Beyond the biomedical: community resources for mental health care in rural Ethiopia.

BACKGROUND: The focus of discussion in addressing the treatment gap is often on biomedical services. However, community resources can benefit health service scale-up in resource-constrained settings. These assets can be captured systematically through resource mapping, a method used in social action research. Resource mapping can be informative in developing complex mental health interventions, particularly in settings with limited formal mental health resources. METHOD: We employed resource mapping within the Programme for Improving Mental Health Care (PRIME), to systematically gather information on community assets that can support integration of mental healthcare into primary care in rural Ethiopia. A semi-structured instrument was administered to key informants. Community resources were identified for all 58 sub-districts of the study district. The potential utility of these resources for the provision of mental healthcare in the district was considered. RESULTS: The district is rich in community resources: There are over 150 traditional healers, 164 churches and mosques, and 401 religious groups. There were on average 5 eddir groups (traditional funeral associations) per sub-district. Social associations and 51 micro-finance institutions were also identified. On average, two traditional bars were found in each sub-district. The eight health centres and 58 satellite clinics staffed by Health Extension Workers (HEWs) represented all the biomedical health services in the district. In addition the Health Development Army (HDA) are community volunteers who support health promotion and prevention activities. DISCUSSION: The plan for mental healthcare integration in this district was informed by the resource mapping. Community and religious leaders, HEWs, and HDA may have roles in awareness-raising, detection and referral of people with mental illness, improving access to medical care, supporting treatment adherence, and protecting human rights. The diversity of community structures will be used to support rehabilitation and social reintegration. Alcohol use was identified as a target disorder for community-level intervention

Experience of traumatic events in people with severe mental illness in a low-income country:a qualitative study

BACKGROUND: This study describes the trauma experiences of people with severe mental illness (SMI) in Ethiopia and presents a model of how SMI and trauma exposure interact to reduce functioning and quality of life in this setting.METHODS: A total of 53 participants living and working in a rural district in southern Ethiopia were interviewed: 18 people living with SMI, 21 caregivers, and 14 primary health care providers.RESULTS: Many participants reported that exposure to traumatic and stressful events led to SMI, exacerbated SMI symptoms, and increased caregiver stress and distress. In addition, SMI symptoms and caregiver desperation, stress or stigma were also reported to increase the possibility of trauma exposure.CONCLUSIONS: Results suggest it is incumbent upon health professionals and the broader health community to view trauma exposure (broadly defined) as a public health problem that affects all, particularly individuals with SMI

Community-based rehabilitation intervention for people with schizophrenia in Ethiopia (RISE):results of a 12-month cluster-randomised controlled trial

BACKGROUND: Community-based rehabilitation (CBR) is recommended to address the social and clinical needs of people with schizophrenia in resource-poor settings. We evaluated the effectiveness of CBR at reducing disability at 12 months in people with schizophrenia who had disabling illness after having had the opportunity to access facility-based care for 6 months METHODS: This cluster-randomised controlled trial was conducted in a rural district of Ethiopia. Eligible clusters were subdistricts in Sodo district that had not participated in the pilot study. Available subdistricts were randomised (in a 1:1 ratio) to either the intervention group (CBR plus facility-based care) or to the control group (facility-based care alone). An optimisation procedure (accounting for the subdistrict mean WHO Disability Assessment Schedule (WHODAS) score and the potential number of participants per subdistrict) was applied for each of the eight health facilities in the district. An independent statistician, masked to the intervention or control label, used a computer programme to randomly choose the allocation sequence from the set of optimal ones. We recruited adults with disabling illness as a result of schizophrenia. The subdistricts were eligible for inclusion if they included participants that met the eligibility criteria. Researchers recruiting and assessing participants were masked to allocation status. Facility-based care was a task-shared model of mental health care integrated within primary care. CBR was delivered by lay workers over a 12-month period, comprising of home visits (psychoeducation, adherence support, family intervention, and crisis management) and community mobilisation. The primary outcome was disability, measured with the proxy-rated 36-item WHODAS score at 12 months. The subdistricts that had primary outcome data available were included in the primary analysis. This study is registered with ClinicalTrials.gov, NCT02160249.FINDINGS: Enrolment took place between Sept 16, 2015 and Mar 11, 2016. 54 subdistricts were randomised (27 to the CBR plus facility-based care group and 27 to the facility-based care group). After exclusion of subdistricts without eligible participants, we enrolled 79 participants (66% men and 34% women) from 24 subdistricts assigned to CBR plus facility-based care and 87 participants (59% men and 41% women) from 24 subdistricts assigned to facility-based care only. The primary analysis included 149 (90%) participants in 46 subdistricts (73 participants in 22 subdistricts in the CBR plus facility-based care group and 76 participants in 24 subdistricts in the facility-based care group). At 12 months, the mean WHODAS scores were 46·1 (SD 23·3) in the facility-based care group and 40·6 (22·5) in the CBR plus facility-based care group, indicating a favourable intervention effect (adjusted mean difference -8·13 [95% CI -15·85 to -0·40]; p=0·039; effect size 0·35). Four (5%) CBR plus facility-based care group participants and nine (10%) facility-based care group participants had one or more serious adverse events (death, suicide attempt, and hospitalisation).INTERPRETATION: CBR delivered by lay workers combined with task-shared facility-based care, was effective in reducing disability among people with schizophrenia. The RISE study CBR model is particularly relevant to low-income countries with few mental health specialists.FUNDING: Wellcome Trust

Community-based rehabilitation intervention for people with schizophrenia in Ethiopia (RISE) cluster-randomised controlled trial:An exploratory analysis of impact on food insecurity, underweight, alcohol use disorder and depressive symptoms

We evaluated the effectiveness of community-based rehabilitation (CBR) in reducing depressive symptoms, alcohol use disorder, food insecurity and underweight in people with schizophrenia. This cluster-randomised controlled trial was conducted in a rural district of Ethiopia. Fifty-four sub-districts were allocated in a 1:1 ratio to the facility-based care [FBC] plus CBR arm and the FBC alone arm. Lay workers delivered CBR over 12 months. We assessed food insecurity (self-reported hunger), underweight (BMI< 18.5 kg/m2), depressive symptoms (PHQ-9) and alcohol use disorder (AUDIT ≥ 8) at 6 and 12 months. Seventy-nine participants with schizophrenia in 24 sub-districts were assigned to CBR plus FBC and 87 participants in 24 sub-districts were assigned to FBC only. There was no evidence of an intervention effect on food insecurity (aOR 0.52, 95% CI 0.16-1.67; p = 0.27), underweight (aOR 0.44, 95% CI 0.17-1.12; p = 0.08), alcohol use disorder (aOR 0.82, 95% CI 0.24-2.74; p = 0.74) or depressive symptoms (adjusted mean difference - 0.06, 95% CI -1.35, 1.22; p = 0.92). Psychosocial interventions in low-resource settings should support access to treatment amongst people with schizophrenia, and further research should explore how impacts on economic, physical and mental health outcomes can be achieved

COVID-19: Initial synthesis of the epidemiology, pathogenesis, diagnosis, treatment, and public health control approaches

Introduction: The coronavirus disease (abbreviated COVID-19) pandemic caused by SARS-CoV-2 has devastated the world in the space of just a few months. Since it was first reported in December 31, 2019 in the Hubei province of China, at the time of writing, over 2 million people have been infected, with over 127,598 deaths in 202 countries and territories. Records of global distribution show a steady increase, although the USA is leading in its distribution, with Italy reporting close to 20,000 deaths. The purpose of this rapid review is to synthesize available evidence on the epidemiology, pathogenesis, diagnosis and public health control measures to inform policy, programs and research on COVID-19. Methods: A rapid review method was employed using PubMed and Google Scholar search engines. Journal articles, reports and government documents were included in our search, which is focused on the disease epidemiology, advancements in diagnostics, treatment and vaccines, public health control measures, and psychosocial interventions for health care providers. The contents of the identified articles were examined and abstracted by a team of investigators. The concepts represented by the individual reviews were collated to give a complete picture of COVID-19 based on the evidence we have so far. The search period spanned December 30, 2019 to April 15, 2020. Findings: The severity of the disease and its fast spread, three times faster than the flu, has challenged the health systems of almost every country in the world. Although, for now, the case burden remains low in Africa, the impact of COVID-19 is anticipated to be severe if it becomes widespread. Efforts to curb the pandemic, involving prevention, disease surveillance, contact tracing, clinical management and the development of new treatments and diagnostics, is ongoing across the globe. While writing this review, more than 73 vaccines are at the exploratory or preclinical stage, while two are in phase I clinical trialsYet, non-pharmaceutical interventions are critical to stopping the spread of the virus. Africa, in particular, should put extra effort into making preventive public health measures work, because health systems in the continent are too weak to withstand the effect of the pandemic should it hit hard, and the economic implications of extreme control measures following a delayed response would be severe. On the bright side, the lessons drawn from this pandemic are likely to improve the preparedness and response to similar future outbreaks and pandemics. [Ethiop. J. Health Dev. 2020; 34(2):129-140] Key words: Coronavirus, COVID-19, pandemic, SARS-CoV-

Developing a mental health care plan in a low resource setting: the theory of change approach

Abstract Background Scaling up mental healthcare through integration into primary care remains the main strategy to address the extensive unmet mental health need in low-income countries. For integrated care to achieve its goal, a clear understanding of the organisational processes that can promote and hinder the integration and delivery of mental health care is essential. Theory of Change (ToC), a method employed in the planning, implementation and evaluation of complex community initiatives, is an innovative approach that has the potential to assist in the development of a comprehensive mental health care plan (MHCP), which can inform the delivery of integrated care. We used the ToC approach to develop a MHCP in a rural district in Ethiopia. The work was part of a cross-country study, the Programme for Improving Mental Health Care (PRIME) which focuses on developing evidence on the integration of mental health in to primary care. Methods An iterative ToC development process was undertaken involving multiple workshops with stakeholders from diverse backgrounds that included representatives from the community, faith and traditional healers, community associations, non-governmental organisations, Zonal, Regional and Federal level government offices, higher education institutions, social work and mental health specialists (psychiatrists and psychiatric nurses). The objective of this study is to report the process of implementing the ToC approach in developing mental health care plan. Results A total of 46 persons participated in four ToC workshops. Four critical path dimensions were identified: community, health facility, administrative and higher level care organisation. The ToC participants were actively engaged in the process and the ToC encouraged strong commitment among participants. Key opportunities and barriers to implementation and how to overcome these were suggested. During the workshops, a map incorporating the key agreed outcomes and outcome indicators was developed and finalized later. Conclusions The ToC approach was found to be an important component in the development of the MHCP and to encourage broad political support for the integration of mental health services into primary care. The method may have broader applicability in planning complex health interventions in low resource settings

Community-based rehabilitation intervention for people with schizophrenia in Ethiopia (RISE): results of a 12-month cluster-randomised controlled trial

Background:Community-based rehabilitation (CBR) is recommended to address the social and clinical needs of people with schizophrenia in resource-poor settings. We evaluated the effectiveness of CBR in reducing disability at 12 months in persons with schizophrenia who had disabling illness after six months access to standard care. Methods: This cluster-randomized controlled trial was conducted in a rural district of Ethiopia. We recruited adults with schizophrenia with disabling illness. 54 sub-districts were allocated in a 1:1 ratio to the intervention arm (facility-based care (FBC) plus CBR) or the control arm (FBC alone). FBC was a task-shared model of mental healthcare integrated within primary care. CBR was delivered by lay workers over 12 months and comprised home visits (psychoeducation, adherence support, family intervention, crisis management) and community mobilization. The primary outcome was disability, measured with the proxy-rated 36-item WHO Disability Assessment Schedule (WHODAS) at 12 months. The analyses used intention-to-treat principles. Trial registration: ClinicalTrials.gov, NCT02160249. Findings: Participants were enrolled between Sept 16, 2015 and Mar 11, 2016. Sub-districts without eligible participants were excluded. 79 participants in 24 sub-districts were assigned to CBR plus FBC and 87 participants in 24 sub-districts were assigned to FBC only. The primary analysis included 149 (89.8%) participants in 46 sub-districts. At 12 months, the mean WHODAS scores were 46.1 (SD 23.3) in the control arm and 40.6 (SD 22.5) in the intervention arm, indicating a favourable intervention effect (adjusted mean difference -8·13, 95%CI -15·85 to -0·40; p=0·039; effect size 0·35). Four (5·1%) intervention arm participants and nine (10·3%) control arm participants had at ≥1 serious adverse event (death, suicide attempt and hospitalization)

Community-based Rehabilitation Intervention for people with Schizophrenia in Ethiopia (RISE) cluster-randomized controlled trial: an exploratory analysis of impact on food insecurity, underweight, alcohol use disorder and depressive symptoms

We evaluated the effectiveness of community-based rehabilitation (CBR) in reducing depressive symptoms, alcohol use disorder, food insecurity and underweight in people with schizophrenia. This cluster-randomised controlled trial was conducted in a rural district of Ethiopia. Fifty-four sub-districts were allocated in a 1:1 ratio to the facility-based care [FBC] plus CBR arm and the FBC alone arm. Lay workers delivered CBR over 12 months. We assessed food insecurity (self-reported hunger), underweight (BMI< 18.5 kg/m2), depressive symptoms (PHQ-9) and alcohol use disorder (AUDIT ≥ 8) at 6 and 12 months. Seventy-nine participants with schizophrenia in 24 sub-districts were assigned to CBR plus FBC and 87 participants in 24 sub-districts were assigned to FBC only. There was no evidence of an intervention effect on food insecurity (aOR 0.52, 95% CI 0.16-1.67; p = 0.27), underweight (aOR 0.44, 95% CI 0.17-1.12; p = 0.08), alcohol use disorder (aOR 0.82, 95% CI 0.24-2.74; p = 0.74) or depressive symptoms (adjusted mean difference - 0.06, 95% CI -1.35, 1.22; p = 0.92). Psychosocial interventions in low-resource settings should support access to treatment amongst people with schizophrenia, and further research should explore how impacts on economic, physical and mental health outcomes can be achieved

Development of a scalable mental healthcare plan for a rural district in Ethiopia

Background:Developing evidence for the implementation and scaling up of mental healthcare in low- and middle-income countries (LMIC) like Ethiopia is an urgent priority.AimsTo outline a mental healthcare plan (MHCP), as a scalable template for the implementation of mental healthcare in rural Ethiopia.Method:A mixed methods approach was used to develop the MHCP for the three levels of the district health system (community, health facility and healthcare organisation).Results:The community packages were community case detection, community reintegration and community inclusion. The facility packages included capacity building, decision support and staff well-being. Organisational packages were programme management, supervision and sustainability.Conclusions:The MHCP focused on improving demand and access at the community level, inclusive care at the facility level and sustainability at the organisation level. The MHCP represented an essential framework for the provision of integrated care and may be a useful template for similar LMIC

Community-based rehabilitation intervention for people with schizophrenia in Ethiopia (RISE): results of a 12-month cluster-randomised controlled trial

Background Community-based rehabilitation (CBR) is recommended to address the social and clinical needs of people with schizophrenia in resource-poor settings. We evaluated the effectiveness of CBR at reducing disability at 12 months in people with schizophrenia who had disabling illness after having had the opportunity to access facility-based care for 6 months Methods This cluster-randomised controlled trial was conducted in a rural district of Ethiopia. Eligible clusters were subdistricts in Sodo district that had not participated in the pilot study. Available subdistricts were randomised (in a 1:1 ratio) to either the intervention group (CBR plus facility-based care) or to the control group (facility-based care alone). An optimisation procedure (accounting for the subdistrict mean WHO Disability Assessment Schedule (WHODAS) score and the potential number of participants per subdistrict) was applied for each of the eight health facilities in the district. An independent statistician, masked to the intervention or control label, used a computer programme to randomly choose the allocation sequence from the set of optimal ones. We recruited adults with disabling illness as a result of schizophrenia. The subdistricts were eligible for inclusion if they included participants that met the eligibility criteria. Researchers recruiting and assessing participants were masked to allocation status. Facility-based care was a task-shared model of mental health care integrated within primary care. CBR was delivered by lay workers over a 12-month period, comprising of home visits (psychoeducation, adherence support, family intervention, and crisis management) and community mobilisation. The primary outcome was disability, measured with the proxy-rated 36-item WHODAS score at 12 months. The subdistricts that had primary outcome data available were included in the primary analysis. This study is registered with ClinicalTrials.gov, NCT02160249. Findings Enrolment took place between Sept 16, 2015 and Mar 11, 2016. 54 subdistricts were randomised (27 to the CBR plus facility-based care group and 27 to the facility-based care group). After exclusion of subdistricts without eligible participants, we enrolled 79 participants (66% men and 34% women) from 24 subdistricts assigned to CBR plus facility-based care and 87 participants (59% men and 41% women) from 24 subdistricts assigned to facility-based care only. The primary analysis included 149 (90%) participants in 46 subdistricts (73 participants in 22 subdistricts in the CBR plus facility-based care group and 76 participants in 24 subdistricts in the facility-based care group). At 12 months, the mean WHODAS scores were 46·1 (SD 23·3) in the facility-based care group and 40·6 (22·5) in the CBR plus facility-based care group, indicating a favourable intervention effect (adjusted mean difference −8·13 [95% CI −15·85 to −0·40]; p=0·039; effect size 0·35). Four (5%) CBR plus facility-based care group participants and nine (10%) facility-based care group participants had one or more serious adverse events (death, suicide attempt, and hospitalisation). Interpretation CBR delivered by lay workers combined with task-shared facility-based care, was effective in reducing disability among people with schizophrenia. The RISE study CBR model is particularly relevant to low-income countries with few mental health specialists. Funding Wellcome Trust