Health system strengthening for mental health in low- and middle-income countries: introduction to the Emerald programme

This paper gives an overview of the Emerald (Emerging mental health systems in low- and middle-income countries) programme and introduces the subsequent seven papers in this BJPsych Open thematic series. The aims of the Emerald research programme were to improve mental health outcomes in six low- and middle-income countries (LMICs), namely Ethiopia, India, Nepal, Nigeria, South Africa and Uganda, by building capacity and by generating evidence to enhance health system strengthening in these six countries. The longer-term aim is to improve mental healthcare, and so contribute to a reduction in the large treatment gap that exists for mental disorders. This series includes papers describing the following components of the Emerald programme: (a) capacity building; (b) mental health financing; (c) integrated care (d) mental health information systems; and (e) knowledge transfer. We also include a cross-cutting paper with recommendations from the Emerald programme as a whole. The inclusion of clear mental-health-related targets and indicators within the United Nations Sustainable Development Goals now intensifies the need for strong evidence about both how to provide effective treatments, and how to deliver these treatments within robust health systems

Health system strengthening for mental health in low- and middle-income countries: introduction to the Emerald programme

This paper gives an overview of the Emerald (Emerging mental health systems in low- and middle-income countries) programme and introduces the subsequent seven papers in this BJPsych Open thematic series. The aims of the Emerald research programme were to improve mental health outcomes in six low- and middle-income countries (LMICs), namely Ethiopia, India, Nepal, Nigeria, South Africa and Uganda, by building capacity and by generating evidence to enhance health system strengthening in these six countries. The longer-term aim is to improve mental healthcare, and so contribute to a reduction in the large treatment gap that exists for mental disorders. This series includes papers describing the following components of the Emerald programme: (a) capacity building; (b) mental health financing; (c) integrated care (d) mental health information systems; and (e) knowledge transfer. We also include a cross-cutting paper with recommendations from the Emerald programme as a whole. The inclusion of clear mental-health-related targets and indicators within the United Nations Sustainable Development Goals now intensifies the need for strong evidence about both how to provide effective treatments, and how to deliver these treatments within robust health systems

Perceived needs among asylum seekers in Sweden: a mixed methods study

The health and well-being of asylum seekers in high-income countries is a concern from both individual and community perspectives. This study aims to describe the perceived needs of adult asylum seekers in Sweden. A mixed methods study was conducted that combined a non-randomized descriptive cross-sectional assessment of perceived serious needs using the Humanitarian Emergency Settings Perceived Needs Scale (HESPER) Web with 85 adult asylum seekers and focus group discussions with 14 adult asylum seekers in Sweden. Descriptive and comparative statistics were used for the quantitative part, and thematic analysis for the qualitative part. The total number of perceived serious needs reported by respondents ranged from zero to 13 needs per person with a mean of four needs (SD 2.71). The most commonly perceived serious needs were related to income or livelihood, separation from loved ones, being displaced from home, distress, and concerns about accessing adequate health care services. Many of the perceived needs appeared to be related to experiences of being dependent, in limbo, and vulnerable. Addressing people’s current perceived needs can contribute to resilience and well-being and therefore should be considered in health care systems that cater to immigrants

What is new within staging of care for people with dementia? The IDEAL schedule and other recent work

Purpose of review This review provides an overview of recent progress within work centred around the ‘International schedule for the integrated assessment and staging of care for dementia’ (IDEAL schedule), and places it within the context of recent work around other staging models for dementia. Recent findings The IDEAL schedule assesses the severity of dementia across seven dimensions. A ‘Menu of care options’ of recommended priorities for interventions accompanies the schedule. A user manual for the schedule has just been published. Other staging models for dementia include those based on biomarkers, such as in the recently published research framework for Alzheimer's disease by the National Institute on Aging and Alzheimer's Association (NIA-AA), or those based on specific aspects of dementia, principally cognitive impairment. Summary The IDEAL schedule is a global staging model to guide the organization of dementia care. The schedule covers a range of domains that extend beyond cognitive functioning and include care needs; it is applicable to all types and stages of dementia; and can be used by any healthcare professional, both within clinical practice and research. The schedule is not in opposition to, or is even complementary to, other stagingmodels for dementia

Community involvement in the care of persons affected by podoconiosis - a lesson for other skin NTDs

Podoconiosis is a neglected tropical disease (NTD) characterized by lower-leg swelling (lymphedema), which is caused by long-term exposure to irritant red-clay soils found within tropical volcanic high-altitude environments with heavy rainfall. The condition places a substantial burden on affected people, their families and communities, including disability, economic consequences, social exclusion, and stigma; mental disorders and distress are also common. This paper focuses on community-based care of podoconiosis, and, in particular, the role that community involvement can have in the reduction of stigma against people affected by podoconiosis. We first draw on research conducted in Ethiopia for this, which has included community-based provision of care and treatment, education, and awareness-raising, and socioeconomic rehabilitation to reduce stigma. Since people affected by podoconiosis and other skin NTDs often suffer the double burden of mental-health illness, which is similarly stigmatized, we then point to examples from the mental-health field in low-resource community settings to suggest avenues for stigma reduction and increased patient engagement that may be relevant across a range of skin NTDs, though further research is needed on this

Service user involvement in global mental health: what have we learned from recent research in low- and middle-income countries?

Purpose of Review The Lancet Commission on global mental health and sustainable development claims the field of global mental health is undergoing a “transformational shift” toward an ethic of “nothing about us without us”. Yet a systematic review published in 2016 identified few examples of meaningful participation by service users in mental health systems strengthening in low- and middle-income countries (LMICs). To investigate whether this is still the case, we conducted a rapid review of primary research published between June 2017 and December 2018. Recent Findings We identified 10 studies reporting on user involvement in LMICs, including three in mental health policy and planning, three in mental health services or capacity-building, and three in treatment decision-making. An additional study was identified as having involved users in data collection, although this was unclear from the original text. Included studies were mostly qualitative and conducted as part of a situation analysis, pilot study or other formative research. Few reported the results of efforts to improve involvement, suggesting this shift remains at an early stage. Summary While the number of studies published on user involvement is rapidly increasing, the potentially “transformational” effects of this shift in global mental health are not yet being felt by most users in LMICs

High levels of depressive symptoms amongst people with lower limb lymphoedema in Rwanda: a cross-sectional study

Background There is a growing body of evidence that mental distress and disorder are common among people with lower limb lymphoedema, although no research has been conducted on this subject in Rwanda. Methods This research was embedded within a mapping study to determine the national prevalence and geographical distribution of podoconiosis in Rwanda. Using a cluster sampling design, adult members of households within 80 randomly selected sectors in all 30 districts of Rwanda were first screened and 1143 patients were diagnosed with either podoconiosis (n=914) or lower limb lymphoedema of another cause (n=229). These 1143 participants completed the Patient Health Questionnaire (PHQ)-9 to establish the prevalence of depressive symptoms. Results Overall, 68.5% of participants reported depressive symptoms- 34.3% had mild depressive symptoms, 24.2% had moderate, 8.8% moderately severe and 1.2% severe depressive symptoms. The mean PHQ-9 score was 7.39 (SD=5.29) out of a possible 0 (no depression) to 27 (severe depression). Linear regression showed unemployment to be a consistently strong predictor of depressive symptoms; the other predictors were region (province), type of lymphoedema and, for those with podoconiosis, female gender, marital status and disease stage. Conclusions Levels of depressive symptoms were very high among people with lower limb lymphoedema in Rwanda, which should be addressed through holistic morbidity management and disability prevention services that integrate mental health, psychosocial and economic interventions alongside physical care

The reliability and feasibility of the HESPER web to assess perceived needs in a population affected by a humanitarian emergency

Needs assessment is essential in the humanitarian response, and perceived needs can be associated with the levels of health in populations affected by humanitarian emergencies. This study aimed to evaluate the reliability and feasibility of The Humanitarian Emergency Settings Perceived Needs Web (HESPER Web) in a humanitarian context and to compare perceived needs of a random walk study sample with a self-selected study sample recruited though social media. The study context was the Dadaab refugee camp in Kenya. An alternate forms reliability evaluation and a feasibility evaluation was conducted. In total, 308 refugees participated in the study. HESPER Web was found to be reliable and usable for assessing needs, with an intraclass correlation coefficient (ICC) of 0.88, Cohen’s κ between 0.43 and 1.0 and a first priority need rating match of 81%. The HESPER Web was positively experienced, and the self-recruited study sample reported similar levels of needs and similar demographics as the randomized sample. The participants reported several unmet needs. HESPER Web offers a reliable tool for needs assessment in humanitarian emergencies where web-based surveys are considered as practical and suitable. It offers new possibilities for conducting remote assessments and research studies that include humanitarian populations that are rarely included in such evaluations

Service user involvement in mental health system strengthening in a rural African setting:qualitative study

Background: It is essential to involve service users in efforts to expand access to mental health care in integrated primary care settings in low- and middle-income countries (LMICs). However, there is little evidence from LMICs to guide this process. The aim of this study was to explore barriers to, and facilitators of, service user/caregiver involvement in rural Ethiopia to inform the development of a scalable approach.Methods: Thirty nine semi-structured interviews were carried out with purposively selected mental health service users (n = 13), caregivers (n = 10), heads of primary care facilities (n = 8) and policy makers/planners/service developers (n = 8). The interviews were audio-recorded and transcribed in Amharic, and translated into English. Thematic analysis was applied.Results: All groups of participants supported service user and caregiver involvement in mental health system strengthening. Potential benefits were identified as (i) improved appropriateness and quality of services, and (ii) greater protection against mistreatment and promotion of respect for service users. However, hardly any respondents had prior experience of service user involvement. Stigma was considered to be a pervasive barrier, operating within the health system, the local community and individuals. Competing priorities of service users included the need to obtain adequate individual care and to work for survival. Low recognition of the potential contribution of service users seemed linked to limited empowerment and mobilization of service users. Potential health system facilitators included a culture of community oversight of primary care services. All groups of respondents identified a need for awareness-raising and training to equip service users, caregivers, service providers and local community for involvement. Empowerment at the level of individual service users (information about mental health conditions, care and rights) and the group level (for advocacy and representation) were considered essential, alongside improved, accessible mental health care and livelihood interventions.Conclusion: As Ethiopia increases access to mental health care, a fundamental barrier to service user involvement is beginning to be addressed. Our study identified further barriers that need to be tackled, including a supportive political climate, and receptiveness amongst stakeholders. The findings will inform the development of a model of service user involvement, which will be piloted and evaluated

Depressive symptoms amongst people with podoconiosis and lower limb lymphoedema of other cause in Cameroon: a cross-sectional study

Evidence is emerging that shows elevated mental distress and disorder amongst people with several neglected tropical diseases (NTDs). This study aimed to establish the prevalence of depressive symptoms amongst people with podoconiosis and lower limb lymphoedema of other cause in Cameroon. The study was part of a larger research piece that mapped the geographical distribution of podoconiosis in Cameroon. The Patient Health Questionnaire (PHQ-9; mean) was employed to determine the prevalence of depressive symptoms amongst people with lower limb lymphoedema. Linear regression was used to assess the association between socio-demographic characteristics of participants and depressive symptoms. Internal consistency of the PHQ-9 was estimated through Cronbach’s alpha (α = 0.651). The mean PHQ-9 score among people with lower limb lymphoedema was 3.48 (SD ± 3.25). Using a PHQ-9 score of 5 or above as the cut-off score, 32 participants (38.6%) displayed at least mild depressive symptoms. Unemployment was the only factor that was significantly associated with more depressive symptoms overall. This study shows that depressive symptoms are common amongst people with lower limb lymphoedema in Cameroon. The findings provide support for the integration of psychosocial interventions into packages of care for the management of lower limb lymphoedema