Does mhGAP training of primary health care providers improve the identification of child- and adolescent mental, neurological or substance use disorders? Results from a randomized controlled trial in Uganda

A Akol, F Makumbi, J N Babirye, J S Nalugya, S Nshemereirwe, I M S Engebretsen, A Akol, F Makumbi, J N Babirye, J S Nalugya, S Nshemereirwe, I M S Engebretsen

Abstract

Background: Integrating child and adolescent mental health (CAMH) into primary health care (PHC) using the WHO mental health gap action program (mhGAP) is recommended for closing a mental health treatment gap in low- and middle-income countries, but PHC providers have limited ability to detect CAMH disorders. We aimed to evaluate the effect of PHC provider mhGAP training on CAMH disorder identification in Eastern Uganda.

Methods: Thirty-six PHC clinics participated in a randomized controlled trial which compared the proportion of intervention (n = 18) to control (n = 18) clinics with a non-epilepsy CAMH diagnosis over 3 consecutive months following mhGAP-oriented CAMH training. Fisher's exact test and logistic regression based on intention to treat principles were applied. (clinicaltrials.gov registration NCT02552056).

Results: Nearly two thirds (63.8%, 23/36) of all clinics identified and recorded at least one non-epilepsy CAMH diagnosis from 40 692 clinic visits of patients aged 1-18 recorded over 4 months. The proportion of clinics with a non-epilepsy CAMH diagnosis prior to training was 27.7% (10/36, similar between study arms). Training did not significantly improve intervention clinics' non-epilepsy CAMH diagnosis (13/18, 72.2%) relative to the control (7/18, 38.9%) arm, p = 0.092. The odds of identifying and recording a non-epilepsy CAMH diagnosis were 2.5 times higher in the intervention than control arms at the end of 3 months of follow-up [adj.OR 2.48; 95% CI (1.31-4.68); p = 0.005].

Conclusion: In this setting, mhGAP CAMH training of PHC providers increases PHC clinics' identification and reporting of non-epilepsy CAMH cases but this increase did not reach statistical significance.

Keywords: Adolescent; Africa; child; mental health; mhGAP; primary care.

Figures

Fig. 1.
Fig. 1.
The Gateway Provider Model of youth access to mental health services, from Stiffman et al. (2004).
Fig. 2.
Fig. 2.
CONSORT flow diagram.

References

    1. Abbo C (2011). Profiles and outcome of traditional healing practices for severe mental illnesses in two districts of Eastern Uganda. Global Health Action 4, 7117.
    1. Akol A, Engebretsen IMS, Skylstad V, Nalugya J, Ndeezi G, Tumwine J (2015). Health managers’ views on the status of national and decentralized health systems for child and adolescent mental health in Uganda: a qualitative study. Child and Adolescent Psychiatry and Mental Health, 9, 1.
    1. Akol A, Nalugya J, Nshemereirwe S, Babirye JN, Engebretsen IMS (2017). Does child and adolescent mental health in-service training result in equivalent knowledge gain among cadres of non-specialist health workers in Uganda? A pre-test post-test study. International Journal of Mental Health Systems 11, 50.
    1. American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5®). Washington, DC: American Psychiatric Pub.
    1. Belfer ML (2008). Child and adolescent mental disorders: the magnitude of the problem across the globe. Journal of Child Psychology and Psychiatry 49, 226–236.
    1. Center for International Health (2014) Available online: [Accessed September 6 2017].
    1. Collins PY, Musisi S, Frehywot S, Patel V (2015). The core competencies for mental, neurological, and substance use disorder care in sub-Saharan Africa. Global Health Action 8, p. 26682.
    1. Cortina MA, Sodha A, Fazel M, Ramchandani PG (2012). Prevalence of child mental health problems in sub-Saharan Africa: a systematic review. Archives of Pediatrics & Adolescent Medicine 166, 276–281.
    1. Eaton J, McCay L, Semrau M, Chatterjee S, Baingana F, Araya R, Ntulo C, Thornicroft G, Saxena S (2011). Scale up of services for mental health in low-income and middle-income countries. The Lancet 378, 1592–1603.
    1. Fisher RA (1922). On the interpretation of χ2 from contingency tables, and the calculation of P. Journal of the Royal Statistical Society 85, 87–94.
    1. Fleiss JL, Levin B, Paik MC (2013). Statistical Methods for Rates and Proportions. New York: John Wiley & Sons.
    1. Frances A (2013). The new somatic symptom disorder in DSM-5 risks mislabeling many people as mentally ill. BMJ 346, f1580.
    1. Gureje O, Abdulmalik J, Kola L, Musa E, Yasamy MT, Adebayo K (2015). Integrating mental health into primary care in Nigeria: report of a demonstration project using the mental health gap action programme intervention guide. BMC Health Services Research 15, 242.
    1. Hoeft TJ, Fortney JC, Patel V, Unützer J (2018). Task-sharing approaches to improve mental health care in rural and other Low-resource settings: a systematic review. The Journal of Rural Health 34, 48–62.
    1. Huang K-Y, Nakigudde J, Brotman LM (2015). Use of task-shifting to scale-up child mental health services in low-resource Ugandan schools: role of contextual factors on program implementation. Implementation Science 10(S1), A23.
    1. Janowitz B, Stanback J, Boyer B (2012). Task sharing in family planning. Studies in Family Planning 43, 57–62.
    1. Jenkins R, Othieno C, Okeyo S, Aruwa J, Kingora J, Jenkins B (2013a). Health system challenges to integration of mental health delivery in primary care in Kenya-perspectives of primary care health workers. BMC Health Services Research 13, 368.
    1. Jenkins R, Othieno C, Okeyo S, Kaseje D, Aruwa J, Oyugi H, Bassett P, Kauye F (2013b). Short structured general mental health in service training programme in Kenya improves patient health and social outcomes but not detection of mental health problems – a pragmatic cluster randomised controlled trial. International Journal of Mental Health Systems 7, 25.
    1. Jerene D, Biru M, Teklu A, Rehman T, Ruff A, Wissow L (2017). Factors promoting and inhibiting sustained impact of a mental health task-shifting program for HIV providers in Ethiopia. Global Mental Health 4, e24.
    1. Kalibala S, Okal J, Zieman B, Jani N, Vu L, Ssali L, Birungi J, Okoboi S, Wangisi J, Nabiryo C (2016). Retrospective review of task-shifting community-based programs supporting ARV treatment and retention in Uganda. Available online: [Accessed September 8 2017].
    1. Kamau JW, Omigbodun OO, Bella-Awusah T, Adedokun B (2017). Who seeks child and adolescent mental health care in Kenya? A descriptive clinic profile at a tertiary referral facility. Child and Adolescent Psychiatry and Mental Health 11, 14.
    1. Katende G, Donnelly M (2016). Shining a light on task-shifting policy: exploring opportunities for adaptability in non-communicable disease management programmes in Uganda. Sultan Qaboos University Medical Journal 16, e161.
    1. Kieling C, Baker-Henningham H, Belfer M, Conti G, Ertem I, Omigbodun O, Rohde LA, Srinath S, Ulkuer N, Rahman A (2011). Child and adolescent mental health worldwide: evidence for action. Lancet 378, 1515–1525.
    1. Kigozi F, Ssebunnya J, Kizza D, Cooper S, Ndyanabangi S (2010). 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). International Journal of Mental Health Systems 4, 1.
    1. Kigozi FN, Ssebunnya J (2009). Integration of mental health into primary health care in Uganda: opportunities and challenges. Mental Health in Family Medicine 6, 37–42.
    1. Kisa R, Baingana F, Kajungu R, Mangen PO, Angdembe M, Gwaikolo W, Cooper J (2016). Pathways and access to mental health care services by persons living with severe mental disorders and epilepsy in Uganda, Liberia and Nepal: a qualitative study. BMC Psychiatry 16, 305.
    1. Liu G, Jack H, Piette A, Mangezi W, Machando D, Rwafa C, Goldenberg M, Abas M (2016). Mental health training for health workers in Africa: a systematic review. The Lancet Psychiatry 3, 65–76.
    1. Lund C, Tomlinson M, Patel V (2016). Integration of mental health into primary care in low- and middle-income countries: the PRIME mental healthcare plans. The British Journal of Psychiatry 208(Suppl 56), s1–s3.
    1. Mendenhall E, De Silva MJ, Hanlon C, Petersen I, Shidhaye R, Jordans M, Luitel N, Ssebunnya J, Fekadu A, Patel V (2014). Acceptability and feasibility of using non-specialist health workers to deliver mental health care: stakeholder perceptions from the PRIME district sites in Ethiopia, India, Nepal, South Africa, and Uganda. Social Science & Medicine 118, 33–42.
    1. Ministry of Health Uganda (2017). Child and Adolescent Mental Health Policy Guidelines. Kampala, Uganda.
    1. Mugisha J, Abdulmalik J, Hanlon C, Petersen I, Lund C, Upadhaya N, Ahuja S, Shidhaye R, Mntambo N, Alem A (2017). Health systems context (s) for integrating mental health into primary health care in six Emerald countries: a situation analysis. International Journal of Mental Health Systems 11, 7.
    1. Murray CJ, Frenk J (2000). A framework for assessing the performance of health systems. Bulletin of the World Health Organization 78, 717–731.
    1. Nabudere H, Asiimwe D, Mijumbi R (2011). Task shifting in maternal and child health care: an evidence brief for Uganda. International Journal of Technology Assessment in Health Care 27, 173–179.
    1. Ovuga E, Boardman JED, Wasserman D (2007). Integrating mental health into primary health care: local initiatives from Uganda. World Psychiatry 6, 60–61.
    1. Patel V, Flisher AJ, Hetrick S, McGorry P (2007). Mental health of young people: a global public-health challenge. The Lancet 369, 1302–1313.
    1. Patel V, Flisher AJ, Nikapota A, Malhotra S (2008). Promoting child and adolescent mental health in low and middle income countries. Journal of Child Psychology and Psychiatry 49, 313–334.
    1. Rowe AK, de Savigny D, Lanata CF, Victora CG (2005). How can we achieve and maintain high-quality performance of health workers in low-resource settings? The Lancet 366, 1026–1035.
    1. Seidman G, Atun R (2017). Does task shifting yield cost savings and improve efficiency for health systems? A systematic review of evidence from low-income and middle-income countries. Human Resources for Health 15, 29.
    1. Stiffman AR, Pescosolido B, Cabassa LJ (2004). Building a model to understand youth service access: the gateway provider model. Mental Health Services Research 6, 189–198.
    1. Tilahun D, Hanlon C, Araya M, Davey B, Hoekstra RA, Fekadu A (2017). Training needs and perspectives of community health workers in relation to integrating child mental health care into primary health care in a rural setting in sub-Saharan Africa: a mixed methods study. International Journal of Mental Health Systems 11, 15.
    1. Tomlinson M, Rudan I, Saxena S, Swartz L, Tsai AC, Patel V (2009). Setting priorities for global mental health research. Bulletin of the World Health Organization 87, 438–446.
    1. Van Ginneken N, Tharyan P, Lewin S, Rao GN, Meera SM, Pian J, Chandrashekar S, Patel V (2013). Non-specialist health worker interventions for the care of mental, neurological and substance-abuse disorders in low- and middle-income countries. Cochrane Database of Systematic Reviews, 11.
    1. World Health Organization (2001). The World Health Report 2001: Mental Health: New Understanding, New Hope. Geneva: World Health Organisation.
    1. World Health Organization (2003). Caring for Children and Adolescents with Mental Disorders: Setting WHO Directions. Geneva: World Health Organization.
    1. World Health Organization (2004). Declaration of Alma-Ata. Geneva: World Health Organization, Regional Office for Europe.
    1. World Health Organization (2010). International Statistical Classification of Diseases and Related Health Problems. Geneva: World Health Organisation; Available online: [Accessed September 2017].
    1. World Health Organization (2007). Task Shifting: Rational Redistribution of Tasks Among Health Workforce Teams: Global Recommendations and Guidelines. Geneva: World Health Organization; Available online: [Accessed June 2018].
    1. World Health Organization (2008a). Integrating Mental Health into Primary Care: A Global Perspective. Geneva: World Health Organization.
    1. World Health Organization (2008b). The World Health Report 2008: Primary Health Care Now More Than Ever. Geneva: World Health Organization.
    1. World Health Organization (2010). mhGAP Intervention Guide. Geneva: World Health Organization.
    1. World Health Organization (2011). Assessment of Health Facility Data Quality. Geneva: World Health Organization.
    1. World Health Organization (2017). mhGAP Training Manuals for the mhGAP Intervention Guide for Mental, Neurological and Substance Use Disorders in Non-Specialized Health Settings-Version 2.0 (for Field Testing). Geneva: World Health Organization.
    1. World Health Organization, World Organization of National Colleges, Academies & Academic Associations of General Practitioners/Family Physicians (2008). Integrating Mental Health Into Primary Care: A Global Perspective. Geneva: World Health Organization.

Source: PubMed

Sponsorer og samarbeidspartnere

Medisinsk tilstand

Legemiddelintervensjoner

3
Abonnere