Scaling-up services for psychosis, depression and epilepsy in sub-Saharan Africa and South Asia: development and application of a mental health systems planning tool (OneHealth).

BACKGROUND: Although financing represents a critical component of health system strengthening and also a defining concern of efforts to move towards universal health coverage, many countries lack the tools and capacity to plan effectively for service scale-up. As part of a multi-country collaborative study (the Emerald project), we set out to develop, test and apply a fully integrated health systems resource planning and health impact tool for mental, neurological and substance use (MNS) disorders. METHODS: A new module of the existing UN strategic planning OneHealth Tool was developed, which identifies health system resources required to scale-up a range of specified interventions for MNS disorders and also projects expected health gains at the population level. We conducted local capacity-building in its use, as well as stakeholder consultations, then tested and calibrated all model parameters, and applied the tool to three priority mental and neurological disorders (psychosis, depression and epilepsy) in six low- and middle-income countries. RESULTS: Resource needs for scaling-up mental health services to reach desired coverage goals are substantial compared with the current allocation of resources in the six represented countries but are not large in absolute terms. In four of the Emerald study countries (Ethiopia, India, Nepal and Uganda), the cost of delivering key interventions for psychosis, depression and epilepsy at existing treatment coverage is estimated at US$ 0.06-0.33 per capita of total population per year (in Nigeria and South Africa it is US$ 1.36-1.92). By comparison, the projected cost per capita at target levels of coverage approaches US$ 5 per capita in Nigeria and South Africa, and ranges from US$ 0.14-1.27 in the other four countries. Implementation of such a package of care at target levels of coverage is expected to yield between 291 and 947 healthy life years per one million populations, which represents a substantial health gain for the currently neglected and underserved sub-populations suffering from psychosis, depression and epilepsy. CONCLUSIONS: This newly developed and validated module of OneHealth tool can be used, especially within the context of integrated health planning at the national level, to generate contextualised estimates of the resource needs, costs and health impacts of scaled-up mental health service delivery.

Validity and diagnostic accuracy of the Luganda version of the 9-item and 2-item Patient Health Questionnaire for detecting major depressive disorder in rural Uganda.

BACKGROUND: The prevalence of depression in rural Ugandan communities is high and yet detection and treatment of depression in the primary care setting is suboptimal. Short valid depression screening measures may improve detection of depression. We describe the validation of the Luganda translated nine- and two-item Patient Health Questionnaires (PHQ-9 and PHQ-2) as screening tools for depression in two rural primary care facilities in Eastern Uganda. METHODS: A total of 1407 adult respondents were screened consecutively using the nine-item Luganda PHQ. Of these 212 were randomly selected to respond to the Mini International Neuropsychiatric Interview diagnostic questionnaire. Descriptive statistics for respondents' demographic characteristics and PHQ scores were generated. The sensitivity, specificity and positive predictive values (PPVs), and area under the ROC curve were determined for both the PHQ-9 and PHQ-2. RESULTS: The optimum trade-off between sensitivity and PPV was at a cut-off of ≧5. The weighted area under the receiver Operating Characteristic curve was 0.74 (95% CI 0.60-0.89) and 0.68 (95% CI 0.54-0.82) for PHQ-9 and PHQ-2, respectively. CONCLUSION: The Luganda translation of the PHQ-9 was found to be modestly useful in detecting depression. The PHQ-9 performed only slightly better than the PHQ-2 in this rural Ugandan Primary care setting. Future research could improve on diagnostic accuracy by considering the idioms of distress among Luganda speakers, and revising the PHQ-9 accordingly. The usefulness of the PHQ-2 in this rural population should be viewed with caution.

Prevalence of hospital-associated infections can be decreased effectively in developing countries.

BACKGROUND: Hospital-acquired infections (HAI) are an important public health problem worldwide. Little information is available from African countries, but published data show that the burden of HAI is greater in Africa than in developed countries. In 2002, the World Health Organization (WHO) published guidelines for preventing HAI. AIM: To evaluate the impact of a hospital infection control programme on the prevalence of HAI among patients in a large Ugandan hospital. METHODS: A one-day cross-sectional prevalence survey and a ward procedure survey were performed in Lacor Hospital in March 2010 using standardized questionnaires. All patients admitted to hospital not less than two days before the survey were eligible to participate in the prevalence survey. Modified WHO criteria for HAI were used. The ward procedure survey examined the procedures to prevent HAI. Several hospital infection control measures were subsequently implemented, in accordance with WHO infection control guidelines, starting in October 2010. The prevalence survey and ward procedure survey were repeated in October 2011. FINDINGS: The prevalence of HAI was 34% in 2010 and 17% in 2011. The prevalence of infected patients reduced from 28% to 14%. The prevalence of HAI was lower in all age groups and for all types of HAI except urinary tract infections following the implementation of infection control activities. CONCLUSION: This study showed that HAI is an important problem in this large African hospital, and that the prevalence of HAI can be reduced effectively following the adoption of basic infection control procedures.

Media and mental health in Uganda.

OBJECTIVE: The media is largely regarded as an important stakeholder in health service delivery, with a great influence on public attitudes. However, little is known about its interest in mental health and the guiding factors that influence media coverage of mental health issues. This article describes the importance accorded to mental health by the media and the factors that influence media coverage of mental health issues in Uganda. METHOD: Semi-structured interviews were held with representatives from six prominent media houses as part of the situational analysis of the mental health system in Uganda. Data was analyzed using Nvivo 7 qualitative data analysis software. RESULTS: The media was found to be interested and actively involved in health initiatives, but with little attention devoted to mental health. Coverage and interest in mental health was noted to be mainly dependent on the individual journalists' interests, and mostly for personal reasons. Low interest was largely attributed to mental health being perceived as a non-priority area, and the fact that mental illness is not a major contributor to mortality. Media coverage and reporting is guided by prioritization of the Health Department. CONCLUSION: The media in Uganda is an important stakeholder in the health care system with a key role of advocacy, publicity and mass education. Media houses however are less interested in mental health as evidenced by low coverage of mental health issues. This calls for advocacy and sensitization as a way of persuading media for more involvement in mental health initiatives.

Integration of mental health into primary health care in a rural district in Uganda.

OBJECTIVE: Mental health has been identified as a major priority in the Ugandan Health Sector Strategic Plan. Efforts are currently underway to integrate mental health services into the Primary Health Care system. In this study, we report aspects of the integration of mental health into primary health care in one rural district in Uganda. METHOD: Qualitative methods were used for data collection. Semi-structured interviews and focus group discussions were conducted with various stakeholders within the ministry of health as well as line ministries. Data analysis was done using Nvivo 7, specifically adopting framework analysis approach. RESULTS: Attempts to offer organized mental health services were found to be present in only a few health facilities. The district had only a single mental health nurse, and very few General Health Workers adequately equipped with the knowledge and skills to provide mental health services. The vertical referral system was not being followed as planned and there was no evidence of any organized community interventions for those with mental disorders. The mental health nurse and a few PHC nurses however expressed interest and commitment to providing services for persons with mental illness, despite the challenges. CONCLUSION: Although mental health is expected to be integrated into primary health care, mental health services in this district have not yet achieved the expected level of integration. This implies that this important policy requirement has not yet been effectively realized in this rural district, which could be the case in many other districts of a similar status. There is thus a need to direct more efforts towards realization of this important policy requirement.

Media and mental health in Uganda

Objective: The media is largely regarded as an important stakeholder in health service delivery; with a great influence on public attitudes. However; little is known about its interest in mental health and the guiding factors that influence media coverage of mental health issues. This article describes the importance accorded to mental health by the media and the factors that influence media coverage of mental health issues in Uganda. Method: Semi-structured interviews were held with representatives from six prominent media houses as part of the situational analysis of the mental health system in Uganda. Data was analyzed using Nvivo 7 qualitative data analysis software. Results: The media was found to be interested and actively involved in health initiatives; but with little attention devoted to mental health. Coverage and interest in mental health was noted to be mainly dependent on the individual journalists' interests; and mostly for personal reasons. Low interest was largely attributed to mental health being perceived as a non-priority area; and the fact that mental illness is not a major contributor to mortality. Media coverage and reporting is guided by prioritization of the Health Department. Conclusion: The media in Uganda is an important stakeholder in the health care system with a key role of advocacy; publicity and mass education. Media houses however are less interested in mental health as evidenced by low coverage of mental health issues. This calls for advocacy and sensitization as a way of persuading media for more involvement in mental health initiatives

Integration of mental health into primary health care in a rural district in Uganda

Objective: Mental health has been identified as a major priority in the Ugandan Health Sector Strategic Plan. Efforts are currently underway to integrate mental health services into the Primary Health Care system. In this study; we report aspects of the integration of mental health into primary health care in one rural district in Uganda. Method: Qualitative methods were used for data collection. Semi-structured interviews and focus group discussions were conducted with various stakeholders within the ministry of health as well as line ministries. Data analysis was done using Nvivo 7; specifically adopting framework analysis approach. Results: Attempts to offer organized mental health services were found to be present in only a few health facilities. The district had only a single mental health nurse; and very few General Health Workers adequately equipped with the knowledge and skills to provide mental health services. The vertical referral system was not being followed as planned and there was no evidence of any organized community interventions for those with mental disorders. The mental health nurse and a few PHC nurses however expressed interest and commitment to providing services for persons with mental illness; despite the challenges. Conclusion: Although mental health is expected to be integrated into primary health care; mental health services in this district have not yet achieved the expected level of integration. This implies that this important policy requirement has not yet been effectively realized in this rural district; which could be the case in many other districts of a similar status. There is thus a need to direct more efforts towards realization of this important policy requirement