An overview of mental health care system in Kilifi, Kenya: results from an initial assessment using the World Health Organization's Assessment Instrument for Mental Health Systems.

Background Little is known about the state of mental health systems in Kenya. In 2010, Kenya promulgated a new constitution, which devolved national government and the national health system to 47 counties including Kilifi County. There is need to provide evidence from mental health systems research to identify priority areas in Kilifi’s mental health system for informing county health sector decision making. We conducted an initial assessment of state of mental health systems in Kilifi County and documented resources, policy and legislation and spectrum of mental, neurological and substance use disorders. Methods This was a pilot study that used the brief version of the World Health Organization’s Assessment Instrument for Mental Health Systems Version 2.2 to collect data. Data collection was based on the year 2014. Results Kilifi county has two public psychiatric outpatient units that are part of general hospitals. There is no standalone mental hospital in Kilifi. There are no inpatients or community based facilities for people with mental health problems. Although the psychiatric facilities in Kilifi have an essential drugs list, supply of drugs is erratic with frequent shortages. There is no psychiatrist or psychologist in Kilifi with only two psychiatric nurses for a population of approximately 1.2 million people. Schizophrenia was the commonest reason for visiting outpatient facilities (47.1%) while suicidal ideation was the least common (0.4%). Kenya’s mental health policy, which is being used by Kilifi County, is outdated and does not cater for the current mental health needs of Kilifi. There is no specific legislation to protect the rights of people with mental health problems. No budget exists specifically for mental health care. There have been no efforts to integrate mental health care into primary care in Kilifi, and there is no empirical research work to evaluate its feasibility. Conclusion There is an urgent need to increase resources allocated for mental health in particular infrastructure and human resource. Policy and legislations need to be established to protect the rights of people with mental illnesses, and mental health should be integrated with primary care to increase access to services.</p

An overview of mental health care system in Kilifi, Kenya: results from an initial assessment using the World Health Organization's Assessment Instrument for Mental Health Systems.

Background Little is known about the state of mental health systems in Kenya. In 2010, Kenya promulgated a new constitution, which devolved national government and the national health system to 47 counties including Kilifi County. There is need to provide evidence from mental health systems research to identify priority areas in Kilifi’s mental health system for informing county health sector decision making. We conducted an initial assessment of state of mental health systems in Kilifi County and documented resources, policy and legislation and spectrum of mental, neurological and substance use disorders. Methods This was a pilot study that used the brief version of the World Health Organization’s Assessment Instrument for Mental Health Systems Version 2.2 to collect data. Data collection was based on the year 2014. Results Kilifi county has two public psychiatric outpatient units that are part of general hospitals. There is no standalone mental hospital in Kilifi. There are no inpatients or community based facilities for people with mental health problems. Although the psychiatric facilities in Kilifi have an essential drugs list, supply of drugs is erratic with frequent shortages. There is no psychiatrist or psychologist in Kilifi with only two psychiatric nurses for a population of approximately 1.2 million people. Schizophrenia was the commonest reason for visiting outpatient facilities (47.1%) while suicidal ideation was the least common (0.4%). Kenya’s mental health policy, which is being used by Kilifi County, is outdated and does not cater for the current mental health needs of Kilifi. There is no specific legislation to protect the rights of people with mental health problems. No budget exists specifically for mental health care. There have been no efforts to integrate mental health care into primary care in Kilifi, and there is no empirical research work to evaluate its feasibility. Conclusion There is an urgent need to increase resources allocated for mental health in particular infrastructure and human resource. Policy and legislations need to be established to protect the rights of people with mental illnesses, and mental health should be integrated with primary care to increase access to services.</p

Behavioral problems in children with epilepsy in rural Kenya. Epilepsy & Behavior

The aims of this study were to record behavioral problems in children with epilepsy (CWE), compare the prevalence with that reported among healthy children without epilepsy, and investigate the risk factors. A child behavioral questionnaire for parents comprising 15 items was administered to the main caregiver of 108 CWE and 108 controls matched for age in Kilifi, Kenya. CWE had a higher mean score for reported behavioral problems than controls (6.9 vs 4.9, t=4.7, P<0.001). CWE with active epilepsy also recorded more behavioral problems than those with inactive epilepsy (8.2 vs 6.2, t=−2.9, P=0.005). A significantly greater proportion of CWE (49% vs 26% of controls) were reported to have behavioral problems. Active epilepsy, cognitive impairment, and focal seizures were the most significant independent covariates of behavioral problems. Behavioral problems in African CWE are common and need to be taken into consideration in planning comprehensive clinical services in this region

Prevalence and mortality of epilepsies with convulsive and non-convulsive seizures in Kilifi, Kenya

Objectives The prevalence of all epilepsies (both convulsive and non-convulsive seizures) in Low- and Middle-Income Countries (LMIC), particularly sub-Saharan Africa is unknown. Under estimation of non-convulsive epilepsies in data from these countries may lead to inadequate and sub-optimal allocation of resources to control and prevent epilepsy. We determined the prevalence of all types of epilepsies and compared the mortality between convulsive seizures and non-convulsive seizures in a resource limited rural area in Kenya. Methods Trained clinicians identified cases of epilepsy in a randomly selected sample of 4,441 residents in the Kilifi Health and Demographic Surveillance System site using a cross-sectional survey design. Seizure types were classified by epileptologists using the current guidelines of the International League Against Epilepsy (ILAE). We estimated prevalence for epilepsy with convulsive seizures and non-convulsive seizures and for epilepsy with non-convulsive seizures only and compared premature mortality between these groups of seizures. Results Of the 4441 people visited, 141 had lifetime epilepsy and 96 active epilepsy, which is a crude prevalence of 31.7/1,000 persons (95% CI: 26.6-36.9) and 21.6/1,000 (95% CI: 17.3-25.9), respectively. Both convulsive and non-convulsive seizures occurred in 7% people with epilepsy (PWE), only convulsive seizures in 52% and only non-convulsive seizures in 35% PWE; there was insufficient information to classify epilepsy in the remainder 6%. The age- and sex-adjusted prevalence of lifetime people was 23.5/1,000 (95% CI: 11.0-36.0), with the adjusted prevalence of epilepsy with non-convulsive seizures only estimated at 8.2/1,000 (95%CI:3.9-12.6). The mortality rate in PWE was 6.3/1,000 (95%CI: 3.4-11.8), compared to 2.8/1,000 (2.3-3.3) in those without epilepsy; hazard ratio (HR) =2.31 (1.22-4.39; p=0.011). The annual mortality rate was 11.2/1,000 (95%CI: 5.3-23.4) in PWE with convulsive and non-convulsive seizures and none died in PWE with non-convulsive seizures alone. Conclusions Our study shows that epilepsy with non-convulsive seizures is common and adds to the prevalence of previously reported estimates of active convulsive epilepsy. Both epilepsy with convulsive seizures and that with non-convulsive seizures should be identified for optimising treatment and for planning resource allocation

Continuous EEG monitoring in Kenyan children with non-traumatic coma

Background: The aim of this study was to describe the EEG and clinical profi le of seizures in children with non-traumatic coma, compare seizure detection by clinical observations with that by continuous EEG, and relate EEG features to outcome. Methods: This prospective observational study was conducted at the paediatric high dependency unit of Kilifi District Hospital, Kenya. Children aged 9 months to 13 years presenting with acute coma were monitored by EEG for 72 h or until they regained consciousness or died. Poor outcome was defi ned as death or gross motor defi cits at discharge. Results: 82 children (median age 2.8 (IQR 2.0-3.9) years) were recruited. An initial medium EEG amplitude (100-300 mV) was associated with less risk of poor outcome compared to low amplitude (≤100 mV) (OR 0.2, 95% CI 0.1 to 0.7; p&lt;0.01). 363 seizures in 28 (34%) children were observed: 240 (66%) were electrographic and 112 (31%) electroclinical. In 16 (20%) children, electrographic seizures were the only seizure types detected. The majority (63%) of electroclinical seizures had focal clinical features but appeared as generalised (79%) or focal with secondary generalisation (14%) on EEG. Occurrence of any seizure or status epilepticus during monitoring was associated with poor outcome (OR 3.2, 95% CI 1.2 to 8.7; p=0.02 and OR 4.5, 95% CI 1.3 to 15.3; p&lt;0.01, respectively). Conclusion: Initial EEG background amplitude is prognostic in paediatric non-traumatic coma. Clinical observations do not detect two out of three seizures. Seizures and status epilepticus after admission are associated with poor outcome

Long-term survival and outcome in children admitted to kilifi district hospital with convulsive status epilepticus.

Objectives. The incidence of convulsive status epilepticus (CSE) is high in Africa but the long-term outcome is unknown. We examined the neurocognitive outcome and survival of children treated for CSE in a Kenyan hospital 3 to 4 years after discharge. Methods. The frequency and nature of neurological deficits among this group of children were determined and compared to a control group. The children were screened with the Ten Questions Questionnaire for neurodevelopmental impairment if alive and those that screened positive were invited for further assessment to determine the pattern and extent of their impairment. A verbal autopsy was performed to determine the cause of death in those that died. Results. In the 119 cases followed-up, 9 (8%) died after discharge, with the majority having seizures during their fatal illness. The 110 survivors (median age 5 years) had significantly more neurological impairments on the screening compared to 282 controls (34/110 (30.9%) versus 11/282 (3.9%), OR = 11.0, 95% CI 5.3-22.8). Fifteen percent of the cases had active epilepsy. Conclusions. This study demonstrates the considerable burden of CSE in African children. Strategies to manage children with CSE that are acceptable to the community need to be explored to improve the longer-term outcome

Long-term survival and outcome in children admitted to kilifi district hospital with convulsive status epilepticus.

Objectives. The incidence of convulsive status epilepticus (CSE) is high in Africa but the long-term outcome is unknown. We examined the neurocognitive outcome and survival of children treated for CSE in a Kenyan hospital 3 to 4 years after discharge. Methods. The frequency and nature of neurological deficits among this group of children were determined and compared to a control group. The children were screened with the Ten Questions Questionnaire for neurodevelopmental impairment if alive and those that screened positive were invited for further assessment to determine the pattern and extent of their impairment. A verbal autopsy was performed to determine the cause of death in those that died. Results. In the 119 cases followed-up, 9 (8%) died after discharge, with the majority having seizures during their fatal illness. The 110 survivors (median age 5 years) had significantly more neurological impairments on the screening compared to 282 controls (34/110 (30.9%) versus 11/282 (3.9%), OR = 11.0, 95% CI 5.3-22.8). Fifteen percent of the cases had active epilepsy. Conclusions. This study demonstrates the considerable burden of CSE in African children. Strategies to manage children with CSE that are acceptable to the community need to be explored to improve the longer-term outcome

Active convulsive epilepsy in a rural district of Kenya: a study of prevalence and possible risk factors.

BACKGROUND: Few large-scale studies of epilepsy have been done in sub-Saharan Africa. We aimed to estimate the prevalence of, treatment gap in, and possible risk factors for active convulsive epilepsy in Kenyan people aged 6 years or older living in a rural area. METHODS: We undertook a three-phase screening survey of 151,408 individuals followed by a nested community case-control study. Treatment gap was defined as the proportion of cases of active convulsive epilepsy without detectable amounts of antiepileptic drugs in blood. FINDINGS: Overall prevalence of active convulsive epilepsy was 2.9 per 1000 (95% CI 2.6-3.2); after adjustment for non-response and sensitivity, prevalence was 4.5 per 1000 (4.1-4.9). Substantial heterogeneity was noted in prevalence, with evidence of clustering. Treatment gap was 70.3% (65.9-74.5), with weak evidence of a difference by sex and area. Adjusted odds of active convulsive epilepsy for all individuals were increased with a family history of non-febrile convulsions (odds ratio 3.3, 95% CI 2.4-4.7; p&lt;0.0001), family history of febrile convulsions (14.6, 6.3-34.1; p&lt;0.0001), history of both seizure types (7.3, 3.3-16.4; p&lt;0.0001), and previous head injury (4.1, 2.1-8.1; p&lt;0.0001). Findings of multivariable analyses in children showed that adverse perinatal events (5.7, 2.6-12.7; p&lt;0.0001) and the child's mother being a widow (5.1, 2.4-11.0; p&lt;0.0001) raised the odds of active convulsive epilepsy. INTERPRETATION: Substantial heterogeneity exists in prevalence of active convulsive epilepsy in this rural area in Kenya. Assessment of prevalence, treatment use, and demographic variation in screening response helped to identify groups for targeted interventions. Adverse perinatal events, febrile illness, and head injury are potentially preventable associated factors for epilepsy in this region