Building capacity for community mental health care in rural Malawi: Findings from a district-wide task-sharing intervention with village-based health workers.

BACKGROUND: The mental health 'treatment gap' is at its widest in low-resource countries where the vast majority of its people have no access to mental health services and where developing effective models of primary mental health care that can expand from research pilot sites to large-scale population-based services is a major research and practice imperative. AIM: The Mental Health in Zomba initiative builds upon an earlier pilot project to establish and sustain a district-wide scale-up of a village-based health workers' mental health task-sharing intervention in Southern Malawi across a population of more than 600,000 people. METHODS: The article describes the development, implementation and structured evaluation of the impact of this task-sharing initiative. RESULTS: Results from an examination of the care for 240 consecutive attendees show how the village-based workers recognised and responded to the needs of people experiencing both common and severe mental health problems and how they facilitated 850 mental health promotion events to more than 40,000 people within their communities. CONCLUSION: A new and essential district-wide tier of mental health service was established at the crucial intersection between health centre and the community. Within the socio-cultural context of rural Malawi with its diverse explanatory models for psychological distress, the approach of the village-based health worker was found to be both credible and practical in meeting the needs of the population and therefore responding to both the 'supply' and 'demand' elements of the mental health treatment gap.

Integrating community mental health within primary care in southern Malawi: a pilot educational intervention to enhance the role of health surveillance assistants.

BACKGROUND: In response to the significant contribution of mental health problems to the global burden of disease, the World Health Organization (WHO, 2008) renewed its call for the integration of mental health services within primary care. The operationalization of this within resource-constrained settings such as rural Malawi, however, presents a challenge, not least the cultural acceptance of approaches to responding to psychological distress. AIM: This study reports on the development, implementation and evaluation of a mental health care training programme for 271 health surveillance assistants (HSAs) designed to overcome such challenges. METHOD: A structured evaluation of the impact of training on HSAs' provision of mental health care was undertaken. RESULTS: Result's demonstrated a statistically significant positive effect on HSAs' knowledge and confidence in providing care and analysis of patient records revealed considerable mental health care and health promotion activity wherein HSAs initiated a new dialogue with the community on mental health and human rights concerns. CONCLUSION: The HSAs' focus on the psychosocial concerns of individuals' 'distress' and 'risk' prepared the way for a practical set of culturally sensitive and therapeutic interventions and offers a potential path towards increasing the capacity of primary care mental health provision that is responsive to local understandings and experiences of distress.

Increasing the capacity of health surveillance assistants in community mental health care in a developing country, Malawi.

Mental health services in Malawi are centralized in the three tertiary units which are located one in each of the three regions of Malawi and this means that most people with mental health problems do not get help. With severe shortages of mental health professionals in the country, integration of mental health into existing primary and community health services is the most feasible way of increasing access to services for people with mental health problems. This paper discusses a pilot program of integrating mental health in the activities of Health Surveillance Assistants (HSAs) who are community health workers in Malawi.