“Like a doctor, like a brother”: achieving competence amongst lay health workers delivering community-based rehabilitation for people with schizophrenia in Ethiopia

BackgroundThere are gaps in our understanding of how non-specialists, such as lay health workers, can achieve core competencies to deliver psychosocial interventions in low- and middle-income countries.MethodsWe conducted a 12-month mixed-methods study alongside the Rehabilitation Intervention for people with Schizophrenia in Ethiopia (RISE) pilot study. We rated a total of 30 role-plays and 55 clinical encounters of ten community-based rehabilitation (CBR) lay workers using an Ethiopian adaptation of the ENhancing Assessment of Common Therapeutic factors (ENACT) structured observational rating scale. To explore factors influencing competence, six focus group discussions and four in-depth interviews were conducted with 11 CBR workers and two supervisors at three time-points. We conducted a thematic analysis and triangulated the qualitative and quantitative data.Results There were improvements in CBR worker competence throughout the training and 12-month pilot study. Therapeutic alliance competencies (e.g., empathy) saw the earliest improvements. Competencies in personal factors (e.g., substance use) and external factors (e.g., assessing social networks) were initially rated lower, but scores improved during the pilot. Problem-solving and giving advice competencies saw the least improvements overall. Multimodal training, including role-plays, field work and group discussions, contributed to early development of competence. Initial stigma towards CBR participants was reduced through contact. Over time CBR workers occupied dual roles of expert and close friend for the people with schizophrenia in the programme. Competence was sustained through peer supervision, which also supported wellbeing. More intensive specialist supervision was needed. ConclusionIt is possible to equip lay health workers with the core competencies to deliver a psychosocial intervention for people with schizophrenia in a low-income setting. A prolonged period of work experience is needed to develop advanced skills such as problem-solving. A structured intervention with clear protocols, combined with peer supervision to support wellbeing, is recommended for good quality intervention delivery. Repeated ENACT assessments can feasibly and successfully be used to identify areas needing improvement and to guide on-going training and supervision

Movement disorders in neuroleptic-naïve patients with schizophrenia spectrum disorders

Abstract Background Spontaneous Movements Disorders (SMDs) or dyskinetic movements are often seen in patients with schizophrenia and other psychotic disorders, and are widely considered to be adverse consequences of the use of antipsychotic medications. Nevertheless, SMDs are also observed in the pre-neuroleptic ear and among patients who were never exposed to antipsychotic medications. The aim of this study was to determine the extent of SMDs among antipsychotic-naïve patients in a low income setting, and to evaluate contextually relevant risk factors. Methods The study was a cross-sectional facility-based survey conducted at a specialist psychiatric hospital in Addis Ababa, Ethiopia. Consecutive consenting treatment-naïve patients with a diagnosis of schizophrenia, schizoaffective disorder and schizophreniform disorder contacting services for the first time were assessed using the Simpson-Angus Rating Scale (SAS) and the Abnormal Involuntary Movement Scale (AIMS) to evaluate the presence of SMDS. Scale for the Assessment of Negative Symptoms (SANS) and Scale for the Assessment of Positive Symptoms (SAPS) were administered to evaluate negative and positive symptom profiles respectively. Body mass index (BMI) was used as a proxy measure for nutritional status. Result Sixty-four patients, 67.2% male (n = 43), with first contact psychosis who met the DSM-IV-TR criteria for schizophrenia (n = 47), schizophreniform disorder (n = 5), and schizoaffective disorder (n = 12) were assessed over a two month study period. Seven patients (10.9%) had SMDs. BMI (OR = 0.6, 95% CI = 0.40, 0.89; p = 0.011) and increasing age (OR = 1.10; 95% CI = 1.02, 1.20; p = 0.017) were associated with SMD. Conclusions This finding supports previous suggestions that abnormal involuntary movements in schizophrenia and other psychotic disorders may be related to the pathophysiology of psychotic disorders and therefore cannot be attributed entirely to the adverse effects of neuroleptic medication

Magnitude of paternal postpartum psychological distress and associated factors in Addis Ababa, Ethiopia: a facility-based cross-sectional study

Abstract Background The psychological distress of fathers in the postpartum period can have adverse effects on the well-being of the family and the newborn’s development in particular. However, fathers’ mental health throughout the postpartum has remained understudied and clinically overlooked in many developing countries, including Ethiopia. This study aims to assess the prevalence of psychological distress among fathers in the postpartum period and to examine the associated factors in an Ethiopian population. Methods A facility-based, cross-sectional study was conducted at Tikur Anbessa Specialized Hospital (TASH) and Gandhi Memorial Hospital (GMH) in Addis Ababa, Ethiopia. A systematic sampling method was employed to include 280 fathers whose partners gave birth 6 to 8 weeks before the interview. Psychological distress was assessed using a validated Amharic version of the Kessler Psychological Distress Scale (K10) through a telephone interview. The collected data was analyzed using SPSS version 26. Descriptive statistics were used to summarize the data. Multivariable logistic regression was run to determine the variables associated with paternal postpartum psychological distress (K10 total score ≥ 7, a validated cut-off score in an urban Ethiopian setting), and odds ratio with 95% confidence intervals were obtained. A two-tailed p-value < 0.05 was considered for statistical significance. Results About one-fifth of the fathers endorsed having distress symptoms during the postpartum period. Those with lower income (AOR = 11.31, 95% CI:  4.10, 31.15), unintended pregnancy (AOR = 3.96, 95% CI: 1.02, 15.46), poor social support (AOR =3.28 95% CI: 1.43, 7.50), poor infantile health (AOR = 8.20, 95% CI: 2.35, 28.66)  and maternal postpartum distress (AOR = 12.10,  95% CI: 3.15, 46.48) had significantly higher odds of having paternal postpartum distress. Conclusions Paternal postpartum distress was present in one-fifth of the fathers included in this study. This calls for due attention and efforts for early detection of those at risk of paternal distress and the development of interventions that consider their specific needs

Developing interventions to improve detection of depression in primary healthcare settings in rural Ethiopia

Background The poor detection of depression in primary healthcare (PHC) in low- and middle-income countries continues to threaten the plan to scale up mental healthcare coverage. Aims To describe the process followed to develop an intervention package to improve detection of depression in PHC settings in rural Ethiopia. Method The study was conducted in Sodo, a rural district in south Ethiopia. The Medical Research Council's framework for the development of complex interventions was followed. Qualitative interviews, observations of provider–patient communication, intervention development workshops and pre-testing of the screening component of the intervention were conducted to develop the intervention. Results A multicomponent intervention package was developed, which included (a) manual-based training of PHC workers for 10 days, adapted from the World Health Organization's Mental Health Gap Action Programme Intervention Guide, with emphasis on depression, locally identified depressive symptoms, communication skills, training by people with lived experience and active learning methods; (b) screening for culturally salient manifestations of depression, using a four-item tool; (c) raising awareness among people attending out-patient clinics about depression, using information leaflets and health education; and (d) system-level interventions, such as supportive supervision, use of posters at health facilities and a decision support mobile app. Conclusions This contextualised, multicomponent intervention package may lead to meaningful impact on the detection of depression in PHC in rural Ethiopia and similar settings. The intervention will be pilot tested for feasibility, acceptability and effectiveness before its wider implementation

Cross-cultural equivalence of the Kessler Psychological Distress Scale (K10) across four African countries in a multi-national study of adults

The Kessler Psychological Distress Scale (K10) has been widely used to screen psychological distress across many countries. However, its performance has not been extensively studied in Africa. The present study sought to evaluate and compare measurement properties of the K10 across four African countries: Ethiopia, Kenya, Uganda, and South Africa. Our hypothesis is that the measure will show equivalence across all.Data are drawn from a neuropsychiatric genetic study among adult participants (N = 9179) from general medical settings in Ethiopia (n = 1928), Kenya (n = 2556), Uganda (n = 2104), and South Africa (n = 2591). A unidimensional model with correlated errors was tested for equivalence across study countries using confirmatory factor analyses and the alignment optimization method. Results displayed 30 % noninvariance (i.e., variation) for both intercepts and factor loadings across all countries. Monte Carlo simulations showed a correlation of 0.998, a good replication of population values, indicating minimal noninvariance, or variation. Items “so nervous,” “lack of energy/effortful tasks,” and “tired” were consistently equivalent for intercepts and factor loadings, respectively. However, items “depressed” and “so depressed” consistently differed across study countries (R2 = 0) for intercepts and factor loadings for both items.The K10 scale likely functions equivalently across the four countries for most items, except “depressed” and “so depressed.” Differences in K10 items were more common in Kenya and Ethiopia, suggesting cultural context may influence the interpretation of some items and the potential need for cultural adaptations in these countries