Research evaluating the effectiveness of dementia interventions in low- and middle-income countries: A systematic mapping of 340 randomised controlled trials.

OBJECTIVES: More people with dementia live in low- and middle-income countries (LMICs) than in high-income countries, but best-practice care recommendations are often based on studies from high-income countries. We aimed to map the available evidence on dementia interventions in LMICs. METHODS: We systematically mapped available evidence on interventions that aimed to improve the lives of people with dementia or mild cognitive impairment (MCI) and/or their carers in LMICs (registered on PROSPERO: CRD42018106206). We included randomised controlled trials (RCTs) published between 2008 and 2018. We searched 11 electronic academic and grey literature databases (MEDLINE, EMBASE, PsycINFO, CINAHL Plus, Global Health, World Health Organization Global Index Medicus, Virtual Health Library, Cochrane CENTRAL, Social Care Online, BASE, MODEM Toolkit) and examined the number and characteristics of RCTs according to intervention type. We used the Cochrane risk of bias 2.0 tool to assess the risk of bias. RESULTS: We included 340 RCTs with 29,882 (median, 68) participants, published 2008-2018. Over two-thirds of the studies were conducted in China (n = 237, 69.7%). Ten LMICs accounted for 95.9% of included RCTs. The largest category of interventions was Traditional Chinese Medicine (n = 149, 43.8%), followed by Western medicine pharmaceuticals (n = 109, 32.1%), supplements (n = 43, 12.6%), and structured therapeutic psychosocial interventions (n = 37, 10.9%). Overall risk of bias was judged to be high for 201 RCTs (59.1%), moderate for 136 (40.0%), and low for 3 (0.9%). CONCLUSIONS: Evidence-generation on interventions for people with dementia or MCI and/or their carers in LMICs is concentrated in just a few countries, with no RCTs reported in the vast majority of LMICs. The body of evidence is skewed towards selected interventions and overall subject to high risk of bias. There is a need for a more coordinated approach to robust evidence-generation for LMICs.

Understanding dementia care pathways for policy development and service planning in Kenya.

BACKGROUND: In Kenya, there is lack of evidence on existing dementia care pathways, with minimal or no presentation for dementia-related symptoms in health care settings. Understanding the services available for people with dementia as well as how communities access the services could offer a practical pattern for policy makers to identify strategies that encourage early detection, care and support for people with dementia and their families. OBJECTIVES: To elucidate initial responses of individuals and their families to dementia and challenges encountered in help seeking through care pathways to inform dementia care-related policies and practice. METHODS: The Strengthening Responses to dementia in Developing Countries (STRiDE) Kenya team adapted case vignettes (brief hypothetical stories meant to elicit responses on how the characters would behave) developed by the entire STRiDE team. A total of 29 stakeholders were then asked to provide feedback on the completed vignettes and summarize a common pathway to dementia care in Kenya while using the proposed case vignettes. FINDINGS: We found four initial responses to dementia suspicion in Kenya where individuals:(i) Perceive symptoms as normal part of ageing, (ii) Consult a spiritual or traditional healer, (iii) Visit a private clinic or primary health care facilities, or (iv) No action taken. These were the first points within the care pathways which determined the care trajectory the person with dementia would follow. CONCLUSIONS: Identification of dementia care pathways could form a basis for improving the way communities perceive dementia etiology and establish standard pathways to care whilst ensuring that some pathways do not further pose an impediment to care and treatment for dementia.

Prevalence and perception of substance abuse and associated economic indicators and mental health disorders in a large cohort of Kenyan students: towards integrated public health approach and clinical management.

BACKGROUND: The earlier younger people begin to use drugs, the more vulnerable they become to both their short term and long-term harmful effects. The overall aim of this study is to determine the prevalence of alcohol and drug abuse, the socio-demographic characteristic, perception of abuse and associated economic indicators and mental disorders and how they inform potential intervention in a cohort of Kenyan students. METHODS: This was a cross-sectional study on a total of 9742 high school, college and university students. We used tools to document socio-demographic characteristics, economic indicators, drug and alcohol use and related perceptions and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) related psychiatric disorders. Basic descriptive statistics (means and standard deviations for numerical variables and frequencies for nominal and ordinal variables) were done. Logistic regression models were used to assess the association and odds ratios between the use of a given substance and the use of the other substances, as well as associations with the various available socio-demographic factors and economic indicators. Chi-squared tests were used in socio-economic characteristics disaggregated by current alcohol use. RESULTS: The mean age was 21.4 ± 2.4; median = 21.3 (range 15-43) years. We found a wide range of different drugs of abuse. Alcohol abuse was the commonest and inhalants were the least, with different perceptions.Both alcohol and drug abuse were associated with various economic indicators and various mental disorders. CONCLUSION: This study has established for the first time in Kenya the multifaceted associations and predictors of alcohol and drug abuse in a cross-sectional student population ranging from high school to college and university levels. In the process, the study contributes to global data on the subject. These associations call for an integrated and multifaceted approach in addressing alcohol and substance abuse. This approach should take into account various associations and predictors as part of holistic approach in both public awareness and clinical interventions.

Heeding the Call of an Innovative Paradigm for Mental Health Interventions in Low- and Middle-income Countries.

The provision of mental health care for people living in low- and middle-income countries presents a particularly complex problem because of fractured service availability and provision, widespread stigma associated with mental illness, and the economic burden inherent in conventional mental health service delivery. People with serious mental illness in these settings are among the most marginalized in their societies and are at risk of becoming increasingly powerless in the face of top-down, service-oriented systems. Innovative intersectoral approaches that are based on asset development and entrepreneurism and that embrace the power of peer-driven networks hold promise to effect transformative and meaningful change.

Suicidal behavior risks during adolescent pregnancy in a low-resource setting: A qualitative study.

BACKGROUND: Suicide is one of the most common causes of death among female adolescents. A greater risk is seen among adolescent mothers who become pregnant outside marriage and consider suicide as the solution to unresolved problems. We aimed to investigate the factors associated with suicidal behavior among adolescent pregnant mothers in Kenya. METHODS: A total of 27 Focus Group Discussions (FGDs) and 8 Key Informant Interviews (KIIs) were conducted in a rural setting (Makueni County) in Kenya. The study participants consisted of formal health care workers and informal health care providers (traditional birth attendants and community health workers), adolescent and adult pregnant and post-natal (up to six weeks post-delivery) women including first-time adolescent mothers, and caregivers (husbands and/or mothers-in-law of pregnant women) and local key opinion leaders. The qualitative data was analyzed using Qualitative Solution for Research (QSR) NVivo version 10. RESULTS: Five themes associated with suicidal behavior risk among adolescent mothers emerged from this study. These included: (i) poverty, (ii) intimate partner violence (IPV), (iii) family rejection, (iv) social isolation and stigma from the community, and (v) chronic physical illnesses. Low economic status was associated with hopelessness and suicidal ideation. IPV was related to drug abuse (especially alcohol) by the male partner, predisposing the adolescent mothers to suicidal ideation. Rejection by parents and isolation by peers at school; and diagnosis of a chronic illness such as HIV/AIDS were other contributing factors to suicidal behavior in adolescent mothers. CONCLUSION: Improved social relations, economic and health circumstances of adolescent mothers can lead to reduction of suicidal behaviour. Therefore, concerted efforts by stakeholders including family members, community leaders, health care workers and policy makers should explore ways of addressing IPV, economic empowerment and access to youth friendly health care centers for chronic physical illnesses. Prevention strategies should include monitoring for suicidal behavior risks during pregnancy in both community and health care settings. Additionally, utilizing lay workers in conducting dialogue discussions and early screening could address some of the risk factors and reduce pregnancy- related suicide mortality in LMICs.

Integration of Traditional Birth Attendants into Mental Healthcare: A Multistakeholder Qualitative Study Exploration.

BACKGROUND: A significant number of people with common mental disorders are undiagnosed or undetected at primary healthcare facilities. The experience of traditional birth attendants (TBAs) in reassuring perinatal mothers could be utilized in maternal mental healthcare. The aim of this study was to gain insight into the feasibility of integrating TBAs into maternal mental healthcare using multiple stakeholder views. METHODS: We conducted an exploratory qualitative study in September 2017 using focus group discussions (FGDs) and in depth interviews in Makueni County, Kenya. A total of 246 participants (TBAs, community health volunteers (CHVs), healthcare workers (HCWs), antenatal and postnatal mothers seeking care from TBAs and those seeking both hospital and TBA services, mothers in law and/or husbands of perinatal mothers, and opinion leaders based in the county) were purposively selected to participate in the discussions. Transcribed data was analyzed using NVivo version 10. RESULTS: Four major themes emerged from the qualitative data and were identified as follows; (a) involving TBAs in perinatal mental healthcare by assigning them roles, (b) utilizing TBAs' patient rapport and counseling experience, (c) recognition and appreciation of TBAs by the healthcare system, and (d) training and collaboration of TBAs with healthcare workers. DISCUSSION: The findings of this study reveal that although TBAs informally provide psychosocial interventions to pregnant mothers, their roles in mental health are not clearly defined. The importance of TBAs sharing their experience and being recognized as important stakeholders in mental healthcare for perinatal mothers was highlighted. Inclusion of TBAs in dialogue and training them to offer evidence-based mental healthcare were identified as important steps towards improving the mental wellbeing of mothers and the future generation.

Exploring mental health practice among Traditional health practitioners: a qualitative study in rural Kenya.

BACKGROUND: Involvement of traditional health practitioners (THPs) in the form of collaboration with the formal health care system is suggested to improve the pathways to mental health care in Kenya, yet understanding of the current traditional practice and THPs' perspectives is lacking. The aim of this study was to explore the views of THPs with respect to their mental health practice. METHODS: This study qualitatively explored the views of THPs, using four focus group discussions (FDGs) each consisting of 8-10 traditional and faith healers, resulting in a total of 36 participants. Thematic content analysis using a grounded theory approach was performed using QSR NVivo 10. Emerging topics were identified and examined by re-reading the transcripts several times and constantly re-sorting the material. RESULTS: Four themes that reflect THPs' mental health practice perspectives emerged as follows: 1) Categorization of mental illness; 2) Diagnostics in traditional mental health practice; 3) Treatments and challenges in current traditional mental health practice; and 4) Solutions to improve traditional mental health practice. CONCLUSIONS: These themes provide insight into the perspectives of Kenyan traditional and faith healers on their mental health practice, in an attempt to offer a meaningful contribution to the debate on collaboration between informal and formal health care providers in improving mental health services in Kenya. Furthermore, the presented challenges and solutions can inform policy makers in their task to improve and scale up mental health services in resource-poor areas in Kenya. Addressing these issues would be a first step towards understanding the solid foundation of traditional medicine that is necessary before collaboration can be successfully attempted. Further research is also recommended to assess patients' needs and explore potential forms of collaboration, in order to achieve sustainable improvement in the mental health care pathways for patients.

Prevalence and determinants of depression among patients under the care of traditional health practitioners in a Kenyan setting: Policy implications.

In Kenya, there is paucity of information on depression among traditional health practitioner (THP) patients, particularly in rural areas. The aim of this study was to estimate prevalence and identify determinants of major depressive disorder (MDD) among patients of THP in rural Kenya using the World Health Organization (WHO) Mental Health Gap Action Programme Intervention Guideline (mhGAP-IG). All adult patients seeking care from trained THPs (either traditional healers such as diviners and herbalists or faith healers, who use treatments such as prayers, laying hands on patients, or providing holy water and ash to their patients) over a period of 3 months (September 2014 to November 2014) were screened for depression using mhGAP-IG and their sociodemographic characteristics recorded. Overall, the prevalence of depression among THP patients was 22.9%. Being older, female, single, divorced or separated, as well as unemployment and lack of education were found to be significant determinants of depression. Patients with MDD frequently presented with suicidal behavior (32.9%, OR = 5.94, p < .0001) compared to those that had at least one psychotic symptom (26.3%, OR = 3.65, p < .0001). A measure of the accuracy of THPs' assessment of MDD showed 86% specificity and 46% sensitivity and the area under receiver operating characteristics (ROC) curve was 0.686. Our findings shed light on the prevalence of depression among THP patients and thus highlight the need for further research on diagnostic tools for use among THPs in order to avoid substandard care and promote reliance on more evidence-based methods of care.

Quality of life of depressed and suicidal patients seeking services from traditional and faith healers in rural Kenya.

BACKGROUND: In rural Kenya, traditional and faith healers provide an alternative pathway to health care, including mental health care. However, not much is known about the characteristics of the populations they serve. The purpose of this study was to determine the relationship between depression, suicidal ideation, and socio-demographic variables with Quality of Life (QoL) indicators in a sample seeking mental health services from traditional and faith healers in rural Kenya. Understanding QoL in this sample can help develop mental health policy and training to improve the well-being of this population. METHOD: This was a cross-sectional epidemiological survey (n = 443) conducted over a period of 3 months among adult patients seeking care from traditional and faith healers in rural Kenya. Data were collected using the Beck Depression Inventory II (BDI-II), Beck Scale for Suicide Ideation (BSS) and WHO Quality of Life Survey- BREF (WHOQOL-BREF), and analyzed using correlation analyses, parametric tests, and regression analyses. RESULTS: Increasing levels of depression were associated with lower QoL among patients seeking care from traditional and faith healers. BSS scores were significantly negatively correlated with overall, physical, psychological, and environmental QoL, p < .05. There was a statistically significant difference between mean scores for overall QoL between depressed (M = 2.35, SD = 0.76) and non-depressed participants (M = 3.03, SD = 0.67), t(441) = 8.899, p < .001. Overall life satisfaction for depressed participants (M = 2.23, SD = 0.69) was significantly lower than non-depressed participants. Regression analyses indicated that depression, suicidal ideation, and being married predicted lower overall QoL controlling for other variables. Post hoc tests and subgroup analysis by gender revealed significant differences for females only. Depression, and older age predicted lower life satisfaction whereas being self-employed predicted higher life satisfaction, when controlling for other variables. CONCLUSION: This study sheds light on correlates of QoL in depressed and non-depressed patients in rural Kenya. Evidence suggests that traditional and faith healers treat patients with a variety of QoL issues. Further research should focus on understanding how these issues tie into QoL, and how these healers can target these to improve care.

Mental Health Outcomes of Psychosocial Intervention Among Traditional Health Practitioner Depressed Patients in Kenya.

Task-shifting in mental health such as engaging Traditional Health Practitioners (THPs) in appropriate management of mental disorders is crucial in reducing global mental health challenges. This study aims to determine the outcomes of using evidence-based mental health Global Action Programme Intervention guide (mhGAP-IG) to provide psychosocial interventions among depressed patients seeking care from THPs. THPs were trained to deliver psychosocial interventions to their patients screening positive for mild to severe depression on Beck's Depression Inventory (BDI). Assessments were conducted at 0, 6 and 12 weeks and Analysis of Variance (ANOVA) performed to determine the change in depression scores over the three time period. BDI mean score was 26.52 before intervention and reduced significantly at 6 (13%) and 12 (35%) weeks after intervention. 58 and 78% of patients showed reduction in symptoms of depression at 6 and 12 weeks. It is therefore crucial to engage THPs in the care of patients with depression and the need for inclusion of training packages; and other mental disorders in order to establish and maintain collaboration between THPs and conventional health workers and promote evidence-based care among marginalized populations. Moreover, further research on randomized control trials of mhGAP-IG intervention versus usual care is required.

Forming a joint dialogue among faith healers, traditional healers and formal health workers in mental health in a Kenyan setting: towards common grounds.

BACKGROUND: Qualitative evidence on dialogue formation and collaboration is very scanty in Kenya. This study thus aimed at the formation of dialogue and establishment of collaboration among the informal (faith and traditional healers) and formal health workers (clinicians) in enhancing community-based mental health in rural Kenya. METHODS: Qualitative approach was used to identify barriers and solutions for dialogue formation by conducting nine Focus Group Discussions each consisting of 8-10 participants. Information on age, gender and role in health care setting as well as practitioners' (henceforth used to mean informal (faith and traditional healers) and formal health workers) perceptions on dialogue was collected to evaluate dialogue formation. Qualitative and quantitative data analysis was performed using thematic content analysis and Statistical Package Social Sciences (SPSS) software respectively. RESULTS: We identified four dominant themes such as; (i) basic understanding about mental illnesses, (ii) interaction and treatment skills of the respondents to mentally ill persons, (iii) referral gaps and mistrust among the practitioners and (iv) dialogue formation among the practitioners. Although participants were conversant with the definition of mental illness and had interacted with a mentally ill person in their routine practice, they had basic information on the causes and types of mental illness. Traditional and faith healers felt demeaned by the clinicians who disregarded their mode of treatment stereotyping them as "dirty". After various discussions, majority of practitioners showed interest in collaborating with each other and stated that they had joined the dialogue in order interact with people committed to improving the lives of patients. CONCLUSION: Dialogue formation between the formal and the informal health workers is crucial in establishing trust and respect between both practitioners and in improving mental health care in Kenya. This approach could be scaled up among all the registered traditional and faith healers in Kenya.