Integrating mental health into primary health care – Uganda's experience

Most developing countries and indeed many African countries have been undertaking reforms of the mental health policies and strategies to improve access and equity for the community to mental health and psychiatric services. This has been in conformity with a health policy philosophy which emphasize decentralization of services to the lower administrative units such as districts, community care as well as integrated delivery of health services within the lower health units. Uganda, one of the developing countries in sub- Saharan Africa, has been implementing its Health Sector Strategic Plan in which mental health has been identified as a major priority. The guidelines from World Health Organisation (WHO), the Alma Ata Declaration and the subsequent WHO recommendations have provided the guiding philosophy for the implementation of this process. However despite embracing the philosophy and having developed sound policies and implementation programs, practical realities are being experienced on the ground. The need for research and evidence-based approach is urgent to evaluate the success of the programmes, which have been developed by many member countries but whose implementation is still a very slow process. The paper reviews some of the international recommendations towards availing mental health to the majority of the population and the steps undertaken in implementing the integration approach with a case study for Uganda, points out the challenges and also proposes a way forward. Keywords: Policies, Plans, Integration, Primary Health Care, Resources, Uganda.> South African Psychiatry Review Vol. 10 (1) 2007: pp 17-1

Integration of Mental Health into Primary Health Care in a rural district in Uganda

Objective: Mental health has been identified as a major priority in the Ugandan Health Sector Strategic Plan. Efforts are currently underway to integrate mental health services into the Primary Health Care system. In this study, we report aspects of the integration of mental health into primary health care in one rural district in Uganda. Method: Qualitative methods were used for data collection. Semi-structured interviews and focus group discussions were conducted with various stakeholders within the ministry of health as well as line ministries. Data analysis was done using Nvivo 7, specifically adopting framework analysis approach. Results: Attempts to offer organized mental health services were found to be present in only a few health facilities. The district had only a single mental health nurse, and very few General Health Workers adequately equipped with the knowledge and skills to provide mental health services. The vertical referral system was not being followed as planned and there was no evidence of any organized community interventions for those with mental disorders. The mental health nurse and a few PHC nurses however expressed interest and commitment to providing services for persons with mental illness, despite the challenges. Conclusion: Although mental healthis expected to be integrated into primary health care, mental health services in this district have not yet achieved the expected level of integration. This implies that this important policy requirement has not yet been effectively realized in this rural district, which could be the case in many other districts of a similar status. There is thus a need to direct more efforts towards realization of this important policy requirement.Key words: Mental health; Primary Health Care; Integration; Ugand

Media and Mental Health in Uganda

Objective: The media is largely regarded as an important stakeholder in health service delivery, with a great influence on publicattitudes. However, little is known about its interest in mental health and the guiding factors that influence media coverage of mentalhealth issues. This article describes the importance accorded to mental health by the media and the factors that influence mediacoverage of mental health issues in Uganda. Method: Semi-structured interviews were held with representatives from sixprominent media houses as part of the situational analysis of the mental health system in Uganda. Data was analyzed using Nvivo7 qualitative data analysis software. Results: The media was found to be interested and actively involved in health initiatives, butwith little attention devoted to mental health. Coverage and interest in mental health was noted to be mainly dependent on theindividual journalists’ interests, and mostly for personal reasons. Low interest was largely attributed to mental health beingperceived as a non-priority area, and the fact that mental illness is not a major contributor to mortality. Media coverage andreporting is guided by prioritization of the Health Department. Conclusion: The media in Uganda is an important stakeholderin the health care system with a key role of advocacy, publicity and mass education. Media houses however are less interested inmental health as evidenced by low coverage of mental health issues. This calls for advocacy and sensitization as a way ofpersuading media for more involvement in mental health initiatives.Key words: Media; Mental health; Uganda; Publi

Supervised versus unsupervised antimalarial treatment with six-dose artemether-lumefantrine: pharmacokinetic and dosage-related findings from a clinical trial in Uganda.

BACKGROUND: A six-dose antimalarial regimen of artemether-lumefantrine (A/L) may soon become one of the most widely used drug combination in Africa, despite possible constraints with adherence and poor absorption due to inadequate nutrition, and a lack of pharmacokinetic and effectiveness data. METHODS: Within a trial of supervised versus unsupervised A/L treatment in a stable Ugandan Plasmodium falciparum transmission setting, plasma lumefantrine concentrations were measured in a subset of patients on day 3 (C [lum]day3) and day 7 (C [lum]day7) post-inclusion. Predictors of lumefantrine concentrations were analysed to show how both C [lum]day7 and the weight-adjusted lumefantrine dose affect 28-day recrudescence and re-infection risks. The implications of these novel findings are discussed in terms of the emergence of lumefantrine-resistant strains in Africa. RESULTS: C [lum]day3 and C [lum]day7 distributions among 241 supervised and 238 unsupervised patients were positively skewed. Unsupervised treatment and decreasing weight-adjusted lumefantrine dose were negatively associated with C [lum]day3. Unsupervised treatment and decreasing age showed strong negative associations with C [lum]day7. Both models were poorly predictive (R-squared < 0.25). There were no recrudescences in either arm, but decreasing lumefantrine dose per Kg resulted in up to 13-fold higher adjusted risks of re-infection. Re-infections occurred only among patients with C [lum]day7 below 400 ng/mL (p < 0.001). CONCLUSION: Maintaining the present six-dose regimen and ensuring high adherence and intake are essential to maximize the public health benefits of this valuable drug combination

Cost effectiveness analysis of clinically driven versus routine laboratory monitoring of antiretroviral therapy in Uganda and Zimbabwe.

BACKGROUND: Despite funding constraints for treatment programmes in Africa, the costs and economic consequences of routine laboratory monitoring for efficacy and toxicity of antiretroviral therapy (ART) have rarely been evaluated. METHODS: Cost-effectiveness analysis was conducted in the DART trial (ISRCTN13968779). Adults in Uganda/Zimbabwe starting ART were randomised to clinically-driven monitoring (CDM) or laboratory and clinical monitoring (LCM); individual patient data on healthcare resource utilisation and outcomes were valued with primary economic costs and utilities. Total costs of first/second-line ART, routine 12-weekly CD4 and biochemistry/haematology tests, additional diagnostic investigations, clinic visits, concomitant medications and hospitalisations were considered from the public healthcare sector perspective. A Markov model was used to extrapolate costs and benefits 20 years beyond the trial. RESULTS: 3316 (1660LCM;1656CDM) symptomatic, immunosuppressed ART-naive adults (median (IQR) age 37 (32,42); CD4 86 (31,139) cells/mm(3)) were followed for median 4.9 years. LCM had a mean 0.112 year (41 days) survival benefit at an additional mean cost of $765 [95$7386 [3277,dominated] per life-year gained and $7793 [4442,39179] per quality-adjusted life year gained. Routine toxicity tests were prominent cost-drivers and had no benefit. With 12-weekly CD4 monitoring from year 2 on ART, low-cost second-line ART, but without toxicity monitoring, CD4 test costs need to fall below$3.78 to become cost-effective (<3xper-capita GDP, following WHO benchmarks). CD4 monitoring at current costs as undertaken in DART was not cost-effective in the long-term. CONCLUSIONS: There is no rationale for routine toxicity monitoring, which did not affect outcomes and was costly. Even though beneficial, there is little justification for routine 12-weekly CD4 monitoring of ART at current test costs in low-income African countries. CD4 monitoring, restricted to the second year on ART onwards, could be cost-effective with lower cost second-line therapy and development of a cheaper, ideally point-of-care, CD4 test

Suicidal ideation and behaviour among community and health care seeking populations in five low- and middle-income countries: a cross-sectional study.

: Aims Suicidal behaviour is an under-reported and hidden cause of death in most low- and middle-income countries (LMIC) due to lack of national systematic reporting for cause-specific mortality, high levels of stigma and religious or cultural sanctions. The lack of information on non-fatal suicidal behaviour (ideation, plans and attempts) in LMIC is a major barrier to design and implementation of prevention strategies. This study aims to determine the prevalence of non-fatal suicidal behaviour within community- and health facility-based populations in LMIC. : Twelve-month prevalence of suicidal ideation, plans and attempts were established through community samples (n = 6689) and primary care attendees (n = 6470) from districts in Ethiopia, Uganda, South Africa, India and Nepal using the Composite International Diagnostic Interview suicidality module. Participants were also screened for depression and alcohol use disorder. : We found that one out of ten persons (10.3%) presenting at primary care facilities reported suicidal ideation within the past year, and 1 out of 45 (2.2%) reported attempting suicide in the same period. The range of suicidal ideation was 3.5-11.1% in community samples and 5.0-14.8% in health facility samples. A higher proportion of facility attendees reported suicidal ideation than community residents (10.3 and 8.1%, respectively). Adults in the South African facilities were most likely to endorse suicidal ideation (14.8%), planning (9.5%) and attempts (7.4%). Risk profiles associated with suicidal behaviour (i.e. being female, younger age, current mental disorders and lower educational and economic status) were highly consistent across countries. : The high prevalence of suicidal ideation in primary care points towards important opportunities to implement suicide risk reduction initiatives. Evidence-supported strategies including screening and treatment of depression in primary care can be implemented through the World Health Organization's mental health Global Action Programme suicide prevention and depression treatment guidelines. Suicidal ideation and behaviours in the community sample will require detection strategies to identify at risks persons not presenting to health facilities.<br/

Validity and diagnostic accuracy of the Luganda version of the 9-item and 2-item Patient Health Questionnaire for detecting major depressive disorder in rural Uganda.

BACKGROUND: The prevalence of depression in rural Ugandan communities is high and yet detection and treatment of depression in the primary care setting is suboptimal. Short valid depression screening measures may improve detection of depression. We describe the validation of the Luganda translated nine- and two-item Patient Health Questionnaires (PHQ-9 and PHQ-2) as screening tools for depression in two rural primary care facilities in Eastern Uganda. METHODS: A total of 1407 adult respondents were screened consecutively using the nine-item Luganda PHQ. Of these 212 were randomly selected to respond to the Mini International Neuropsychiatric Interview diagnostic questionnaire. Descriptive statistics for respondents' demographic characteristics and PHQ scores were generated. The sensitivity, specificity and positive predictive values (PPVs), and area under the ROC curve were determined for both the PHQ-9 and PHQ-2. RESULTS: The optimum trade-off between sensitivity and PPV was at a cut-off of ≧5. The weighted area under the receiver Operating Characteristic curve was 0.74 (95% CI 0.60-0.89) and 0.68 (95% CI 0.54-0.82) for PHQ-9 and PHQ-2, respectively. CONCLUSION: The Luganda translation of the PHQ-9 was found to be modestly useful in detecting depression. The PHQ-9 performed only slightly better than the PHQ-2 in this rural Ugandan Primary care setting. Future research could improve on diagnostic accuracy by considering the idioms of distress among Luganda speakers, and revising the PHQ-9 accordingly. The usefulness of the PHQ-2 in this rural population should be viewed with caution

Evaluation of the impacts of a district-level mental health care plan on contact coverage, detection and individual outcomes in rural Uganda: a mixed methods approach

Abstract Background The burden of mental disorders in low- and middle-income countries is large. Yet there is a major treatment gap for these disorders which can be reduced by integrating the care of mental disorders in primary care. Aim We aimed to evaluate the impact of a district mental health care plan (MHCP) on contact coverage for and detection of mental disorders, as well as impact on mental health symptom severity and individual functioning in rural Uganda. Results For adults who attended primary care facilities, there was an immediate positive effect of the MHCP on clinical detection at 3 months although this was not sustained at 12 months. Those who were treated in primary care experienced significant reductions in symptom severity and functional impairment over 12 months. There was negligible change in population-level contact coverage for depression and alcohol use disorder. Conclusion The study found that it is possible to integrate mental health care into primary care in rural Uganda. Treatment by trained primary care workers improves clinical and functioning outcomes for depression, psychosis and epilepsy. Challenges remain in accessing the men for care, sustaining the improvement in detection over time, and creating demand for services among those with presumed need

Quantifying HIV transmission flow between high-prevalence hotspots and surrounding communities: a population-based study in Rakai, Uganda.

BACKGROUND: International and global organisations advocate targeting interventions to areas of high HIV prevalence (ie, hotspots). To better understand the potential benefits of geo-targeted control, we assessed the extent to which HIV hotspots along Lake Victoria sustain transmission in neighbouring populations in south-central Uganda. METHODS: We did a population-based survey in Rakai, Uganda, using data from the Rakai Community Cohort Study. The study surveyed all individuals aged 15-49 years in four high-prevalence Lake Victoria fishing communities and 36 neighbouring inland communities. Viral RNA was deep sequenced from participants infected with HIV who were antiretroviral therapy-naive during the observation period. Phylogenetic analysis was used to infer partial HIV transmission networks, including direction of transmission. Reconstructed networks were interpreted through data for current residence and migration history. HIV transmission flows within and between high-prevalence and low-prevalence areas were quantified adjusting for incomplete sampling of the population. FINDINGS: Between Aug 10, 2011, and Jan 30, 2015, data were collected for the Rakai Community Cohort Study. 25 882 individuals participated, including an estimated 75·7% of the lakeside population and 16·2% of the inland population in the Rakai region of Uganda. 5142 participants were HIV-positive (2703 [13·7%] in inland and 2439 [40·1%] in fishing communities). 3878 (75·4%) people who were HIV-positive did not report antiretroviral therapy use, of whom 2652 (68·4%) had virus deep-sequenced at sufficient quality for phylogenetic analysis. 446 transmission networks were reconstructed, including 293 linked pairs with inferred direction of transmission. Adjusting for incomplete sampling, an estimated 5·7% (95% credibility interval 4·4-7·3) of transmissions occurred within lakeside areas, 89·2% (86·0-91·8) within inland areas, 1·3% (0·6-2·6) from lakeside to inland areas, and 3·7% (2·3-5·8) from inland to lakeside areas. INTERPRETATION: Cross-community HIV transmissions between Lake Victoria hotspots and surrounding inland populations are infrequent and when they occur, virus more commonly flows into rather than out of hotspots. This result suggests that targeted interventions to these hotspots will not alone control the epidemic in inland populations, where most transmissions occur. Thus, geographical targeting of high prevalence areas might not be effective for broader epidemic control depending on underlying epidemic dynamics. FUNDING: The Bill & Melinda Gates Foundation, the National Institute of Allergy and Infectious Diseases, the National Institute of Mental Health, the National Institute of Child Health and Development, the Division of Intramural Research of the National Institute for Allergy and Infectious Diseases, the World Bank, the Doris Duke Charitable Foundation, the Johns Hopkins University Center for AIDS Research, and the President's Emergency Plan for AIDS Relief through the Centers for Disease Control and Prevention