Roles and effectiveness of lay community health workers in the prevention of mental, neurological and substance use disorders in low and middle income countries: a systematic review.

BACKGROUND: It has been suggested that lay community health workers (LHWs) could play a role in primary and secondary prevention of Mental, Neurological and Substance use (MNS) disorders in low resourced settings. We conducted a systematic review of the literature with the aim of assessing the existing evidence base for the roles and effectiveness of LHWs in primary and secondary prevention of MNS disorders in low and middle income countries (LMICs). METHODS: Internet searches of relevant electronic databases for articles published in English were done in August 2011 and repeated in June 2013. Abstracts and full text articles were screened according to predefined criteria. Authors were asked for additional information where necessary. RESULTS: A total of 15 studies, 11 of which were randomised, met our inclusion criteria. Studies were heterogeneous with respect to interventions, outcomes and LHWs' roles. Reduction in symptoms of depression and improved child mental development were the common outcomes assessed. Primary prevention and secondary prevention strategies were carried out in 11 studies and 4 studies respectively .There was evidence of effectiveness of interventions however, most studies (n = 13) involved small sample sizes and all were judged to have an unclear or high risk of bias. CONCLUSIONS: LHWs have the potential to provide psychosocial and psychological interventions as part of primary and secondary prevention of MNS disorders in LMICs, but there is currently insufficient robust evidence of effectiveness of LHW led preventive strategies in this setting. More studies need to be carried out in a wider range of settings in LMICs that control for risk of bias as far as possible, and that also collect indicators relating to the fidelity and cost of interventions

An exploration of caregiver burden for children with nodding syndrome (lucluc) in Northern Uganda

BACKGROUND: Caregivers of patients with chronic illnesses are often uncompensated for work that is physically demanding, time consuming and emotionally and economically draining. This is particularly true for caregivers of children with nodding syndrome, an emergent neurological disorder of unknown etiology in resource poor settings in Africa. We aimed to explore perceptions of caregivers regarding challenges that a typical caregiver faces when caring for a child with nodding syndrome. METHODS: We used a qualitative exploratory study design with focus group discussions and in-depth interviews to collect data. We analyzed data using the qualitative analysis software package of NVivo and thematic query building. RESULTS: Emergent themes centered on burden of care with emotional agony as the most prominent. Subthemes reflecting the burden of care giving included child and caregiver safety concerns, burnout, social isolation and rejection, and homicidal ideation. Caregivers also complained of physical and financial constraints associated with the care of children with nodding syndrome. CONCLUSIONS: The findings point to a high burden of care for caregivers of children with nodding syndrome and suggests the need to incorporate community-based psychosocial and mental health care services for the caregivers of affected children into the national health system response

Strengthening care in collaboration with people with lived experience of psychosis in Uganda (SCAPE-U): A protocol for a cluster randomized controlled feasibility trial

BackgroundMental health services are most effective and equitable when designed, delivered, and evaluated in collaboration with People With Lived Experience of mental health conditions (PWLE). However, PWLE are rarely involved in health systems strengthening, and when they are, it is limited to specific components (e.g., peer helpers) rather than multi-tiered collaboration in the full continuum of home to community to facility based services. Moreover, programs that do involve PWLE typically involve people with a history of substance use conditions or common mental disorders. The collaboration of People With Lived Experience of Psychosis (PWLP) is especially rare. Therefore, we aim to explore the feasibility of collaborating with PWLP for health systems strengthening in this feasibility trial.MethodsThis pilot cluster randomized controlled feasibility trial will randomize 36 health facilities to a standard implementation arm where primary care workers (PCW) will be trained by mental health specialists (control), or a collaborative care model with added co-facilitation of PCW trainings by PWLP as well as home visits by PWLP to service users (intervention). The intervention condition is referred to as “Strengthening CAre in collaboration with People with lived Experience of psychosis in Uganda” (SCAPE-U). The 36 health facilities will be distributed across six clusters with three clusters in each arm. PhotoVoice will be used to train PWLP to be co-facilitators of PCW training and provide home-based support to service users in the intervention arm. The primary outcomes of the feasibility trial will be the feasibility, acceptability, and safety of collaborating with PWLP. Data will also be collected on individual-level outcomes for PCWs, and service users to inform the feasibility of data collection and obtain effect size estimates.DiscussionFindings from this feasibility trial will inform a fully powered trial to evaluate the benefits of an implementation strategy characterized by collaboration with PWLP across the continuum of healthcare services

A 'hidden problem': Nature, prevalence and factors associated with sexual dysfunction in persons living with HIV/AIDS in Uganda.

BACKGROUND: We conducted a clinic-based cross-sectional survey among 710 people living with HIV/AIDS in stable 'sexual' relationships in central and southwestern Uganda. Although sexual function is rarely discussed due to the private nature of sexual life. Yet, sexual problems may predispose to negative health and social outcomes including marital conflict. Among individuals living with HIV/AIDS, sexual function and dysfunction have hardly been studied especially in sub-Saharan Africa. In this study, we aimed to determine the nature, prevalence and factors associated with sexual dysfunction (SD) among people living with HIV/AIDS (PLWHA) in Uganda. METHODS: We conducted a clinic based cross sectional survey among 710 PLWHA in stable 'sexual' relationships in central region and southwestern Uganda. We collected data on socio-demographic characteristics (age, highest educational attainment, religion, food security, employment, income level, marital status and socio-economic status); psychiatric problems (major depressive disorder, suicidality and HIV-related neurocognitive impairment); psychosocial factors (maladaptive coping styles, negative life events, social support, resilience, HIV stigma); and clinical factors (CD4 counts, body weight, height, HIV clinical stage, treatment adherence). RESULTS: Sexual dysfunction (SD) was more prevalent in women (38.7%) than men (17.6%) and majority (89.3% of men and 66.3% of women) did not seek help for the SD. Among men, being of a religion other than Christianity was significantly associated with SD (OR = 5.30, 95%CI 1.60-17.51, p = 0.006). Among women, older age (> 45 years) (OR = 2.96, 95%CI 1.82-4.79, p<0.01), being widowed (OR = 1.80, 95%CI 1.03-3.12, p = 0.051) or being separated from the spouse (OR = 1.69, 95% CI 1.09-2.59, p = 0.051) were significantly associated with SD. Depressive symptoms were significantly associated with SD in both men (OR = 0.27, 95%CI 0.74-0.99) and women (OR = 1.61, 95%CI 1.04-2.48, p = 0.032). In women, high CD4 count (OR = 1.42, 95% CI 1-2.01, p = 0.05) was associated with SD. CONCLUSION: Sexual dysfunction has considerable prevalence among PLWHA in Uganda. It is associated with socio-demographic, psychiatric and clinical illness factors. To further improve the quality of life of PLWHA, they should be screened for sexual dysfunction as part of routine assessment

Community acceptability of use of rapid diagnostic tests for malaria by community health workers in Uganda

<p>Abstract</p> <p>Background</p> <p>Many malarious countries plan to introduce artemisinin combination therapy (ACT) at community level using community health workers (CHWs) for treatment of uncomplicated malaria. Use of ACT with reliance on presumptive diagnosis may lead to excessive use, increased costs and rise of drug resistance. Use of rapid diagnostic tests (RDTs) could address these challenges but only if the communities will accept their use by CHWs. This study assessed community acceptability of the use of RDTs by Ugandan CHWs, locally referred to as community medicine distributors (CMDs).</p> <p>Methods</p> <p>The study was conducted in Iganga district using 10 focus group discussions (FGDs) with CMDs and caregivers of children under five years, and 10 key informant interviews (KIIs) with health workers and community leaders. Pre-designed FGD and KII guides were used to collect data. Manifest content analysis was used to explore issues of trust and confidence in CMDs, stigma associated with drawing blood from children, community willingness for CMDs to use RDTs, and challenges anticipated to be faced by the CMDs.</p> <p>Results</p> <p>CMDs are trusted by their communities because of their commitment to voluntary service, access, and the perceived effectiveness of anti-malarial drugs they provide. Some community members expressed fear that the blood collected could be used for HIV testing, the procedure could infect children with HIV, and the blood samples could be used for witchcraft. Education level of CMDs is important in their acceptability by the community, who welcome the use of RDTs given that the CMDs are trained and supported. Anticipated challenges for CMDs included transport for patient follow-up and picking supplies, adults demanding to be tested, and caregivers insisting their children be treated instead of being referred.</p> <p>Conclusion</p> <p>Use of RDTs by CMDs is likely to be acceptable by community members given that CMDs are properly trained, and receive regular technical supervision and logistical support. A well-designed behaviour change communication strategy is needed to address the anticipated programmatic challenges as well as community fears and stigma about drawing blood. Level of formal education may have to be a criterion for CMD selection into programmes deploying RDTs.</p

Belonging home: capabilities, belonging and mental health recovery in low resourced settings

Abstract There are significant barriers to the development of a ‘balanced model’ of mental health in low-income countries. These include gaps in the evidence base on effective responses to severe mental health issues and what works in the transition from hospital to home, and a low public investment in primary and community care. These limitations were the drivers for the formation of the non-government organization, YouBelong Uganda (YBU), which works to contribute to the implementation of a community-based model of mental health care in Uganda. This paper overviews an intervention protocol developed by YBU, which is a combined model of parallel engagement with the national mental hospital in Kampala, Uganda, movement of ‘ready for discharge’ patients back to their families and communities, and community development. The YBU programme is theoretically underpinned by a capabilities approach together with practical application of a concept of ‘belonging’. It is an experiment in implementation with hopes that it may be a positive step towards the development of an effective model in Uganda, which may be applicable in other countries. Finally, we discuss the value in joining ideas from social work, sociology, philosophy, public health and psychiatry into a community mental health ‘belonging framework’.</jats:p

Psychological distress and adherence to highly active anti-retroviral therapy (HAART) in Uganda: A pilot study.

Background: Mental health related risk factors for non-adherence to highly active anti-retroviral therapy (HAART) have not been investigated in Uganda and yet adherence is critical to the success of the current scale up in the provision of HAART to HIV positive individuals in rural areas of Uganda. Objective: To determine whether psychological distress is a risk factor for non-adherence to HAART among HIV positive individuals. Method: One hundred twenty-two HIV positive adult individuals receiving care from an Urban HIV clinic were enrolled in the study. Participants were screened for psychological distress with the Self Report Questionnaire (SRQ-20). Adherence was assessed using the self report method. Multivariate logistic regression analysis was used to determine whether psychological distress is a risk factor for non-adherence to HAART adjusting for various socio-demographic and clinical factors. Results: Psychological distress and living in isolation were significantly associated with non-adherence to HAART after adjusting for other demographic and clinical variables [OR=3.66, 95%CI (1.39 - 9.78) and OR=9.80, 95%CI (2.27 - 18.70)] respectively. Among HIV positive individuals who were receiving additional treatment for a mental disorder, psychological distress was not significantly associated with non-adherence to HAART [OR= 1.25, 95%CI (0.30 - 5.20)] Conclusion: Regular screening and management of psychological distress may prevent further complications in HIV positive individuals in Uganda

Psychological distress and adherence to highly active anti-retroviral therapy (HAART) in Uganda: A pilot study

Background: Mental health related risk factors for non-adherence to highly active anti-retroviral therapy (HAART) have not been investigated in Uganda and yet adherence is critical to the success of the current scale up in the provision of HAART to HIV positive individuals in rural areas of Uganda. Objective: To determine whether psychological distress is a risk factor for non-adherence to HAART among HIV positive individuals. Method: One hundred twenty-two HIV positive adult individuals receiving care from an Urban HIV clinic were enrolled in the study. Participants were screened for psychological distress with the Self Report Questionnaire (SRQ-20). Adherence was assessed using the self report method. Multivariate logistic regression analysis was used to determine whether psychological distress is a risk factor for non-adherence to HAART adjusting for various socio-demographic and clinical factors. Results: Psychological distress and living in isolation were significantly associated with non-adherence to HAART after adjusting for other demographic and clinical variables [OR=3.66, 95%CI (1.39 - 9.78) and OR=9.80, 95%CI (2.27 - 18.70)] respectively. Among HIV positive individuals who were receiving additional treatment for a mental disorder, psychological distress was not significantly associated with non-adherence to HAART [OR= 1.25, 95%CI (0.30 - 5.20)] Conclusion: Regular screening and management of psychological distress may prevent further complications in HIV positive individuals in Uganda

Mapping Services at Two Nairobi County Primary Health Facilities: Identifying Challenges and Opportunities in Integrated Mental Health Care as a Universal Health Coverage (UHC) Priority

Abstract Introduction: We describe a facility mapping exercise conducted in two low-income/primary health facilities in Kenya to identify available service resources, cadres, and developmental partners as well as existing barriers and facilitators in the delivery of mental health services in general and specifically for peripartum adolescents in primary health care. We have tried to embrace the principles of integrating mental health services in primary care and keeping WHO mhGAP in mind. Additionally, primary care facilities’ capacity is a major limiting factor for expanding universal health coverage in low- and middle-income countries. Method and Measures: This study utilized a qualitative evidence synthesis through semi-structured facility services mapping and stakeholder interviews. Services-related data was collected from two facility in-charges using the Nairobi City County Human Resource Health Strategy record forms. Additionally, we conducted 12 key informant interviews (KIIs) with and clinical officers (Clinicians at diploma level), Nurses, Community Health Assistants (CHAs), Prevention of Mother-to-child Transmission of HIV Mentor Mothers (PMTCTMs), around both general and adolescent mental health as well as psychosocial services they offered. Using the World Health Organization Assessments Instrument for Mental Health Systems (WHO-AIMS) as a guideline for the interview, all KII questions were structured to identify the extent of mental health integration in primary health care services. Interview transcripts were then systematically analyzed for common themes and discussed by the first three authors to eliminate discrepancies. Results: Our findings show that health care services centered around physical health were offered daily while the mental health services were offered weekly through specialist services by the Ministry of Health directly or non-governmental partner. Despite Health care workers being aware of the urgent need to integrate mental health services into routine care, they expressed limited knowledge about mental health disorders, lack of trained mental health personnel, the need for more significant funding and resources to provide mental health services, and promotion of CMHS to treat mental health conditions in the primary care setting. Our stakeholders underscored the urgency of integrating mental health treatment, prevention, and well-being promotive activities targeting adolescents especially peripartum adolescent girls.Conclusion: There is a need for further refining of the integrated care model in mental health services and targeted capacity building for health care providers to deliver quality services.</jats:p