Household economic costs associated with mental, neurological and substance use disorders: a cross-sectional survey in six low- and middle-income countries.

BACKGROUND: Little is known about the household economic costs associated with mental, neurological and substance use (MNS) disorders in low- and middle-income countries. AIMS: To assess the association between MNS disorders and household education, consumption, production, assets and financial coping strategies in Ethiopia, India, Nepal, Nigeria, South Africa and Uganda. METHOD: We conducted an exploratory cross-sectional household survey in one district in each country, comparing the economic circumstances of households with an MNS disorder (alcohol-use disorder, depression, epilepsy or psychosis) (n = 2339) and control households (n = 1982). RESULTS: Despite some heterogeneity between MNS disorder groups and countries, households with a member with an MNS disorder had generally lower levels of adult education; lower housing standards, total household income, effective income and non-health consumption; less asset-based wealth; higher healthcare expenditure; and greater use of deleterious financial coping strategies. CONCLUSIONS: Households living with a member who has an MNS disorder constitute an economically vulnerable group who are susceptible to chronic poverty and intergenerational poverty transmission. DECLARATION OF INTEREST: D.C. is a staff member of the World Health Organization. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy or views of the World Health Organization.

Information systems for mental health in six low and middle income countries: cross country situation analysis.

BACKGROUND: Research on information systems for mental health in low and middle income countries (LMICs) is scarce. As a result, there is a lack of reliable information on mental health service needs, treatment coverage and the quality of services provided. METHODS: With the aim of informing the development and implementation of a mental health information sub-system that includes reliable and measurable indicators on mental health within the Health Management Information Systems (HMIS), a cross-country situation analysis of HMIS was conducted in six LMICs (Ethiopia, India, Nepal, Nigeria, South Africa and Uganda), participating in the 'Emerging mental health systems in low and middle income countries' (Emerald) research programme. A situation analysis tool was developed to obtain and chart information from documents in the public domain. In circumstances when information was inadequate, key government officials were contacted to verify the data collected. In this paper we compare the baseline policy context, human resources situation as well as the processes and mechanisms of collecting, verifying, reporting and disseminating mental health related HMIS data. RESULTS: The findings suggest that countries face substantial policy, human resource and health governance challenges for mental health HMIS, many of which are common across sites. In particular, the specific policies and plans for the governance and implementation of mental health data collection, reporting and dissemination are absent. Across sites there is inadequate infrastructure, few HMIS experts, and inadequate technical support and supervision to junior staff, particularly in the area of mental health. Nonetheless there are also strengths in existing HMIS where a few mental health morbidity, mortality, and system level indicators are collected and reported. CONCLUSIONS: Our study indicates the need for greater technical and resources input to strengthen routine HMIS and develop standardized HMIS indicators for mental health, focusing in particular on indicators of coverage and quality to facilitate the implementation of the WHO mental health action plan 2013-2020.

Perinatal mental health care in a rural African district, Uganda: a qualitative study of barriers, facilitators and needs.

BACKGROUND: Perinatal mental illness is a common and important public health problem, especially in low and middle-income countries (LMICs). This study aims to explore the barriers and facilitators, as well as perceptions about the feasibility and acceptability of plans to deliver perinatal mental health care in primary care settings in a low income, rural district in Uganda. METHODS: Six focus group discussions comprising separate groups of pregnant and postpartum women and village health teams as well as eight key informant interviews were conducted in the local language using a topic guide. Transcribed data were translated into English, analyzed, and coded. Key themes were identified using a thematic analysis approach. RESULTS: Participants perceived that there was an important unmet need for perinatal mental health care in the district. There was evidence of significant gaps in knowledge about mental health problems as well as negative attitudes amongst mothers and health care providers towards sufferers. Poverty and inability to afford transport to services, poor partner support and stigma were thought to add to the difficulties of perinatal women accessing care. There was an awareness of the need for interventions to respond to this neglected public health problem and a willingness of both community- and facility-based health care providers to provide care for mothers with mental health problems if equipped to do so by adequate training. CONCLUSION: This study highlights the acceptability and relevance of perinatal mental health care in a rural, low-income country community. It also underscores some of the key barriers and potential facilitators to delivery of such care in primary care settings. The results of this study have implications for mental health service planning and development for perinatal populations in Uganda and will be useful in informing the development of integrated maternal mental health care in this rural district and in similar settings in other low and middle income countries.

Estimating the cost of implementing district mental healthcare plans in five low- and middle-income countries: the PRIME study.

BACKGROUND: An essential element of mental health service scale up relates to an assessment of resource requirements and cost implications. AIMS: To assess the expected resource needs of scaling up services in five districts in sub-Saharan Africa and south Asia. METHOD: The resource quantities associated with each site's specified care package were identified and subsequently costed, both at current and target levels of coverage. RESULTS: The cost of the care package at target coverage ranged from US$0.21 to 0.56 per head of population in four of the districts (in the higher-income context of South Africa, it was US$1.86). In all districts, the additional amount needed each year to reach target coverage goals after 10 years was below $0.10 per head of population. CONCLUSIONS: Estimation of resource needs and costs for district-level mental health services provides relevant information concerning the financial feasibility of locally developed plans for successful scale up.

Development of a district mental healthcare plan in Uganda.

BACKGROUND: Evidence is needed for the integration of mental health into primary care advocated by the national health sector strategic investment plan in Uganda. AIMS: To describe the processes of developing a district mental healthcare plan (MHCP) in rural Uganda that facilitates integration of mental health into primary care. METHOD: Mixed methods using a situational analysis, qualitative studies, theory of change workshops and partial piloting of the plan at two levels informed the MHCP. RESULTS: A MHCP was developed with packages of care to facilitate integration at the organisational, facility and community levels of the district health system, including a specified human resource mix. The partial embedding period supports its practical application. Key barriers to scaling up the plan were identified. CONCLUSIONS: A real-world plan for the district was developed with involvement of stakeholders. Pilot testing demonstrated its feasibility and implications for future scaling up.

Men in despair: a qualitative psychological autopsy study of suicide in northern Uganda.

The psychosocial circumstances surrounding men's suicide in postconflict Central Northern Uganda were investigated using qualitative psychological autopsy interviews. Records of 17 men who died by suicide were identified through police and local leaders in Internally Displaced Peoples' camps of Amuru and Gulu Districts. Two to five significant others were interviewed around each case. Data were analyzed by interpretative phenomenological analysis (IPA). Lost dignity and social value, lack of hope for the family's future, overwhelming family responsibility, and mental illness were circumstances found to have preceded the suicides. The protracted war in the Northern region of Uganda left men in rural communities feeling disempowered and disenfranchised. This may have contributed to suicidal behavior in some of them. Suicide prevention in this area needs to be multidisciplinary with an emphasis on helping both men and women understand and deal with the many social changes that have evolved over time and affected their traditional roles and responsibilities.

An escape from agony: a qualitative psychological autopsy study of women's suicide in a post-conflict northern Uganda.

We set out to investigate suicide among women in a post-conflict context in Northern Uganda using qualitative psychological autopsy interviews. Three to five relatives and friends for each of the three suicides recruited were interviewed (N=11). Through interpretative phenomenological analysis (IPA) we found that the women all had been through traumatic experiences attributable to the protracted war/conflict between the rebel groups and Ugandan Government armed forces. Nevertheless, the decision of self-inflicted death seemed to have been due to a combination of unpleasant experiences/events that prevailed within the last 3 months prior to the suicide. These experiences are summarized in two broad themes: No control in life and No care. Changes in the traditional gender roles, men's quest for their lost masculinity, and women's attempt to fight for their rights that was perceived as a cultural transgression contributed to the women's suicides.

Alcohol and suicide in postconflict northern Uganda: a qualitative psychological autopsy study.

BACKGROUND: Alcohol has been noted to be an important factor in nearly 68% of the suicides in Northern Uganda, yet exactly how alcohol contributes to suicide in this region has not been studied. AIMS: To determine how alcohol contributes to suicide in this region. METHODS: Qualitative psychological autopsy interviews were conducted with bereaved relatives and friends of 20 suicides mainly from Internally Displaced Peoples' camps in Northern Uganda. Data were analyzed using a modified Interpretative Phenomenological analysis (IPA). RESULTS: Alcohol had a direct or an indirect influence on the suicide of 16 out of the 20 decedents. Directly, alcohol facilitated the suicidal process, was a means to suicide, or had an influence on the decedents' lifestyles. Indirectly, alcohol had an influence on the suicidal process of the deceased through the drinking behavior of significant others. CONCLUSIONS: This study established that alcohol not only contributes to the suicidal process of the individuals through acute and chronic alcohol consumption, but also through victimization of those lowest in the power hierarchy by alcohol abusers higher up in the power hierarchy. Therefore, future development of suicide prevention programs should address the interrelated public health problem of alcohol abuse.

Qualitative psychological autopsy interviews on suicide in post-conflict Northern Uganda: the participants' perceptions.

Participants' perceptions of psychological autopsy interviews were investigated in post-conflict Northern Uganda. Data were derived out of their responses in the debriefing session after the formal interviews. These responses were subjected to Interpretative Phenomenological Analysis (IPA). The majority of the participants were positive about the interview as reflected in the two broad themes: positivation of the situation through the possibility of helping others and opportunity for personal development through sharing. To some few participants the interview aroused guilt, self-reproach, and anger and reactivated painful memories. As regards suicide postvention, the findings implied that not much has been done to help the bereaved by suicide in this region, and few resources for such efforts are currently available. However, the bereaved are ready to contribute toward the fight against suicide in their communities. Hence, it is argued that a community-based mental health and Primary Health Care approaches should be encouraged in this context.

Stakeholder's perceptions of help-seeking behaviour among people with mental health problems in Uganda.

INTRODUCTION: Mental health facilities in Uganda remain underutilized, despite efforts to decentralize the services. One of the possible explanations for this is the help-seeking behaviours of people with mental health problems. Unfortunately little is known about the factors that influence the help-seeking behaviours. Delays in seeking proper treatment are known to compromise the outcome of the care. AIM: To examine the help-seeking behaviours of individuals with mental health problems, and the factors that may influence such behaviours in Uganda. METHOD: Sixty-two interviews and six focus groups were conducted with stakeholders drawn from national and district levels. Thematic analysis of the data was conducted using a framework analysis approach. RESULTS: The findings revealed that in some Ugandan communities, help is mostly sought from traditional healers initially, whereas western form of care is usually considered as a last resort. The factors found to influence help-seeking behaviour within the community include: beliefs about the causes of mental illness, the nature of service delivery, accessibility and cost, stigma. CONCLUSION: Increasing the uptake of mental health services requires dedicating more human and financial resources to conventional mental health services. Better understanding of socio-cultural factors that may influence accessibility, engagement and collaboration with traditional healers and conventional practitioners is also urgently required.

An overview of Uganda's mental health care system: results from an assessment using the world health organization's assessment instrument for mental health systems (WHO-AIMS).

BACKGROUND: The Ugandan government recognizes mental health as a serious public health and development concern, and has of recent implemented a number of reforms aimed at strengthening the country's mental health system. The aim of this study was to provide a profile of the current mental health policy, legislation and services in Uganda. METHODS: A survey was conducted of public sector mental health policy and legislation, and service resources and utilisation in Uganda, in the year 2005, using the World Health Organization's Assessment Instrument for Mental Health Systems (WHO-AIMS) Version 2.2. RESULTS: Uganda's draft mental health policy encompasses many positive reforms, including decentralization and integration of mental health services into Primary Health Care (PHC). The mental health legislation is however outdated and offensive. Services are still significantly underfunded (with only 1% of the health expenditure going to mental health), and skewed towards urban areas. Per 100,000 population, there were 1.83 beds in mental hospitals, 1.4 beds in community based psychiatric inpatient units, and 0.42 beds in forensic facilities. The total personnel working in mental health facilities were 310 (1.13 per 100,000 population). Only 0.8% of the medical doctors and 4% of the nurses had specialized in psychiatry. CONCLUSION: Although there have been important developments in Uganda's mental health policy and services, there remains a number of shortcomings, especially in terms of resources and service delivery. There is an urgent need for more research on the current burden of mental disorders and the functioning of mental health programs and services in Uganda.

Stakeholder perceptions of mental health stigma and poverty in Uganda.

BACKGROUND: World wide, there is plentiful evidence regarding the role of stigma in mental illness, as well as the association between poverty and mental illness. The experiences of stigma catalyzed by poverty revolve around experiences of devaluation, exclusion, and disadvantage. Although the relationship between poverty, stigma and mental illness has been documented in high income countries, little has been written on this relationship in low and middle income countries.The paper describes the opinions of a range of mental health stakeholders regarding poverty, stigma, mental illness and their relationship in the Ugandan context, as part of a wider study, aimed at exploring policy interventions required to address the vicious cycle of mental ill-health and poverty. METHODS: Semi-structured interviews and focus group discussions (FGDs) were conducted with purposefully selected mental health stakeholders from various sectors. The interviews and FGDs were audio-recorded, and transcriptions were coded on the basis of a pre-determined coding frame. Thematic analysis of the data was conducted using NVivo7, adopting a framework analysis approach. RESULTS: Most participants identified a reciprocal relationship between poverty and mental illness. The stigma attached to mental illness was perceived as a common phenomenon, mostly associated with local belief systems regarding the causes of mental illness. Stigma associated with both poverty and mental illness serves to reinforce the vicious cycle of poverty and mental ill-health. Most participants emphasized a relationship between poverty and internalized stigma among people with mental illness in Uganda. CONCLUSION: According to a range of mental health stakeholders in Uganda, there is a strong interrelationship between poverty, stigma and mental illness. These findings re-affirm the need to recognize material resources as a central element in the fight against stigma of mental illness, and the importance of stigma reduction programmes in protecting the mentally ill from social isolation, particularly in conditions of poverty.