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) 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.

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.

Adherence to COVID -19 protective practices in Ethiopia: Use and predictors of face mask-wearing.

Introduction: The Ethiopian Ministry of Health strongly recommends that anyone, regardless of vaccination status, wears a standard face mask consistently when in public. This study aimed to assess the self-reported use and predictors of wearing face masks in the general population in Ethiopia. Methods: This was a population-based cross-sectional study using a telephone survey. Adults living in Ethiopia were randomly selected from the Ethio Telecom list of mobile phone numbers and interviewed about their mask-wearing practice and individual and household-level factors that could impact on the use of face masking. Multivariable logistic regression was used to measure associations. Results: A total of 614 participants were interviewed from September to November 2021. The prevalence of self-reported face mask use when in public was 81.1%. Living outside Addis Ababa, including Oromia [adjusted odds ratio [(AOR) 0.30, 95% confidence interval (CI) (0.14, 0.63)], Amhara [AOR 0.11, 95% CI (0.05, 0.23)], and Southern Nations, Nationalities and People's Region [AOR 0.31, 95% CI (0.12-0.79)] and being divorced or widowed [AOR 0.18, 95% CI (0.06, 0.62)] were found to be inversely associated with face mask use. Female gender [AOR 1.91, 95% CI (1.02, 3.58)] and older age [age ≥ 50, AOR 2.96, 95% CI (1.09-7.97)] were positively associated with the use of face masks. Attending social events [AOR 0.51, 95% CI (0.31-0.82)], was negatively associated with the use of face masks. Conclusion: Self-reported use of face masks was relatively high nationally, but inconsistent among different regions and demographics. The findings imply that policies and messaging campaigns may need to focus on specific populations and behaviors in this ongoing pandemic.

COVID -19 vaccine hesitancy and determinants in Ethiopia: A national pilot survey.

Introduction: Despite major advances in Corona Virus Disease 2019 (COVID-19) vaccine development, vaccine hesitancy threatens the progress made to curb the disease. We aimed to assess the level of COVID-19 vaccine hesitancy and the underlying determinants in Ethiopia. Methods: A pilot mobile phone survey of adults in Ethiopia with mobile phones selected randomly. Results: The pilot survey included 614 participants who were predominantly male (71.7%), and married (68.2%) with a median age of 34 years (interquartile range [IQR] = 14.0). Overall, 150 (24.4%) participants reported to have been vaccinated; either the first [57 (38%)], second [19 (12.7%)], or both [74 (49.3%)] doses. About one in six participants (16.3%; n=100) reported vaccine hesitancy, with a significant difference by employment status, with self-employed more likely to show hesitancy [adjusted odds ratio (AOR) 1.85, 95% CI (1.05-3.27)], and region. Major drivers of hesitancy were lack of interest [n=30 (30%)], fear of side-effects [n=24 (24%)], and lack of trust in the vaccine [n=13 (13%)]. Having chronic disease conditions in the family had no association with hesitancy (p > 0.05). Conclusion: While representativeness of the sample is an issue, the findings show a relatively low rate of COVID-19 vaccine hesitancy among the Ethiopian population. The major drivers of hesitancy, lack of interest, fear of side-effects, and lack of trust in the vaccine, may be reversed by disseminating accurate and timely information using credible sources across communities.

Mental wellbeing during the time of COVID-19 pandemic: A national pilot survey in Ethiopia.

Introduction: The Coronavirus Disease 2019 (COVID-19) pandemic substantially disrupts population health and wellbeing globally, while little is known about the effect on mental wellbeing in developing countries. This study aimed to assess the impact of COVID-19 on mental wellbeing of individuals and households in Ethiopia. Methods: A cross-sectional, national pilot survey was conducted through phone interviews from September to November 2021. Mental wellbeing and disability were assessed using a questionnaire adapted from the 5-item World Health Organization Wellbeing Index (WHO-5), the Oslo Social Support Scale (OSSS-3), and the WHO Disability Assessment Scale (WHODAS 2.0). Results: A total of 614 adults completed the pilot survey. The mean age was 36 years (standard deviation 11) and 71.7% were male. Mental wellbeing was poor in 218 (35.5%) participants. The most important predictors for poor mental wellbeing were rural residence (Adjusted Odds Ratio [AOR] 1.89; 95% CI 1.14, 3.14; p=0.012), perceived COVID-19 risk (AOR 1.75; 95% CI 1.18, 2.60; p=0.005), household stress (AOR 2.09; 95% CI 1.31, 3.34; p=0.002), experience of symptom of COVID-19 in the household (AOR 2.14; 95% CI 1.13, 4.04; p=0.019), and poor social support (AOR 2.43; 95% CI 1.51, 3.91; p<0.001). Conclusion: The study provides evidence that COVID-19 had a significant adverse impact on the mental wellbeing of individuals and households in Ethiopia. Further studies are needed to understand in detail the implications of the pandemic and interventions needed to keep mental wellbing of citizens.

Pathways into and out of homelessness among people with severe mental illness in rural Ethiopia: a qualitative study.

BACKGROUND: Little is known about the pathways followed into and out of homelessness among people with experience of severe mental illness (SMI) living in rural, low-income country settings. Understanding these pathways is essential for the development of effective interventions to address homelessness and promote recovery. The aim of this study was to explore pathways into and out of homelessness in people with SMI in rural Ethiopia. METHODS: In-depth interviews were conducted with 15 people with SMI who had experienced homelessness and 11 caregivers. Study participants were identified through their participation in the PRIME project, which implemented a multi-component district level plan to improve access to mental health care in primary care in Sodo district, Ethiopia. People enrolled in PRIME who were diagnosed with SMI (schizophrenia, schizoaffective disorder or bipolar disorder) and who had reported experiencing homelessness at recruitment formed the sampling frame for this qualitative study. We used OpenCode 4.0 and Microsoft Excel for data management. Thematic analysis was conducted using an inductive approach. RESULTS: Study participants reported different patterns of homelessness, with some having experienced chronic and others an intermittent course. Periods of homelessness occurred when family resources were overwhelmed or not meeting the needs of the person with SMI. The most important pathways into homelessness were reported to result from family conflict and the worsening of mental ill health, interplaying with substance use in many cases. Participants also mentioned escape and/or wanting a change in environment, financial problems, and discrimination from the community as contributing to them leaving the home. Pathways out of homelessness included contact with (mental and physical) health care as a catalyst to the mobilization of other supports, family and community intervention, and self-initiated return. CONCLUSIONS: Homelessness in people with SMI in this rural setting reflected complex health and social needs that were not matched by adequate care and support. Our study findings indicate that interventions to prevent and tackle homelessness in this and similar settings ought to focus on increasing family support, and ensuring access to acceptable and suitable housing, mental health care and social support.

Impact of integrated mental health care on food insecurity of households of people with severe mental illness in a rural African district: a community-based, controlled before-after study.

OBJECTIVES: To evaluate the impact of integrated mental health care upon food insecurity (FI) in households of people with severe mental illness (SMI) in a rural Ethiopian district, and to investigate mediation by improved work impairment and discrimination. METHODS: A community-based, controlled before-after study was conducted. People with probable SMI were identified in the community, diagnosed by primary healthcare workers, with diagnostic confirmation from a psychiatric nurse. Households of a person with SMI were matched to control households. District-wide integration of mental health care was implemented. Change in FI status over 12 months of follow-up was measured using the Household Food Insecurity Access Scale. Multivariable models were used to assess improvement in FI. Direct and indirect mediators of change in FI status were modelled using path analysis. RESULTS: A total of 239 (81.8%) people with SMI and 273 (96.5%) control households were assessed after 12 months. Maintenance of food security or improvement in food insecurity status was observed in 51.5% of households of a person with SMI vs. 39.7% of control households (adjusted risk ratio 1.41: 95% CI 1.11, 1.80). Reduction in symptom severity was indirectly associated with improved FI status via an impact on reducing work impairment and discrimination (P < 0.001). CONCLUSIONS: Improving access to mental health care may reduce food insecurity in households of people with SMI. Optimising engagement in care and adding interventions to improve work functioning and tackle discrimination may further reduce food insecurity.

OBJECTIFS: Evaluer l'impact des soins de santé mentale intégrés sur l'insécurité alimentaire (IA) dans les ménages de personnes souffrant de maladie mentale sévère (MMS) dans un district rural éthiopien, et investiguer sur la médiation en améliorant les perturbations au travail et la discrimination. MÉTHODES: Une étude communautaire contrôlée avant et après a été menée. Des personnes avec une MMS probable ont été identifiées dans la communauté, diagnostiquées par des agents de santé primaires, avec confirmation diagnostique d'une infirmière psychiatrique. Les ménages de personnes atteintes de MMS ont été appariés pour effectuer des ajustements sur les ménages. Une intégration des soins de santé mentale à l'échelle du district a été mise en œuvre. Le changement de statut de l'IA au cours un suivi de 12 mois a été mesuré à l'aide de l'Echelle d'Accès à l'Insécurité Alimentaire des ménages. Des modèles multivariés ont été utilisés pour évaluer l'amélioration de l'IA. Les médiateurs directs et indirects du changement de statut de l'IA ont été modélisés à l'aide d'une analyse de chemin. RÉSULTATS: Un total de 239 (81,8%) ménages de personnes avec une MMS et 273 (96,5%) ménages témoins ont été évaluées après 12 mois. Le maintien de la sécurité alimentaire ou l'amélioration de l'état d'insécurité alimentaire a été observé dans 51,5% des ménages d'une personne avec une MMS vs 39,7% des ménages témoins (rapport de risque ajusté: 1,41 ; IC95%: 1,11 à 1,80). La réduction de la sévérité des symptômes était indirectement associée à une amélioration du statut de l'IA via un impact sur la réduction des perturbations au travail et de la discrimination (p <0,001). CONCLUSIONS: L'amélioration de l'accès aux soins de santé mentale peut réduire l'IA dans les ménages de personnes atteintes de MMS. L'optimisation de l'engagement dans les soins et l'ajout d'interventions pour améliorer le fonctionnement au travail et lutter contre la discrimination peuvent encore réduire l'IA.

Rural vs urban residence and experience of discrimination among people with severe mental illnesses in Ethiopia.

BACKGROUND: Few studies have addressed mental illness-related discrimination in low-income countries, where the mental health treatment gap is highest. We aimed to evaluate the experience of discrimination among persons with severe mental illnesses (SMI) in Ethiopia, a low-income, rapidly urbanizing African country, and hypothesised that experienced discrimination would be higher among those living in a rural compared to an urban setting. METHODS: The study was a cross-sectional survey of a community-ascertained sample of people with SMI who underwent confirmatory diagnostic interview. Experienced discrimination was measured using the Discrimination and Stigma Scale (DISC-12). Zero-inflated negative binomial regression was used to estimate the effect of place of residence (rural vs. urban) on discrimination, adjusted for potential confounders. RESULTS: Of the 300 study participants, 63.3% had experienced discrimination in the previous year, most commonly being avoided or shunned because of mental illness (38.5%). Urban residents were significantly more likely to have experienced unfair treatment from friends (χ2(1) = 4.80; p = 0.028), the police (χ2(1) =11.97; p = 0.001), in keeping a job (χ2(1) = 5.43; p = 0.020), and in safety (χ2(1) = 5.00; p = 0.025), and had a significantly higher DISC-12 score than those living in rural areas (adjusted risk ratio: 1.66; 95% CI: 1.18, 2.33). CONCLUSIONS: Persons with SMI living in urban settings report more experience of discrimination than their rural counterparts, which may reflect a downside of wider social opportunities in urban settings. Initiatives to expand access to mental health care should consider how social exclusion can be overcome in different settings.

The psychosis treatment gap and its consequences in rural Ethiopia.

BACKGROUND: The "treatment gap" (TG) for mental disorders, widely advocated by the WHO in low-and middle-income countries, is an important indicator of the extent to which a health system fails to meet the care needs of people with mental disorder at the population level. While there is limited research on the TG in these countries, there is even a greater paucity of studies looking at TG beyond a unidimensional understanding. This study explores several dimensions of the TG construct for people with psychosis in Sodo, a rural district in Ethiopia, and its implications for building a more holistic capacity for mental health services. METHOD: The study was a cross-sectional survey of 300 adult participants with psychosis identified through community-based case detection and confirmed through subsequent structured clinical evaluations. The Butajira Treatment Gap Questionnaire (TGQ), a new customised tool with 83 items developed by the Ethiopia research team, was administered to evaluate several TG dimensions (access, adequacy and effectiveness of treatment, and impact/consequence of the treatment gap) across a range of provider types corresponding with the WHO pyramid service framework. RESULTS: Lifetime and current access gap for biomedical care were 41.8 and 59.9% respectively while the corresponding figures for faith and traditional healing (FTH) were 15.1 and 45.2%. Of those who had received biomedical care for their current episode, 71.7% did not receive minimally adequate care. Support from the community and non-governmental organisations (NGOs) were negligible. Those with education (Adj. OR: 2.1; 95% CI: 1.2, 3.8) and history of use of FTH (Adj. OR: 3.2; 95% CI: 1.9-5.4) were more likely to use biomedical care. Inadequate biomedical care was associated with increased lifetime risk of adverse experiences, such as history of restraint, homelessness, accidents and assaults. CONCLUSION: This is the first study of its kind. Viewing TG not as a unidimensional, but as a complex, multi-dimensional construct, offers a more realistic and holistic understanding of health beliefs, help-seeking behaviors, and need for care. The reconceptualized multidimensional TG construct could assist mental health services capacity building advocacy and policy efforts and allow community and NGOs play a larger role in supporting mental healthcare.

Functional impairment among people diagnosed with depression in primary healthcare in rural Ethiopia: a comparative cross-sectional study.

BACKGROUND: There have been few studies examining the functioning of clinically-diagnosed people with depression in primary healthcare (PHC) in low- and middle-income countries (LMICs). The aim of this study was to identify factors associated with functional impairment among people diagnosed with depression in PHC in Ethiopia as part of implementation of a task-shared model of mental healthcare. METHODS: A comparative cross-sectional study was conducted. As part of the Programme for Improving Mental health carE (PRIME), PHC clinicians were trained to diagnose depression using an adapted version of the World Health Organization (WHO) mental health Gap Action Programme (mhGAP). A total of 2038 adult consecutive PHC attendees were screened for depressive symptoms using the 9-item Patient Health Questionnaire (PHQ-9). Those who scored five or above on the PHQ-9 (n = 131) were assessed by PHC workers. Of these, 92 were diagnosed to have depression ("PHC diagnosed cases") and the remaining 39 people were PHQ positive but considered not to have depression ("non-diagnosed controls"). PHC diagnosed cases were also compared to a community representative sample of adult healthy controls (n = 197; "community controls"). The 12-item version of the WHO Disability Assessment Schedule (WHODAS-2.0) was used to assess functional impairment. Multivariable negative binomial regression models were fitted to examine the association of demographic, social, economic and clinical characteristics with functional impairment. RESULTS: No significant difference in functional impairment was found between diagnosed cases and non-diagnosed controls. PHC diagnosed cases were found to have higher depressive symptom severity and suicidality, but lower social support compared to non-diagnosed controls (P < 0.05). In the multivariable model, greater functional impairment was associated with higher depressive symptoms (RR = 1.04; 95% CI 1.02, 1.05) and lower social support (RR = 0.96; 95% CI 0.95, 0.98). Diagnosed cases were found to have higher functional impairment compared to community controls (RR = 1.91; 95% CI 1.74, 2.09). CONCLUSION: In this study, PHC clinicians identified cases of depression with high symptom burden, suicidality and functional impairment. These findings support current initiatives to scale-up mental health services at the PHC level; and indicate that social support is an important target for intervention.

Burnout among primary healthcare workers during implementation of integrated mental healthcare in rural Ethiopia: a cohort study.

BACKGROUND: The short-term course of burnout in healthcare workers in low- and middle-income countries has undergone limited evaluation. The aim of this study was to assess the short-term outcome of burnout symptoms in the context of implementation of a new mental health programme in a rural African district. METHODS: We followed up 145 primary healthcare workers (HCWs) working in 66 rural primary healthcare (PHC) facilities in Southern Ethiopia, where a new integrated mental health service was being implemented. Burnout was assessed at baseline, i.e. when the new service was being introduced, and after 6 months. Data were collected through self-administered questionnaires, including the Maslach Burnout Inventory (MBI) and instruments measuring professional satisfaction and psychosocial factors. Generalised estimating equations (GEE) were used to assess the association between change in the core dimension of burnout (emotional exhaustion) and relevant work-related and psychosocial factors. RESULTS: A total of 136 (93.8%) of HCWs completed and returned their questionnaires at 6 months. There was a non-significant reduction in the burnout level between the two time points. In GEE regression models, high depression symptom scores (adjusted mean difference (aMD) 0.56, 95% CI 0.29, 0.83, p < 0.01), experiencing two or more stressful life events (aMD 1.37, 95% CI 0.06, 2.14, p < 0.01), being a community health extension worker vs. facility-based HCW (aMD 5.80, 95% CI 3.21, 8.38, p < 0.01), perceived job insecurity (aMD 0.73, 95% CI 0.08, 1.38, p = 0.03) and older age (aMD 0.36, 95% CI 0.09, 0.63, p = 0.01) were significantly associated with higher levels of emotional exhaustion longitudinally. CONCLUSION: In the short-term, there was no significant change in the level of burnout in the context of adding mental healthcare to the workload of HCWs. However, longer term and larger scale studies are required to substantiate this. This evidence can serve as baseline information for an intervention development to enhance wellbeing and reduce burnout.

Conceptualisation of job-related wellbeing, stress and burnout among healthcare workers in rural Ethiopia: a qualitative study.

BACKGROUND: Wellbeing of healthcare workers is important for the effective functioning of health systems. The aim of this study was to explore the conceptualisations of wellbeing, stress and burnout among healthcare workers in primary healthcare settings in rural Ethiopia in order to inform the development of contextually appropriate interventions. METHODS: A qualitative study was conducted in a rural zone of southern Ethiopia. A total of 52 frontline primary healthcare workers participated in in-depth interviews (n = 18) or Focus Group Discussions (FGDs) (4 groups, total n = 34). There were 35 facility based healthcare professionals and 17 community-based health workers. Data were analysed using thematic analysis. RESULTS: Most participants conceptualised wellbeing as absence of stress rather than as a positive state. Many threats to wellbeing were identified. For facility-based workers, the main stressors were inadequate supplies leading to fears of acquiring infection and concerns about performance evaluation. For community health workers, the main stressor was role ambiguity. Workload and economic self-sufficiency were a concern for both groups. Burnout and its symptoms were recognised and reported by most as a problem of other healthcare workers. Derogatory and stigmatising terms, such as "chronics", were used to refer to those who had served for many years and who appeared to have become drained of all compassion. Most participants viewed burnout as inevitable if they continued to work in their current workplace without career progression. Structural and environmental aspects of work emerged as potential targets to improve wellbeing, combined with tackling stigmatising attitudes towards mental health problems. An unmet need for intervention for healthcare workers who develop burnout or emotional difficulties was identified. CONCLUSION: Ethiopian primary healthcare workers commonly face job-related stress and experience features of burnout, which may contribute to the high turnover of staff and dissatisfaction of both patients and providers. Recent initiatives to integrate mental healthcare into primary care provide an opportunity to promote the wellbeing of healthcare workers and intervene to address burnout and emotional problems by creating a better understanding of mental health.

Recognition of depression by primary care clinicians in rural Ethiopia.

BACKGROUND: Depression is a common health condition affecting up to a third of patients attending primary care, where most of the care for people with depression is provided. Adequate recognition of depression is the critical step in the path to effective care, particularly in low income countries. As part of the Programme for Improving Mental healthcare (PRIME), a project supporting the implementation of integrated mental healthcare in primary care, we evaluated the level of recognition of depression by clinicians working in primary care in rural Ethiopia prior to in service training. We hypothesised that the detection rate of depression will be under 10% and that detection would be affected by gender, education and severity of depression. METHODS: Cross-sectional survey in eight health centres serving a population of over 160,000 people. A validated version of the 9-item patient health questionnaire (PHQ-9) was administered as an indicator of probable depression. In addition, primary care clinicians completed a clinician encounter form. Participants were consecutive primary care attendees aged 18 years and above. RESULTS: A total of 1014 participants were assessed. Primary care clinicians diagnosed 13 attendees (1.3%) with depression. The PHQ9 prevalence of depression at a cut-off score of ten was 11.5% (n = 117), of whom 5% (n = 6/117) had received a diagnosis of depression by primary care clinicians. Attendees with higher PHQ scores and suicidality were significantly more likely to receive a diagnosis of depression by clinicians. Women (n = 9/13) and participants with higher educational attainment were more likely to be diagnosed with depression, albeit non-significantly. All cases diagnosed with depression by the clinicians had presented with psychological symptoms. CONCLUSION: Although not based on a gold standard diagnosis, over 98% of cases with PHQ-9 depression were undetected. Failure of recognition of depression may pose a serious threat to the scale up of mental healthcare in low income countries. Addressing this threat should be an urgent priority, and requires a better understanding of the nature of depression and its presentation in rural low-income primary care settings.

Equitable access to integrated primary mental healthcare for people with severe mental disorders in Ethiopia: a formative study.

BACKGROUND: The provision of mental healthcare through integration into primary care is expected to improve access to care, but not all population groups may benefit equally. The aim of this study was to inform delivery of a new primary care-based mental health service in rural Ethiopia by identifying potential barriers to equitable access to mental healthcare and strategies to overcome them. METHODS: A qualitative study was conducted as formative work for the PRogramme for Improving Mental healthcarE (PRIME), a project supporting delivery of mental healthcare integrated into primary care in a rural district in south central Ethiopia. In-depth interviews (n = 21) were carried out with stakeholders selected purposively from mental health service users, caregivers, community leaders and healthcare administrators. A focus group discussion (n = 12) was conducted with community health extension workers. Framework analysis was employed using an adapted version of the access framework developed for use in contexts of livelihood insecurity, which considers (1) availability, (2) accessibility and affordability. and (3) acceptability and adequacy dimensions of access. RESULTS: Primary care-based mental healthcare was considered as a positive development, and would increase availability, accessibility and affordability of treatments. Low levels of community awareness, and general preference for traditional and religious healing were raised as potential challenges to the acceptability of integrated mental healthcare. Participants believed integrated mental healthcare would be comprehensive and of satisfactory quality. However, expectations about the effectiveness of treatment for mental disorders were generally low. Threats to equitable access to mental healthcare were identified for perinatal women, persons with physical disability, those living in extreme poverty and people with severe and persistent mental disability. CONCLUSION: Establishing an affordable service within reach, raising awareness and financial support to families from low socioeconomic backgrounds were suggested to improve equitable access to mental healthcare by vulnerable groups including perinatal women and people with disabilities. Innovative approaches, such as telephone consultations with psychiatric nurses based in nearby towns and home outreach need to be developed and evaluated.

Non-fatal suicidal behaviour in rural Ethiopia: a cross-sectional facility- and population-based study.

BACKGROUND: Injury related to self-harm is one of the leading causes of global disease burden. As a formative work for a programme to implement comprehensive mental healthcare in a rural district in Ethiopia, we determined the 12-month prevalence of non-fatal suicidal behaviour as well as factors associated with this behaviour to understand the potential burden of the behaviour in the district. METHOD: Population-based (n = 1485) and facility-based (n = 1014) cross-sectional surveys of adults, using standardised, interview-based measures for suicidality (items on suicide from the Composite International Diagnostic Interview), depressive symptoms (the Patient Health Questionnaire) and alcohol use disorders (Alcohol Use Disorder Investigation Test; AUDIT). RESULTS: The overall 12-month prevalence of non-fatal suicidal behaviour, consisting of suicidal ideation, plan and attempt, was 7.9 % (95 % Confidence Interval (CI) = 6.8 % to 8.9 %). The prevalence was significantly higher in the facility sample (10.3 %) compared with the community sample (6.3 %). The 12-month prevalence of suicide attempt was 4.4 % (95 % CI = 3.6 % to 5.3 %), non-significantly higher among the facility sample (5.4 %) compared with the community sample (3.8 %). Over half of those with suicidal ideation (56.4 %) transitioned from suicidal ideation to suicide attempt. Younger age, harmful use of alcohol and higher depression scores were associated significantly with increased non-fatal suicidal behaviours. The only factor associated with transition from suicidal ideation to suicide attempt was high depression score. Only 10.5 % of the sample with suicidal ideation had received any treatment for their suicidal behaviour: 10.8 % of the community sample and 10.2 % of the facility sample. Although help seeking increased with progression from ideation to attempt, there was no statistically significant difference between the groups. CONCLUSION: Non-fatal suicidal behaviour is an important public health problem in this rural district. A more in-depth understanding of the context of the occurrence of the behaviour, improving access to care and targeting depression and alcohol use disorder are important next steps. The role of other psychosocial factors should also be explored to assist the provision of holistic care.

Hazardous alcohol use and associated factors in a rural Ethiopian district: a cross-sectional community survey.

BACKGROUND: Alcohol related health and social problems are on the rise in sub-Saharan Africa. This survey reports the prevalence and associated factors for hazardous drinking in rural Sodo district, southern Ethiopia. The survey was part of a multi-center study, Programme for Improving Mental Health Care (PRIME), which is a consortium of research institutions and ministries of health of five low and middle income countries, namely Ethiopia, India, Nepal, South Africa and Uganda in partnership with UK institutions and World Health Organization (WHO). METHODS: A cross-sectional community survey was conducted involving 1500 adults, age 18 and above, recruited using multi-stage random sampling. Data on alcohol use was collected using the Fast Alcohol Screening Test (FAST). Standardised instruments were used to measure potential associated factors, including a validated adaptation of the Kessler 10 (psychological distress), the List of Threatening Experiences (number of adverse life events). Exploratory multivariable logistic regression was conducted to examine factors associated with hazardous alcohol use. RESULTS: The overall prevalence of hazardous alcohol use was found to be 21 %; 31 % in males and 10.4 % in females, P < 0.05. Factors independently associated with hazardous alcohol use were being male (adjusted OR = 4.0, 95 % CI = 2.44, 6.67), increasing age, having experienced one or more stressful life events (adjusted OR = 1.71, 95 % CI = 1.18, 2.48, and adjusted OR = 2.12, 95 % CI = 1.36, 3.32 for 1-2 and 3 or more adverse life events, respectively) and severe psychological distress (adjusted OR = 2.96, 95 % CI = 1.49, 5.89). High social support was found to be protective from hazardous alcohol use (adjusted OR = 0.41, 95 % CI = 0.23, 0.72). CONCLUSION: High level of hazardous alcohol use was detected in this predominantly rural Ethiopian setting. The finding informed the need to integrate services for hazardous alcohol use such as brief intervention at different levels of primary care services in the district. Public health interventions to reduce hazardous alcohol use also need to be launched.

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. AIMS: To 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.

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

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.

Validity of brief screening questionnaires to detect depression in primary care in Ethiopia.

BACKGROUND: Brief depression screening questionnaires may increase detection of depression in primary care settings but there have been few validation studies carried out in typical populations in low-income countries. METHODS: Cultural validation of the Patient Health Questionnaire (PHQ-9/PHQ-2), the 20-item Self-Reporting Questionnaire (SRQ-20) and the Kessler scales (K6/K10) was carried out in 306 adults consecutively attending primary care facilities in small towns in Ethiopia. To assess criterion validity, the gold standard assessment for presence of Major Depressive Disorder (MDD) was made by Ethiopian psychiatric nurses using the Mini International Neuropsychiatric Interview. RESULTS: The prevalence of gold standard MDD was 5.9%, with irritability more common than depressed mood or anhedonia. The area under the receiver operating characteristic curve indicated good performance of the PHQ-9, SRQ-20, K6 and K10 (0.83-0.85) but only fair for the PHQ-2 (0.78). No cut-off score had acceptable sensitivity combined with adequate positive predictive value. All screening questionnaires were associated with disability and the PHQ-9 and SRQ-20 were associated with higher health service contacts, indicating convergent validity. Construct validity of all scales was indicated by unidimensionality on exploratory factor analysis. LIMITATIONS: Test-retest reliability was not assessed. CONCLUSIONS: Brief depression screening questionnaires were found to be valid in primary care in this low-income country. However, these questionnaires do not have immediate applicability in routine clinical settings. Further studies should evaluate utility of indicated screening embedded within health system changes that support MDD detection. Investigation of irritability as a core depression symptom is warranted.