primary healthcare. However, there has been general as well as context specific shortcomings in the implementation of these recommendations. In Uganda, mental health services are intended to be decentralized and integrated into general healthcare, but, the services are still underutilized especially in rural areas.

Purpose

The purpose of this study was to explore the health systems constraints to the integration of mental health services into PHC in Uganda from the perspective of primary health care providers (PHCPs).

Methods

This was a cross sectional qualitative study guided by the Supporting the Use of Research Evidence (SURE) framework. We used a semi-structured interview guide to gain insight into the health systems constraints faced by PHCPs in integrating mental health services into PHC.

Results

Key health systems constraints to integrating mental health services into PHC identified included inadequate practical experience during training, patient flow processes, facilities, human resources, gender related factors and challenges with accessibility of care.

Conclusion

There is need to strengthen the training of healthcare providers as well as improving the health care system that supports health workers. This would include periodic mental healthcare in-service training for PHCPs; the provision of adequate processes for outreach, and receiving, referring and transferring patients with mental health problems; empowering PHCPs at all levels to manage and treat mental health problems and adequately provide the necessary medical supplies; and increase the distribution of health workers across the health facilities to address the issue of high workload and compromised quality of care provided.

Electronic supplementary material

The online version of this article (10.1186/s13033-019-0272-0) contains supplementary material, which is available to authorized users.

Barriers and facilitators to the integration of mental health services into primary health care: a systematic review

BACKGROUND

The objective of the review was to synthesize evidence of barriers and facilitators to the integration of mental health services into PHC from existing literature. The structure of the review was guided by the SPIDER framework which involves the following: Sample or population of interest-primary care providers (PCPs); Phenomenon of Interest-integration of mental health services into primary health care (PHC); Design-influenced robustness and analysis of the study; Evaluation-outcomes included subjective outcomes (views and attitudes); and Research type-qualitative, quantitative, and mixed methods studies.

METHODS

Studies that described mental health integration in PHC settings, involved primary care providers, and presented barriers/facilitators of mental health integration into PHC were included in the review. The sources of information included PubMed, PsycINFO, Cochrane Central Register of Controlled trials, the WHO website, and OpenGrey. Assessment of bias and quality was done using two separate tools: the Critical Appraisal Skills Program (CASP) qualitative checklist and the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies.

RESULTS

Twenty studies met the inclusion criteria out of the 3353 search results. The most frequently reported barriers to integration of mental health services into PHC were (i) attitudes regarding program acceptability, appropriateness, and credibility; (ii) knowledge and skills; (iii) motivation to change; (iv) management and/or leadership; and (v) financial resources. In order to come up with an actionable approach to addressing the barriers, these factors were further analyzed along a behavior change theory.

DISCUSSION

We have shown that the integration of mental health services into PHC has been carried out by various countries. The analysis from this review provides evidence to inform policy on the existing barriers and facilitators to the implementation of the mental health integration policy option. Not all databases may have been exhausted.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2016 (Registration Number: CRD42016052000 ) and published in BMC Systematic Reviews August 2017.

Interactions among poverty, gender, and health systems affect women's participation in services to prevent HIV transmission from mother to child: A causal loop analysis

Retention in care remains an important issue for prevention of mother-to-child transmission (PMTCT) programs according to WHO guidelines, formerly called the “Option B+” approach. The objective of this study was to examine how poverty, gender, and health system factors interact to influence women’s participation in PMTCT services. We used qualitative research, literature, and hypothesized variable connections to diagram causes and effects in causal loop models. We found that many factors, including antiretroviral therapy (ART) use, service design and quality, stigma, disclosure, spouse/partner influence, decision-making autonomy, and knowledge about PMTCT, influence psychosocial health, which in turn affects women’s participation in PMTCT services. Thus, interventions to improve psychosocial health need to address many factors to be successful. We also found that the design of PMTCT services, a modifiable factor, is important because it affects several other factors. We identified 66 feedback loops that may contribute to policy resistance—that is, a policy’s failure to have its intended effect. Our findings point to the need for a multipronged intervention to encourage women’s continued participation in PMTCT services and for longitudinal research to quantify and test our causal loop model.

Group Mentorship Model to Enhance the Efficiency and Productivity of PhD Research Training in Sub-Saharan Africa

INTRODUCTION

High quality PhD training in sub-Saharan Africa is important to strengthen research evidence to advance development and health. Training a critical mass of independent investigators capable of original scientific research requires strong mentorship, research environments, and international networks. We sought to iteratively improve a PhD training model in Uganda through systems capacity building.

METHODS

PhD students were selected through a rigorous competitive application and selection process, which included a written proposal and a face-to-face panel interview. The program provided administrative support, paid tuition fees, tools (space, equipment, research money), skills (short research courses on study design, biostatistics, manuscript and grant writing), and infrastructure (finance, grants management support, and lab infrastructure). Guidance to identify local and international mentorship was also provided in addition to two to three group meetings per year where data was presented and progress assessed by the program leaders in addition to available local mentors.

RESULTS

Seventeen PhD students were selected, and fifteen will complete training through the MEPI-MESAU program. To date, 60% have completed, including 2 students who started 2 years into the program. So far, 169 publications have been published in the peer-reviewed literature. Our PhD students have supervised and mentored 65 Master's students, which illustrates the cascade effect of PhD training on the academic medical school environment.

CONCLUSIONS

The systems capacity building approach to PhD training is an efficient and productive training model that allowed strong outputs at lower cost and with relatively few additional mentors to rapidly achieve a critical mass of independent scientists able to conduct original research and mentor others.

Barriers and facilitators to the integration of mental health services into primary health care: a systematic review protocol

BACKGROUND

Mental health is an integral part of health and well-being and yet health systems have not adequately responded to the burden of mental disorders. Integrating mental health services into primary health care (PHC) is the most viable way of closing the treatment gap and ensuring that people get the mental health care they need. PHC was formally adapted by the World Health Organization (WHO), and they have since invested enormous amounts of resources across the globe to ensure that integration of mental health services into PHC works.

METHODS

This review will use the SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, Research type) framework approach to identify experiences of mental health integration into PHC; the findings will be reported using the "Best fit" framework synthesis. PubMed, EMBASE, PsycINFO, and Cochrane Central Register of Controlled trials (CENTRAL) will be searched including other sources like the WHO website and OpenGrey database. Assessment of bias and quality will be done at study level using two separate tools to check for the quality of evidence presented. Data synthesis will take on two synergistic approaches (qualitative and quantitative studies). Synthesizing evidence from countries across the globe will provide useful insights into the experiences of integrating mental health services into PHC and how the barriers and challenges have been handled. The findings will be useful to a wide array of stakeholders involved in the implementation of the mental health integration into PHC.

DISCUSSION

The SPIDER framework has been chosen for this review because of its suitable application to qualitative and mixed methods research and will be used as a guide when selecting articles for inclusion. Data extracted will be synthesized using the "Best fit" framework because it has been used before and proved its suitability in producing new conceptual models for explaining decision-making and possible behaviors. Synthesizing evidence from countries across the globe will provide useful insights into the experiences of integrating mental health services into PHC and how the barriers and challenges have been handled.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016052000.

"If my husband leaves me, I will go home and suffer, so better cling to him and hide this thing": The influence of gender on Option B+ prevention of mother-to-child transmission participation in Malawi and Uganda

The role of gender in prevention of mother-to-child transmission (PMTCT) participation under Option B+ has not been adequately studied, but it is critical for reducing losses to follow-up. This study used qualitative methods to examine the interplay of gender and individual, interpersonal, health system, and community factors that contribute to PMTCT participation in Malawi and Uganda. We conducted in-depth interviews with women in PMTCT, women lost to follow-up, government health workers, and stakeholders at organizations supporting PMTCT as well as focus group discussions with men. We analyzed the data using thematic content analysis. We found many similarities in key themes across respondent groups and between the two countries. The main facilitators of PMTCT participation were knowledge of the health benefits of ART, social support, and self-efficacy. The main barriers were fear of HIV disclosure and stigma and lack of social support, male involvement, self-efficacy, and agency. Under Option B+, women learn about their HIV status and start lifelong ART on the same day, before they have a chance to talk to their husbands or families. Respondents explained that very few husbands accompanied their wives to the clinic, because they felt it was a female space and were worried that others would think their wives were controlling them. Many respondents said women fear disclosing, because they fear HIV stigma as well as the risk of divorce and loss of economic support. If women do not disclose, it is difficult for them to participate in PMTCT in secret. If they do disclose, they must abide by their husbands' decisions about their PMTCT participation, and some husbands are unsupportive or actively discouraging. To improve PMTCT participation, Ministries of Health should use evidence-based strategies to address HIV stigma, challenges related to disclosure, insufficient social support and male involvement, and underlying gender inequality.

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.

Alcohol, Substance Use and Psychosocial Competence of Adolescents in Selected Secondary Schools in Uganda: A Cross Sectional Survey

Aims

1) To determine the nature and extent of alcohol and substance use and 2) To describe the relationship between alcohol use and psychosocial competence among secondary school youths in Northern and Central Uganda.

Study Design

This was a cross-sectional study.

Place and Duration of study

Departments of Mental Health, Gulu University (Northern Uganda) and Department of Psychiatry, Makerere University College of Health Sciences (Central Uganda) between September 2011 and April 2012.

Methodology

Four (4) and eight (8) secondary schools located in the rural and urban areas of Gulu and Kampala districts respectively were randomly selected to participate in the survey. A total of 3,200 students aged 12 to 24 years were recruited by proportionate multistage sampling. Data was collected using a socio-demographic questionnaire that included questions about nature and frequency of alcohol and substance use. A pre-tested self-administered survey questionnaire with scales to measure components of psychosocial competence (PSC) was administered. Data was entered in Epidata, and exported to SPSS version 16.0 for analysis. Psychosocial competence was classified as high or low depending on the responses in the sub-scales of decision making, self efficacy, empathy, emotional awareness, coping with stress and emotions, and accurate self-assessment and self-confidence.

Results

A total of 2,902 questionnaires comprising of 2,502, (86.2%) from Kampala district and 400 (13.8%)) from Gulu district were analyzed. Male to female ratio was 1:1 with an age range of 12 to 24 years and a mean of 16.5. About 70.1% had ever used alcohol and substances. Only 39.1% used substances regularly. The commonest substance used was alcohol (23.3%), followed by kuber (10.8%), khat (10.5%), aviation fuel (10.1%), cannabis (9.2%) and cigarettes (5.9%). Respondents from the Gulu district were twice more likely to use all substances. Users and regular users from the North Northern Uganda had lower psychosocial competence. Factors significantly associated with non-use of alcohol were high levels of self-confidence, non-use of cannabis and kuber and age. In the alcohol user groups, a high level of coping was associated with discontinued and experimental use of drugs of abuse.

Conclusion

More than two-thirds (70.1%) of young people in this study had ever used substances of abuse only once and slightly over a third had used it regularly. From the perspectives of service provision, mental health promotion and prevention of illicit substance use, school mental health programmes that target both non-users and users are recommended.

Gaps and gains from engaging districts stakeholders for community-based health professions education in Uganda: a qualitative study

Community-based education research and service (COBERS) is a brand of community-based education that has been adopted by the Medical Education and Service for All Ugandans consortium. The COBERS programme is aimed at equipping students in health professional education with the knowledge, attitudes and skills required to provide appropriate health care services. For sustainability purposes, the health professional training institutions have made efforts to involve various stakeholders in the implementation of the programme. However, the actual engagement process and outcome of such efforts have not been documented. This paper documents gaps and gains made in engaging district stakeholders for community-based education. Key informant interviews, focus group discussions and document review were used to collect data. Atlas.ti, computer software for qualitative data was used to aid analysis. The analysis revealed that the adopted engagement model has registered some gains including increased awareness among district leaders about potential opportunities offered by COBERS such as boosting of human resources at health facilities, opportunities for professional development for health care workers at health facilities, and establishment of linkages between prospective employees and employers. However, the engagement model left some gaps in terms of knowledge, awareness and ownership of the programme among some sections of stakeholders. The apparent information gap about the programme among district stakeholders, especially the political leadership, may hinder concerted partnership. The findings highlight the need for health professional education institutions to broaden the scope of actively engaged stakeholders with the district level.

Psychological reactions of adolescent schoolgirls to human papillomavirus vaccination in western Uganda: A comparative cross-sectional study

Schoolgirls in two Ugandan districts were recently vaccinated against human papillomavirus that causes most cervical cancer. This cross-sectional comparative study used mixed research methods to assess influence of human papillomavirus vaccination on adolescents’ worrisome thoughts about being vaccinated and psychological distress. Vaccination predicted worrisome thoughts among the recently vaccinated (adjusted odds ratio: 1.65, confidence interval: 1.13–2.41; p = 0.01). Vaccination predicted distress (1.75, confidence interval: 1.09–2.82; p = 0.02), particularly among those recently vaccinated (1.92, confidence interval: 1.27–2.89; p = 0.001) and those who experienced worrisome thoughts (1.80, confidence interval: 1.06–3.07; p = 0.02). Parental communication mitigated distress (0.50, confidence interval: 0.35–0.72; p = 0.000).

Is the glass half full or half empty? A qualitative exploration on treatment practices and perceived barriers to biomedical care for patients with nodding syndrome in post-conflict northern Uganda

Background

Nodding syndrome has increasingly become an issue of public health concern internationally. The etiology of the disorder is still unknown and there are yet no curative treatments. We explored perceptions about treatment practices and barriers to health seeking for nodding syndrome in Pader and Kitgum districts in northern Uganda in order to provide data necessary for informing policy on treatment adherence and rehabilitations.

Methods

We used focus group discussions and individual interviews to gain deep insights into help-seeking and treatment practices for nodding syndrome. Purposive sampling was used to identify information-rich participants that included village health teams, community members not directly affected with nodding syndrome, district leaders, healthcare professionals, and caregivers of children affected with nodding syndrome. We used qualitative content analysis to analyze data and presented findings under distinct categories and themes.

Results

Caregivers and communities sought care from multiple sources including biomedical facilities, traditional healers, traditional rituals from shrines, and spiritual healing. Nodding syndrome affected children reportedly have showed no enduring improvement with traditional medicines, traditional rituals, and prayers. A substantial minority of participants reported minimal improvements in symptoms of convulsions with use of western medicines. Challenges involved in health seeking included; (1) health system factors e.g. long distances to facilities, frequent unavailability of medicines, few healthcare providers, and long waiting times; (2) contextual and societal challenges e.g. lack of money for transport and medical bills, overburdening nature of the illness that does not allow time for other activities, and practical difficulties involved in transporting the physically deformed and mentally retarded children to the health facilities.

Conclusions

Help-seeking for nodding syndrome is pluralistic and include use of traditional and biomedical practices. Western medicines admittedly showed at least short term control on nodding syndrome symptoms, especially convulsions and led in a few cases to regain of functional abilities. However, multiple barriers hinder health seeking and interfere with adherence to biomedical treatments. Regarding cure, there are hitherto no treatments participants perceive cure nodding syndrome.

Qualitative study of the influence of antidepressants on the psychological health of patients on antiretroviral therapy in Uganda

The study set out to explore how HIV-positive individuals conceptualise and describe depression and its manifestation in their lives, and how this may change over time in the context of antiretroviral therapy (ART) and antidepressant treatment. We conducted in-depth interviews using a semi-structured interview guide with 26 adult HIV-positive clients receiving ART in Uganda. We asked the participants to describe their depression and its impact on their general health, physical functioning and psychological wellbeing, as well as the influences of receiving ART or antidepressant treatment. Although depressive experience among the patients was largely described in terms of criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), some of the symptoms used to describe depression, such as 'thinking too much' or worrisome thoughts, did not fit into the DSM-IV criteria. The participants attributed their depression to news of the HIV diagnosis, a fear of dying, the potential socioeconomic consequences of their HIV infection on their family, ART side-effects and continued bad health. Their subjective reports indicated that the treatment of depression with antidepressants had made a positive impact on their general and psychological health. These findings highlight the need for models of HIV care that integrate mental health services and promote the diagnosis and treatment of depression in culturally sensitive ways so as to improve the quality of life and health outcomes for clients. However, keeping the particular study design in mind, these findings should be interpreted as preliminary.

Mental health literacy among secondary school students in North and Central Uganda: a qualitative study

OBJECTIVES

There has been limited effort to explore young people's perceptions about mental illness in Uganda. For mental health programs targeting young people to succeed, it is important to incorporate their understanding of mental illness, their perceptions about causes of mental illness and their attitudes about mentally ill people. The objective of this study was to explore the mental health of young people in secondary schools in Northern and Central Uganda.

SUBJECTS AND METHODS

This was a qualitative study where 24 focus group discussions (FGDs) were held with young people in secondary schools. Respondents aged 14-24 years were purposively selected from 4 secondary schools in the two regions. During the FGDs, young people's perceptions and understanding of three areas listed below were explored: meaning of mental health/mental illness; causes of mental illness and attitudes toward mental illness. Data management and analysis was done with the help of Atlas.ti, a-qualitative-analysis software. Thematic analysis approach was employed.

RESULTS

FGD participants used concepts like a sound and normal mind, right thinking, normal behavior and normal thoughts to define mental health. Mental illness on the other hand was defined as loss of sense of reality, malfunctioning of the brain, impaired thinking and bizarre behavior. Young people attributed mental illness to; substance abuse (Marijuana, alcohol), witnessing traumatic events (seeing ones your relatives being killed, or being forced to participate in killing-frequently mentioned by young people in Northern Uganda); witch craft, effect of physical illness e.g. HIV/epilepsy, thinking too much, accidents and genetic explanations. They had mixed opinions about interacting with mentally ill individuals. Unpredictability and dangerousness were known to be a recurrent theme among people with negative views about mentally ill. Nonetheless, some FGD participants believed that the level of interaction with mentally ill persons depended on familiarity with mental illness and the severity of the symptoms. Similarly, there were mixed opinions regarding mental illness and work. Three main clusters of responses emerged. These were: i) "mentally ill people should not work"; ii) "mentally ill people should work but.."; iii) "mentally ill people should work like everyone else".

CONCLUSIONS

Findings point to key gaps in the knowledge and attitudes of young people that need to be targeted by young-people-focused-interventions for mental health. In order for such interventions to succeed, young people must be able to recognize and respond appropriately to signs of distress, reduced functioning, and other early signs of poor mental health.

Effect of school-based human papillomavirus (hpv) vaccination on adolescent girls' knowledge and acceptability of the HPV vaccine in Ibanda District in Uganda

From 2008 to 2011, schoolgirls were vaccinated against HPV in two districts in Uganda following sensitization. This study assessed girls' knowledge of cervical cancer and HPV vaccine, and their acceptance of future vaccination of friends and hypothetical daughters. The cross-sectional, mixed methods comparative study was conducted in two districts. Univariate, bivariate, logistic regression and thematic analyses were done. HPV vaccination was positively associated with knowledge (Crude OR: 5.31, CI: 3.19-8.86; p = 0.000); but knowledge (Adjusted OR: 1.13, CI: 0.56-2.28; p = 0.73) and HPV vaccination (Adjusted OR: 0.92, CI: 0.16-5.36; p = 0.93) did not predict vaccine acceptability. Seemingly important motivations for vaccine acceptance were: its role in cancer prevention and advancement of reproductive health, minimal side effects, and positive peer role models. Major deterrents to vaccine acceptance were: rumours and misconceptions about possible side effects, perceived inadequate information about vaccine, and fear of side effects.

Barriers to biomedical care and use of traditional medicines for treatment of cervical cancer: an exploratory qualitative study in northern Uganda

Use of traditional medicines for treatment of cancers has increased worldwide. We used a qualitative approach to explore barriers to biomedical care and reasons for use of traditional medicines for the treatment of cervical cancer in Gulu, northern Uganda. We carried out 24 focus group discussions involving men and women aged 18-59 years. We employed content analyses technique in data analysis. Traditional medicines were used mainly due to barriers to biomedical care for cervical cancer. The barriers included health system factors, for example long distances to health facilities and unavailability of medicines; health workers' factors, for example negative attitudes towards patients and demands for bribes; individual patient's factors, for example inability to pay for medical care; and socio-cultural beliefs about superiority of traditional medicines and perceived greater privacy in accessing traditional healers. Barriers to biomedical care and community beliefs in the effectiveness of traditional medicines encourage use of traditional medicines for treatment of cervical cancer but might hinder help-seeking at biomedical facilities. There is need for targeted culturally sensitive awareness campaign to promote effectiveness of modern medicine and to encourage cautious use of traditional medicines in the treatment of cervical cancer.

The role of psycho-education in improving outcome at a general hospital psychiatry clinic in Uganda

OBJECTIVE

While psychoeducation has been shown to positively affect outcomes in psychiatric disorders, its utility has been little studied in developing countries. The current study sought to examine the role of psychoeducation at a general psychiatric outpatient clinic in Kampala, Uganda in improving clinic attendance, treatment adherence, and clinical outcomes.

METHOD

A prospective case-control study using a quasi-experimental design was conducted in 117 patients suffering various psychiatric disorders. Participants were recruited for two months and then followed for a further three months after recruitment ended. Participants in the intervention group received formalized psychoeducation sessions at each clinic visit in addition to the usual psychiatric evaluation and care. Participants in the control group received the usual clinical care. Measured outcomes were knowledge of mental illness, compliance with medications and follow-up, and Clinical Global Impression (CGI).

RESULTS

The groups did not differ with respect to sociodemographic characteristics or attendance at scheduled follow-up visits. Both groups significantly improved on the CGI, but with no significant difference between the groups. However, the intervention group was more likely to adhere to medication, and their knowledge of mental illness was significantly higher at follow-up.

CONCLUSION

These data suggest that psychoeducation is a beneficial mental health intervention in a developing country that may increase compliance with medication and result in greater knowledge of mental illness. However, other factors such as distance from a centralized clinic or cost of treatment may impact outcomes, including attendance at scheduled follow-up visits.

Effect of brief training on reliability and applicability of Global Assessment of functioning scale by Psychiatric clinical officers in Uganda

BACKGROUND

The Global Assessment of Functioning (GAF) is the standard method and an essential tool for representing a clinician's judgment of a patient's overall level of psychological, social and occupational functioning. As such, it is probably the single most widely used method for assessing impairment among the patients with psychiatric illnesses.

OBJECTIVE

To assess the effects of one-hour training on application of the GAF by Psychiatric Clinical Officers' in a Ugandan setting.

METHOD

Five Psychiatrists and five Psychiatric Clinical Officers (PCOs) or Assistant Medical Officers who hold a 2 year diploma in Clinical Psychiatry were randomly selected to independently rate a video-recorded psychiatric interview according to the DSM IV-TR. The PCOs were then offered a one-hour training on how to rate the GAF scale and asked to rate the video case interview again. All ratings were assigned on the basis of past one year, at admission and current functioning. Interclass correlations (ICC) were computed using two-way mixed models.

RESULTS

The ICC between the psychiatrists and the PCOs before training in the past one year, at admission and current functioning were +0.48, +0.51 and +0.59 respectively. After training, the ICC coefficients were +0.60, +0.82 and +0.83.

CONCLUSION

Brief training given to PCOs improved the applications of their ratings of GAF scale to acceptable levels. There is need for formal training to this cadre of psychiatric practitioners in the use of the GAF.

Naturalistic outcome of treatment of psychosis by traditional healers in Jinja and Iganga districts, Eastern Uganda - a 3- and 6 months follow up

OBJECTIVE

To determine the naturalistic outcome of treatment of psychosis by traditional healers in Jinja and Iganga districts of Eastern Uganda.

METHOD

A cohort of patients with psychosis receiving treatment from traditional healers' shrines were recruited between January and March 2008 and followed up at three and six months. The Mini International Neuropsychiatry Interview (MINI Plus) was used for making specific diagnosis at the point of contact. For specific symptoms, Positive and Negative Symptom Scale (PANSS), Young Mania Rating Scale (YMRS) and Montgomery Asberg Depression Rating Scale (MADRS) were used to measure severity of schizophrenia, mania and psychotic depression, respectively. The Clinical Global Impression (CGI) and Global Assessment of Functioning (GAF) were used for objective assessments. The Compass Mental Health Index measured well being. Mean scores of the scales were computed using one way ANOVA for independent samples. Associations between outcome and categorical variables were examined at bivariate and multivariate levels.

RESULTS

All the symptom scales had a percentage reduction of more than 20% at three and six months follow up. The differences between the mean scores of the scales at baseline and 3 months, baseline and 6 months, and 3 and 6 months were all significant (P < 0.0001). The post test for pair wise comparisons, the Tukey HSD (Honestly Significant Difference) test was also all significant at P < 0.01 except for MADRS where there was no significant difference between 3 and 6 months for depression severity. Over 80% of the participants used biomedical services for the same symptoms in the study period. At 3 months follow up, patients who combined treatment were less likely to be cases (P = 0.002; OR 0.26 [0.15-0.58]), but more likely to be cases at 6 months follow up (P = 0.020; OR 2.05 [1.10-3.189]). Being in debt was associated with caseness both at 3 and 6 months.

CONCLUSION

This study suggests that there may be some positive effects for patients with psychosis who combine both biomedical services and traditional healing. Further research in the area of naturalistic outcome of traditional healing is necessary.

Gender-based profiling of Quality of Life (QOL) of primary health care (PHC) attendees in central Uganda: a cross sectional analysis

OBJECTIVE

To analyze gender differences in QOL of patients presenting at PHC centres and to identify the socio-demographic variables associated with poor QOL.

METHODS

This was a cross-sectional study. Consecutive adult patients at outpatient departments of three PHC centres were eligible. Those selected were interviewed using the WHOQOL-BREF, a 26-item questionnaire generating four domain scores of physical, psychological, environment and social relationships.

RESULTS

The study had 446 respondents aged 18-84 years. Female parents significantly performed poorly on the physical health domain (OR 2.47: 95 % CI: 1.32 - 4.61). Respondents reported comparable scores on the 3 WHOQOL-BREF domains, except on poor physical health where being a parent had a positive association (OR 2.12; 95% CI: 1.27 - 3.55). Belonging to an age-range of 18-29 years had a positive association with poor physical health (OR 1.74; 95% CI: 1.13 - 2.68).

CONCLUSION

Generally, women reported poorer physical health. Health workers need orientation and training to appreciate the role of gender in health care. There is need to appreciate the complexities affecting QOL of women that are physically ill. Interventions aimed at improving patients' QOL at PHC centres should take a gender-based perspective that recognizes the greater vulnerability of women to poor physical health.

Explanatory models and help-seeking behavior: Pathways to psychiatric care among patients admitted for depression in Mulago hospital, Kampala, Uganda

In this article, the authors present findings from a qualitative study exploring how people diagnosed with depression conceptualize their condition and how their conceptualization shaped their efforts to seek help. They used an interview guide based on an explanatory model framework for data collection. Four major themes emerged from the analysis: (a) somatization, social meaning of illness, and help seeking; (b) meaning and perceived consequences of illness; (c) How did I get here? Making sense of psychiatric admission; and (d) variations in the causal attribution and the role of significant others in help seeking. Somatization of emotional problems, variations in causal attribution between patients and their significant others, the nature of the available health care system, and burden of infectious disease complicate access to care. These findings suggest the need to raise the awareness of primary care providers on how to recognize and help people with depression appropriately in this setting.

Lay concepts of depression among the Baganda of Uganda: a pilot study

The literature indicates that although depression is highly prevalent, it is rarely recognized as such. The aim was to test the use of case vignettes in exploring the explanatory models of various subtypes of depression, in six individual interviews, and four focus-group discussions. Depressive symptoms presented in these vignettes seem to be conceptualized as a problem related to cognition (thinking too much) rather than emotion (sadness) and the resulting condition is referred to as 'illness of thoughts.' Worrisome thoughts resulting from various socioeconomic problems are seen as important aetiological factors for the illness of thoughts and require no medication as it is believed that there is no medication for thoughts. There are culturally accepted ways of dealing with and healing the condition. Once illness becomes recurrent or chronic, other explanations about causes and a different course of action have to be considered. Further exploration of the relationship between thoughts and emotions among the Baganda may be an important avenue for further research.