Generating evidence to narrow the treatment gap for mental disorders in sub-Saharan Africa: rationale, overview and methods of AFFIRM.

There is limited evidence on the acceptability, feasibility and cost-effectiveness of task-sharing interventions to narrow the treatment gap for mental disorders in sub-Saharan Africa. The purpose of this article is to describe the rationale, aims and methods of the Africa Focus on Intervention Research for Mental health (AFFIRM) collaborative research hub. AFFIRM is investigating strategies for narrowing the treatment gap for mental disorders in sub-Saharan Africa in four areas. First, it is assessing the feasibility, acceptability and cost-effectiveness of task-sharing interventions by conducting randomised controlled trials in Ethiopia and South Africa. The AFFIRM Task-sharing for the Care of Severe mental disorders (TaSCS) trial in Ethiopia aims to determine the acceptability, affordability, effectiveness and sustainability of mental health care for people with severe mental disorder delivered by trained and supervised non-specialist, primary health care workers compared with an existing psychiatric nurse-led service. The AFFIRM trial in South Africa aims to determine the cost-effectiveness of a task-sharing counselling intervention for maternal depression, delivered by non-specialist community health workers, and to examine factors influencing the implementation of the intervention and future scale up. Second, AFFIRM is building individual and institutional capacity for intervention research in sub-Saharan Africa by providing fellowship and mentorship programmes for candidates in Ethiopia, Ghana, Malawi, Uganda and Zimbabwe. Each year five Fellowships are awarded (one to each country) to attend the MPhil in Public Mental Health, a joint postgraduate programme at the University of Cape Town and Stellenbosch University. AFFIRM also offers short courses in intervention research, and supports PhD students attached to the trials in Ethiopia and South Africa. Third, AFFIRM is collaborating with other regional National Institute of Mental Health funded hubs in Latin America, sub-Saharan Africa and south Asia, by designing and executing shared research projects related to task-sharing and narrowing the treatment gap. Finally, it is establishing a network of collaboration between researchers, non-governmental organisations and government agencies that facilitates the translation of research knowledge into policy and practice. This article describes the developmental process of this multi-site approach, and provides a narrative of challenges and opportunities that have arisen during the early phases. Crucial to the long-term sustainability of this work is the nurturing and sustaining of partnerships between African mental health researchers, policy makers, practitioners and international collaborators.

How much do patients in Blantyre, Malawi know about antibiotics and other prescription only medicines?

INTRODUCTION: This qualitative and quantitative exploratory study was conducted to assess patients'/customers' knowledge, beliefs and practices about antibiotics and other prescription only medication (POM) in 10 community pharmacies in Blantyre, Malawi. METHOD: 5 out of 10 pharmacies were selected by simple random sampling and 54 participants attending the selected pharmacies were interviewed. RESULTS: The major antibiotic drugs frequently requested without a doctor's prescription were Bactrim (Cotrimoxazole) and amoxicillin. Knowledge of these medicines was attributed to the patients' previous medical conditions and doctor's prescription. However this knowledge does not extend to understanding of proper therapeutic indications and dosage regimens for antibiotic therapy. The majority (30 out of 54 participants) did not know about the importance of completing a prescribed course of antibiotics. All 54 participants believed in the efficacy of antibiotics. CONCLUSION: Study participants had wide range of knowledge about antibiotics and other POM from hospital, but the majority had limited knowledge regarding clinical indications and correct dosage schedules.

HIV Disclosure: Parental dilemma in informing HIV infected Children about their HIV Status in Malawi.

BACKGROUND: Increasingly many perinatally HIV-infected children are surviving through adolescence and adulthood as a result of improvements in the management of paediatric HIV infection, particularly the increased use of combination therapy. It is usually the parents or guardians of these children who are faced with the task of informing the child living with HIV about his or her positive status. However, many parents-particularly biological parents -find this disclosure process difficult to initiate, and this study explored some of the difficulties that these parents encounter. OBJECTIVE: This study set out to explore potential factors that challenge parents and guardians when informing their perinatally HIV-infected child about the child's HIV status. DESIGN: This was a qualitative narrative study that employed in-depth interviews with parents or guardians of children perinatally infected with HIV. A total of 20 parents and guardians of children who attend the outpatient HIV clinic at the Baylor College of Medicine-Abbott Fund Children's Clinical Centre of Excellence (COE) in Lilongwe, Malawi were interviewed. Of these, 14 were biological parents and six were guardians. RESULTS: Guardians and parents expressed uneasiness and apprehension with the disclosure conversation, whether or not they had already told their child that he or she had HIV. Participants who had not told their children recounted that they had contemplated starting the conversation but could not gather enough courage to follow through with those thoughts. They cited the fear of robbing their child of the happiness of living without the knowledge of being positive, fear of making their own status known to more people, and fear of confrontation or creating enmity with their child as impediments to disclosing their child's positive HIV status to him or her. CONCLUSIONS: It is apparent that guardians-more particularly biological parents-of children perinatally infected by HIV find it difficult to inform their children about their children's HIV status. From this disempowered position, parents dread the disclosure of a positive HIV status to a child as a psychosocial process that has the potential to disturb a family's previously established equilibrium with threats of stigmatization, marginalization, and parent-child conflict. This calls for strategies that could support parents to make disclosure to the child less challenging.

Diversity in Health: Sharing Global Perspectives. 28-30 May 2001, Sydney, Australia.

This landmark conference on multicultural health and well being was held in the Sydney Convention ind Exhibition Centre overlooking Darling Harbour. The conference was organised by the Australian Transcultural Mental Health Network as well as the Australian Multicultural Health Conference. It brought together over 300 delegates mainly from Australia. A unique feature of this conference was the presentation of five speakers from Southern Africa who gave an African perspective to health and well being. Of the five, three were from South Africa, one represented Zimbabwe and I represented Malawi.

The experience of family foster care in Malawi: a preliminary investigation.

This preliminary investigation into family foster care in Malawi set out to provide information on the Malawi government family foster care structure primarily through the qualitative experience of foster caregivers. A semistructured interview schedule was used to interview 24 foster parents, who were selected from a government family foster care register, in two regions of Malawi. The study revealed that cultural factors influenced various aspects of family foster care, ranging from the caregivers' decision to foster children to the caregivers' determination not to disclose to the children that they were fostered. Social and economic factors also played a role, particularly with regard to some shortcomings in service delivery.

Characteristics and sexual behaviour of individuals attending the sexually transmitted diseases clinic at Queen Elizabeth Central Hospital Blantyre, Malawi.

Characteristics and sexual behaviour, knowledge of HIV and knowledge of attitudes to and use of the condom were assessed by a questionnaire survey of a sample of 734 patients attending a sexually transmitted diseases clinic at the Queen Elizabeth Central Hospital, Blantyre, Malawi. The male respondents had a mean age of 27.4 years compared with 24.5 for the women. Nearly two thirds of either sex reported more than one sexual partner during the previous year. Thirty one percent of the females and 43% of the males admitted having ever exchanged money directly for sex. Knowledge about HIV transmission and prevention, and the condom was generally good. Only 24% male and 45% female respondents reported having ever used the condom, with 27% and 43% respectively using it sometimes. No respondent used the condom always. The most common reported reason for not using the condom was partner refusal. Many of the respondents exhibited a high level of HIV risk behaviour.

AIDS-related beliefs, attitudes and intentions among Malawian students in three secondary schools.

This preliminary investigation into factors influencing the intention of Malawian secondary school students to engage in low-risk AIDS-related behaviours was based on the Theory of Reasoned Action (Ajzen & Fishbein, 1980). A total of 191 male and female subjects (mean age 19.32) from three secondary schools in Malawi filled in a questionnaire that sought to elicit their intention to use condoms and to stick to the one same sexual partner. The study lent support to the theory that intention can be predicted from attitudes and subjective norms, F(2,186) = 31.93, p < 0.001 for condom use and F(2, 187) = 15.23, p < 0.001 for sticking to one sexual partner. The results showed that, for the subjects, the intention to comply with these two behavioural regimens was predominantly under attitudinal control though one sub-sample's intention was under normative influence. The study also provided quantitative data on the sexual behavioural patterns of the subjects and used these data to furnish explanations of the main findings. Behavioural change intervention strategies in the light of the findings are discussed.

PIP: This preliminary investigation into factors influencing the intention of Malawian secondary school students to engage in low-risk AIDS-related behaviors was based on the Theory of Reasoned Action (Ajzen & Fishbein, 1980). A total of 191 male and female subjects (mean age, 19.32) from three secondary schools in Malawi filled in a questionnaire that sought to elicit their intention to use condoms and to stick to the one same sexual partner. The study lent support to the theory that intention can be predicted from attitudes and subjective norms [F(2,186) = 31.93, p 0.001 for condom use; F(2,187) = 15.23, p 0.001 for sticking to one sexual partner]. The results showed that for the subjects the intention to comply with these two behavioral regimens was predominantly under attitudinal control though one sub-sample's intention was under normative influence. The study also provided quantitative data on the sexual behavioral patterns of the subjects and used these data to furnish explanations of the main findings. Behavioral change intervention strategies in the light of the findings are discussed.