Cultural explanatory models of depression i Uganda

Background: Depressive disorders are among the most frequent psychiatric disorders, accounting for up to 30% of primary care service utilisation in developing countries in general, and Uganda in particular. However, delays in seeking treatment, misdiagnosis and non-specific treatments have compromised appropriate care for people with depression. The general aim of this thesis is to explore and describe how depressive symptoms are conceptualised and communicated by the Baganda and how this conceptualisation may influence their help-seeking behaviour and processes. The research questions that the studies aimed to answer were: i) How do the Baganda understand, talk about and cope with depression? ii) What is perceived as effective treatment and how severe must symptoms be to warrant treatment? iii) Are the sub-types of depression seen as constituting one illness? Methods: The thesis consists of four exploratory papers employing qualitative methods of individual interviews and Focus Group Discussions. Paper I reports preliminary results of a pilot study on lay explanations of causes, effects and help-seeking behaviour for depression among the Ganda cultural group. Twenty-nine adults participated in four focus group discussions and four individual interviews. Paper II reports results of an interview study among 25 adults receiving treatment for depression, regarding their personal and social meaning of depression, their beliefs on causes and consequences of depression, and what triggered seeking psychiatric help. Paper III reports results of the study that aimed to explore the Baganda's conceptualization of psychotic depression in terms of illness identity, causes and treatment. Members of the general population participated in 31 individual interviews and 12 focus group discussions. Unlabelled case vignettes based on DSM-IV criteria for psychotic depression were used as stimulants for discussion. Paper IV reports results of a study exploring traditional healers' explanatory model of depression without psychotic features. Interviews were conducted with 22 traditional healers. Results: Depression without psychotic features was regarded as illness of thoughts. Depression with psychotic features was regarded as a "clan illness" (eByekika), arising from poor relationships between the living and the dead. Both illnesses were perceived as not requiring Western medication but culturally accepted corrective traditional therapies. Patients' illness behaviours, particularly those defined as socially disruptive, were important determinants of entry to psychiatric care. Non-disruptive symptoms were often ignored, misdiagnosed or treated as physical problems by health-care providers. Concluding remarks: Conceptualisation of depression among the Baganda differs from the Western biomedical model of depression in terms of cause and treatment. Psychiatric help was sought if patients' behaviour became socially disruptive. There are similarities in the conceptualisation of depression between lay people and traditional healers who are the alternative care providers. Implications for clinical practice: It may be important to review the way depression is managed in the Western form of psychiatry when the patients reach mental health services in hospitals. The noted similarity between the alternative care providers and the users of their service has clinical implications for therapeutic approaches such as psychotherapy, where the agreement between the care provider and care receiver is key in a therapeutic relationship. These results have policy, research and training implications

Psychological distress and associated factors among the attendees of traditional healing practices in Jinja and Iganga districts, Eastern Uganda: a cross-sectional study

<p>Abstract</p> <p>Background</p> <p>Mental health problems are a major public health concern worldwide. Evidence shows that African communities, including Uganda, use both modern and traditional healing systems. There is limited literature about the magnitude of psychological distress and associated factors among attendees of traditional healing practices. This study aimed to determine the prevalence and associated factors of psychological distress among attendees of traditional healing practices in two districts in Uganda.</p> <p>Methods</p> <p>Face-to-face interviews with the Lusoga version of the Self Reporting Questionnaire (SRQ-20) were carried out with 400 patients over the age of 18 years attending traditional healing in Iganga and Jinja districts in Eastern Uganda. Patients were recruited consecutively in all the traditional healers' shrines that could be visited in the area. Persons with 6 or more positive responses to the SRQ were identified as having psychological distress. Prevalence was estimated and odds ratios of having psychological distress were obtained with multiple logistic regression analysis.</p> <p>Results</p> <p>387 questionnaire responses were analyzed. The prevalence of psychological distress in connection with attendance at the traditional healers' shrines was 65.1%. Having a co-wife and having more than four children were significantly associated with psyclogical distress. Among the socioeconomic indicators, lack of food and having debts were significantly associated with psychological distress. The distressed group was more likely to need explanations for ill health. Those who visited both the healer and a health unit were less likely to be distressed.</p> <p>Conclusion</p> <p>This study provides evidence that a substantial proportion of attendees of traditional healing practices suffer from psychological distress. Associated factors include poverty, number of children, polygamy, reason for visiting the healer and use of both traditional healing and biomedical health units. These findings may be useful for policy makers and biomedical health workers for the engagement with traditional healers.</p

Factors perceived to facilitate or hinder handwashing among primary students: a qualitative assessment of the Mikono Safi intervention schools in NW Tanzania.

OBJECTIVE: To qualitatively assess the effects of a multi-modal school-based water, sanitation and hygiene (WASH) intervention on handwashing behaviour among primary students in North Western (NW) Tanzania. DESIGN: The study was a qualitative assessment of barriers and facilitators to handwashing among students attending primary schools participating in the Mikono Safi Trial (Kiswahili for 'Clean Hands), a cluster-randomised trial assessing the impact of a school-based WASH intervention on selected soil transmitted helminth infections. Data collection methods included in-depth interviews with teachers, focus group discussions and friendship pair interviews with students collected between April and October 2018. The Capability-Opportunity-Motivation and Behaviour model was used to inform data collection and analysis. SETTING: The study was conducted in four purposively selected intervention schools in three districts of Kagera region, NW Tanzania (Bukoba urban, Bukoba rural and Muleba districts). PARTICIPANTS: Participants comprised 16 purposively selected teachers aged between 23 and 52 years and 100 students aged 7-15 years RESULTS: The Mikono Safi intervention increased students' reported capability and motivation to wash their hands with soap at key times, particularly after visiting the toilet. Improvements in students' handwashing knowledge and skills were reported by both teachers and students, and motivation for handwashing was enhanced by emotional drivers such as disgust, fear and nurture. Newly established handwashing stations improved the physical opportunity to wash hands, although the availability of water and the provision of soap was not always consistent (eg, due to internal organisational shortcomings or during the dry season). Students and teachers were actively engaged in intervention implementation which created a school community that valued and supported improved hand hygiene. CONCLUSION: The intervention was successful in improving capability and motivation for handwashing. Handwashing opportunity was also greatly improved, although the supply with water and soap was sometimes interrupted, calling for much stronger multi-sectoral collaboration to improve access to water at schools. TRIAL REGISTRATION NUMBER: ISRCTN45013173; Pre-results

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 CRD4201605200

Perinatal mental health care in a rural African district, Uganda: a qualitative study of barriers, facilitators and needs

Abstract 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

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 ªOption B+º 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 resistanceÐthat 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

Does a school-based intervention to engage parents change opportunity for handwashing with soap at home? Practical experience from the Mikono Safi trial in Northwestern Tanzania.

BACKGROUND: School-based de-worming is advocated as a strategy for reducing the burden of soil-transmitted helminth (STH) infections among children. However, re-infection tends to occur rapidly, suggesting that comprehensive water, sanitation, and hygiene (WASH) improvements may be needed to prevent this. We qualitatively assessed the influence of parental engagement activities on parents' motivation to improve WASH infrastructure and hygiene practices at home in the context of a school-based de-worming programme. METHODOLOGY: We conducted a longitudinal qualitative study nested within the Mikono Safi trial, designed to assess the effect of a WASH intervention on STH infection prevalence in children. Meetings were organized for parents/guardians at schools where they were given information about STH infection, the role of WASH in STH infection prevention, and actionable steps they could take at home. During the meetings, parents/guardians received information about their own child's STH infection status. Twenty purposively selected households were visited and interviewed 3 times over a period of about 8-months. We employed thematic analysis; findings are reported following the Capability-Opportunity-Motivation and Behaviour (COM-B) framework. PRINCIPAL FINDINGS: The engagement strategy improved parents'/guardians' knowledge and skills about handwashing with soap and its benefits. Parents/guardians reported that the sessions had motivated them to improve WASH infrastructure at home. Of 20 households included in this study, 17 renovated or built new latrines and 18 installed handwashing facilities. However, only 8 households established and maintained handwashing stations with both soap and water at 8 months. CONCLUSIONS: The engagement of parents/guardians in a school-based WASH education intervention as part of the Mikono Safi trial resulted in increased knowledge and motivation about handwashing and sanitation. This led to improvements in sanitation facilities and handwashing opportunities at home. However, long-term success in provision of water and soap was limited, indicating that sustained engagement may be required to encourage households to ensure these materials are consistently available at home

Understanding mobility and sexual risk behaviour among women in fishing communities of Lake Victoria in East Africa: a qualitative study.

BACKGROUND: HIV-prevalence and incidence is high in many fishing communities around Lake Victoria in East Africa. In these settings, mobility among women is high and may contribute to increased risk of HIV infection and poor access to effective prevention and treatment services. Understanding the nature and patterns of this mobility is important for the design of interventions. We conducted an exploratory study to understand the nature and patterns of women's mobility to inform the design of HIV intervention trials in fishing communities of Lake Victoria. METHODS: This was a cross-sectional formative qualitative study conducted in six purposively selected fishing communities in Kenya, Tanzania and Uganda. Potential participants were screened for eligibility on age (18+ years) and having stayed in the fishing community for more than 6 months. We collected data using introductory and focus group discussions, and in-depth interviews with key informants. Data focused on: history and patterns of mobility, migration in and out of fishing communities and the relationship between mobility and HIV infection. Since the interviews and discussions were not audio-recorded, detailed notes were taken and written up into full scripts for analysis. We conducted a thematic analysis using constant comparison analysis. RESULTS: Participants reported that women in fishing communities were highly mobile for work-related activities. Overall, we categorized mobility as travels over long and short distances or periods depending on the kind of livelihood activity women were involved in. Participants reported that women often travelled to new places, away from familiar contacts and far from healthcare access. Some women were reported to engage in high risk sexual behaviour and disengaging from HIV care. However, participants reported that women often returned to the fishing communities they considered home, or followed a seasonal pattern of work, which would facilitate contact with service providers. CONCLUSION: Women exhibited circular and seasonal mobility patterns over varying distances and duration away from their home communities. These mobility patterns may limit women's access to trial/health services and put them at risk of HIV-infection. Interventions should be tailored to take into account mobility patterns of seasonal work observed in this study

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

Co-development and piloting of a menstrual, sexual and reproductive health intervention to improve social and psychological outcomes among secondary schoolgirls in Northern Tanzania: the PASS MHW study protocol.

INTRODUCTION: Poor menstrual health negatively impacts psychosocial and physical health, and subsequently leads to poor school outcomes, but the effort to improve adolescent girls' menstrual health in Tanzania remains fragmented. This study aimed to develop and pilot a scalable, comprehensive menstrual, sexual and reproductive health (MSRH) intervention within Tanzanian government structures to improve MSRH practices and perceptions and the overall school climate to ensure the psychosocial well-being and optimal school participation and performance among secondary schoolgirls. METHODS AND ANALYSIS: This study will be conducted in three phases. Phase I will be a formative research to iteratively refine an existing puberty and menstrual health intervention, and to collaboratively design strategies to embed the intervention into government structures thereby promoting scalability. In Phase II, we will pilot and evaluate the refined intervention and implementation strategies using a mixed-methods design to assess (1) feasibility, acceptability and sustainability; and (2) effect on MSRH practices and perceptions and the overall school climate. In Phase III, we will synthesise the research findings in collaboration with the national, regional and district government and non-government stakeholders. ETHICS AND DISSEMINATION: This pilot study will provide evidence-based recommendations for a comprehensive, complex menstrual and puberty intervention within secondary schools in Tanzania that can be further tested for broader effectiveness across a larger population. Papers, policy briefs and both regional/international conference presentations are planned to reach academic and non-academic groups. Protocol, tools and consent have been reviewed and approved by the independent Tanzanian national ethics committee (NIMR/HQ/R.8a/Vol.IX/3647) and the LSHTM Observational/Interventions Research Ethics Committee (LSHTM Ethics Ref: 22854). The project will involve adolescents, and procedures will be followed to ensure that we obtain permission and consent of parents and guardians and assent from all adolescents below 18 years of age that will be enrolled in the study