Integration of perinatal mental health care into district health services in Uganda: Why is it not happening? The Four Domain Integrated Health (4DIH) explanatory framework.

The Sustainable Development Goals recognise mental health and well-being as a target area, however, mobilizing funding and prioritisation of the same remains a challenge. Perinatal mental health care has the potential for incorporation and integration across the overall maternal health agenda, and can be especially relevant for low- and middle-income countries in their overall health systems strengthening strategies. This study aimed at qualitatively situating the extent to which integration of perinatal mental health care into maternal health care was considered desirable, possible and opportune within the existing policy and service-delivery environment in Uganda. A total of 81 in-depth interviews and nine focus group discussions (N = 64) were conducted with a variety of national, district, health system and community-level stakeholders. Data were analysed thematically using theory- and data-driven codebooks in NVivo 11. Analysis of the desirability, possibility and opportunity for integrating perinatal mental health care within the Ugandan district health system, highlights that concerned stakeholders perceive this as a worthwhile endeavour that would benefit the communities as well as the health system as a whole. Based on these current realities and ideal scenarios, a tentative explanatory framework that brings together various perspectives - that is, the perceived nature of the health problem, local and national health system issues, alternative systems of care and support, and international global perspectives - was constructed. The framework needs further validation but already hints at the need for global, national and local forces to concurrently rally behind the inclusion and integration of perinatal mental health care, especially at the primary care level in low- and middle-income contexts. If the global health community is poised to achieve high quality, women-centered care and people-centered health systems across the lifespan, then the sustainable integration of mental health care into general health care, is a commitment that can no longer be delayed.

Intra-household Variation in Pathways to Care for Epilepsy and Mental Disorders in Eastern Uganda.

Integrating mental, neurological, and substance use (MNS) health care into the public health system has become a global priority, with mental health, and well-being now being part of the Sustainable Development Goals. In the aim to provide good quality care for MNS disorders, understanding patients' pathways to care is key. This qualitative study explores the pathways to care of patients attending an outpatient mental health clinic of a district hospital in eastern rural Uganda, from the perspectives of their caregivers. Twenty seven in-depth interviews were conducted with caregivers of MNS patients visiting the clinic, with a focus on four case-presentations. Data analysis consisted of thematic and emergent content analyses using NVivo 11. Results across all interviews highlight that chosen help-seeking itineraries were largely pluralistic, combining and alternating between traditional healing practices, and biomedical care, regardless of the specific MNS disorder. Intra-household differences in care seeking pathways-e.g., where one patient received traditional help or no care at all, while the other received biomedical care-depended on caregivers' perceived contextual illness narrative for each patient, in combination with a variety of other factors. If interpreted as a form of bewitchment, traditional medicine and healing was often the first form of care sought, while the mental health clinic was seen as a recourse to "free" care. Patients, especially younger children, who showed visible improvements once stabilized on psychotropic medication was a source of motivation for caregivers to continue with biomedical care at the mental health clinic. However, stock-outs of the free psychotropic medication at the clinic led to dissatisfaction with services due to out-of-pocket expenses and precipitated returning to alternative therapy choices. This article showcases the importance of understanding the complex and varied combinations of individual, cultural, socioeconomic and structural factors that may affect caregivers' choices of pathways to care for patients with MNS disorders in eastern rural Uganda. These cumulative complex processes and context-specific help-seeking behaviors, which ultimately impact patient treatment and MNS health outcomes, need to be first acknowledged, understood and taken into account if we are to promote more inclusive, effective and integrated public mental health systems globally.

Precarity at the Margins of Malaria Control in the Chittagong Hill Tracts in Bangladesh: A Mixed-Methods Study.

Bangladesh has achieved significant progress towards malaria elimination, although health service delivery for malaria remains challenging in remote forested areas such as the Chittagong Hill Tracts (CHT). The aim of this study was to investigate perceptions of malaria and its treatment among the local population to inform contextualized strategies for rolling out radical cure for P. vivax in Bangladesh. The study comprised two sequential strands whereby the preliminary results of a qualitative strand informed the development of a structured survey questionnaire used in the quantitative strand. Results show that ethnic minority populations in the CHT live in precarious socio-economic conditions which increase their exposure to infectious diseases, and that febrile patients often self-treat, including home remedies and pharmaceuticals, before attending a healthcare facility. Perceived low quality of care and lack of communication between Bengali health providers and ethnic minority patients also affects access to public healthcare. Malaria is viewed as a condition that affects vulnerable people weakened by agricultural work and taking away blood is perceived to increase such vulnerability. Healthcare providers that initiate and sustain a dialogue about these issues with ethnic minority patients may foster the trust that is needed for local malaria elimination efforts.

Stakeholder perceptions on patient-centered care at primary health care level in rural eastern Uganda: A qualitative inquiry.

BACKGROUND: Patient-centered care (PCC) offers opportunities for African health systems to improve quality of care. Nonetheless, PCC continually faces implementation challenges. In 2015, Uganda introduced PCC as a concept in their national quality improvement guidelines. In order to investigate whether and how this is implemented in practice, this study aims to identify relevant stakeholders' views on the current quality of primary health care services and their understanding of PCC. This is an important step in understanding how the concept of PCC can be implemented in a resource constrained, sub-Saharan context like Uganda. METHODS: This qualitative study was conducted in Uganda at national, district and facility level, with a focus on three public and three private health centres. Data collection consisted of in-depth interviews (n = 49); focus group discussions (n = 7); and feedback meetings (n = 14) across the four main categories of stakeholders identified: patients/communities, health workers, policy makers and academia. Interviews and discussions explored stakeholder perceptions on the interpersonal aspects of quality primary health care and meanings attached to the concept of PCC. A content analysis of Ugandan policy documents mentioning PCC was also conducted. Thematic content analysis was conducted using NVivo 11 to organize and analyze the data. FINDINGS AND CONCLUSION: While Ugandan stakeholder groups have varying perceptions of PCC, they agree on the following: the need to involve patients in making decisions about their health, the key role of healthcare workers in that endeavor, and the importance of context in designing and implementing solutions. For that purpose, three avenues are recommended: Firstly, fora that include a wide range of stakeholders may offer a powerful opportunity to gain an inclusive vision on PCC in Uganda. Secondly, efforts need to be made to ensure that improved communication and information sharing-important components of PCC-translate to actual shared decision making. Lastly, the Ugandan health system needs to strengthen its engagement of the transformation from a community health worker system to a more comprehensive community health system. Cross-cutting the entire analysis, is the need to address, in a culturally-sensitive way, the many structural barriers in designing and implementing PCC policies. This is essential in ensuring the sustainable and effective implementation of PCC approaches in low- and middle-income contexts.

The Social Nature of Perceived Illness Representations of Perinatal Depression in Rural Uganda.

While the global health community advocates for greater integration of mental health into maternal health agendas, a more robust understanding of perinatal mental health, and its role in providing integrated maternal health care and service delivery, is required. The present study uses the Illness Representation Model, a theoretical cognitive framework for understanding illness conceptualisations, to qualitatively explore multiple stakeholder perspectives on perinatal depression in rural Uganda. A total of 70 in-depth interviews and 9 focus group discussions were conducted with various local health system stakeholders, followed by an emergent thematic analysis using NVivo 11. Local communities perceived perinatal depression as being both the fault of women, and not. It was perceived as having socio-economic and cultural causal factors, in particular, as being partner-related. In these communities, perinatal depression was thought to be a common occurrence, and its negative consequences for women, infants and the community at large were recognised. Coping and help-seeking behaviours prescribed by the participants were also primarily socio-cultural in nature. Placing the dynamics and mechanisms of these local conceptualisations of perinatal depression alongside existing gaps in social and health care systems highlights both the need of, and the opportunities for, growth and prioritisation of integrated perinatal biomedical, mental, and social health programs in resource-constrained settings.

The complex challenge of providing patient-centred perinatal healthcare in rural Uganda: A qualitative enquiry.

RATIONALE: Increasing research and reflections on quality of healthcare across the perinatal period slowly propels the global community to lobby for improved standards of quality perinatal healthcare, especially in low- and middle-income countries. OBJECTIVE: The purpose of this qualitative study was to obtain a deeper understanding of how interpersonal dimensions of the quality of care relate to real-life experiences of perinatal care, in a resource-constrained local health system. METHODS: In total, 41 in-depth interviews and five focus group discussions (N = 34) were conducted with perinatal women and local health system health professionals living and working in rural Uganda. Data analysis used an emergent and partially inductive, thematic framework based on the grounded theory approach. RESULTS: The results indicated that interpersonal aspects of quality of perinatal care and service delivery are largely lacking in this low-resource setting. Thematic analysis showed three interrelated process aspects of quality of perinatal care: negative reported patient-provider interactions, the perceptions shaping patient-provider interactions, and emergent consequences arising out of these processes of care. Further reflections expose the central, yet often-unheeded, role of perinatal women's agency in their own health seeking behaviours and overall well-being, as well as that of underlying practical norms surrounding health worker attitudes and behaviours. CONCLUSION: These findings highlight the complexity of patient-centred perinatal healthcare provision in rural Uganda and point to the relevance of linking the interpersonal dimensions of quality of care to the larger systemic and structural dimensions of perinatal healthcare.