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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.

ABSTRACT: Three-quarters of the global mental health burden exists in low- and middle-income countries (LMICs), yet the lack of mental health services in resource-poor settings is striking. Task-sharing (also, task-shifting), where mental health care is provided by non-specialists, has been proposed to improve access to mental health care in LMICs. This multi-site qualitative study investigates the acceptability and feasibility of task-sharing mental health care in LMICs by examining perceptions of primary care service providers (physicians, nurses, and community health workers), community members, and service users in one district in each of the five countries participating in the PRogramme for Improving Mental health carE (PRIME): Ethiopia, India, Nepal, South Africa, and Uganda. Thirty-six focus group discussions and 164 in-depth interviews were conducted at the pre-implementation stage between February and October 2012 with the objective of developing district level plans to integrate mental health care into primary care. Perceptions of the acceptability and feasibility of task-sharing were evaluated first at the district level in each country through open-coding and then at the cross-country level through a secondary analysis of emergent themes. We found that task-sharing mental health services is perceived to be acceptable and feasible in these LMICs as long as key conditions are met: 1) increased numbers of human resources and better access to medications; 2) ongoing structured supportive supervision at the community and primary care-levels; and 3) adequate training and compensation for health workers involved in task-sharing. Taking into account the socio-cultural context is fundamental for identifying local personnel who can assist in detection of mental illness and facilitate treatment and care as well as training, supervision, and service delivery. By recognizing the systemic challenges and sociocultural nuances that may influence task-sharing mental health care, locally-situated interventions could be more easily planned to provide appropriate and acceptable mental health care in LMICs.

SUBMITTER: Mendenhall E

PROVIDER: S-EPMC4167946 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundPatient-centered care (PCC) offers opportunities for African health systems to improve quality of care. Nonetheless, PCC continually faces implementation challenges. In 2015, Uganda introduced PCC as a concept in their national quality improvement guidelines. In order to investigate whether and how this is implemented in practice, this study aims to identify relevant stakeholders' views on the current quality of primary health care services and their understanding of PCC. This is an important step in understanding how the concept of PCC can be implemented in a resource constrained, sub-Saharan context like Uganda.MethodsThis qualitative study was conducted in Uganda at national, district and facility level, with a focus on three public and three private health centres. Data collection consisted of in-depth interviews (n = 49); focus group discussions (n = 7); and feedback meetings (n = 14) across the four main categories of stakeholders identified: patients/communities, health workers, policy makers and academia. Interviews and discussions explored stakeholder perceptions on the interpersonal aspects of quality primary health care and meanings attached to the concept of PCC. A content analysis of Ugandan policy documents mentioning PCC was also conducted. Thematic content analysis was conducted using NVivo 11 to organize and analyze the data.Findings and conclusionWhile Ugandan stakeholder groups have varying perceptions of PCC, they agree on the following: the need to involve patients in making decisions about their health, the key role of healthcare workers in that endeavor, and the importance of context in designing and implementing solutions. For that purpose, three avenues are recommended: Firstly, fora that include a wide range of stakeholders may offer a powerful opportunity to gain an inclusive vision on PCC in Uganda. Secondly, efforts need to be made to ensure that improved communication and information sharing-important components of PCC-translate to actual shared decision making. Lastly, the Ugandan health system needs to strengthen its engagement of the transformation from a community health worker system to a more comprehensive community health system. Cross-cutting the entire analysis, is the need to address, in a culturally-sensitive way, the many structural barriers in designing and implementing PCC policies. This is essential in ensuring the sustainable and effective implementation of PCC approaches in low- and middle-income contexts.

Project description:BACKGROUND:To improve the performance of the healthcare system, Mali's government implemented a pilot project of performance-based financing (PBF) in the field of reproductive health. It was established in the Koulikoro region. This research analyses the process of implementing PBF at district hospital (DH) level, something which has rarely been done in Africa. METHODS:This qualitative research is based on a multiple, explanatory, and contrasting case study with nested levels of analysis. It covered three of the 10 DHs in the Koulikoro region. We conducted 36 interviews: 12 per DH with council of circle's members (2) and health personnel (10). We also conducted 24 non-participant observation sessions, 16 informal interviews, and performed a literature review. We performed data analysis using the Consolidated Framework for Implementation Research (CFIR). RESULTS:Stakeholders perceived the PBF pilot project as a vertical intervention from outside that focused solely on reproductive health. Local actors were not involved in the design of the PBF model. Several difficulties regarding the quality of its design and implementation were highlighted: too short duration of the intervention (8 months), choice and insufficient number of indicators according to the priority of the donors, and impossibility of making changes to the model during its implementation. All health workers adhered to the principles of PBF intervention. Except for members of the district health management team (DHMT) involved in the implementation, respondents only had partial knowledge of the PBF intervention. The implementation of PBF appeared to be easier in District 3 Hospital compared to District 1 and District 2 because it benefited from a pre-pilot project and had good leadership. CONCLUSION:The PBF programme offered an opportunity to improve the quality of care provided to the population through the motivation of health personnel in Mali. However, several obstacles were observed during the implementation of the PBF pilot project in DHs. When designing and implementing PBF in DHs, it is necessary to consider factors that can influence the implementation of a complex intervention.

Project description:BackgroundHigh rates of unintended adolescent pregnancy are a significant health problem in Uganda. To improve access to family planning (FP) services, community-based Village Health Teams (VHTs) are widely employed in Uganda to deliver education and services. However, evaluations of FP programs suggest that mainly older, married women use VHT FP services.MethodsTo better understand youth reluctance to use VHTs, we collected quantitative FP and contraceptive-seeking behavior data from a survey of 250 youths aged 15-25 in randomly selected households in Nakaseke District, which we triangulated with data from 3 focus group discussions (FGDs) (n = 15).ResultsMost respondents received FP services from the formal health sector, not VHTs. Only half had talked to a VHT, but 65% knew that VHTs provide free FP services, and most (82%) felt comfortable talking to VHTs about FP. The main reasons for discomfort were fear that VHTs would violate privacy (mentioned by 60% of those not comfortable), that VHTs would talk to parents (33%), shyness (mentioned by 42% of those ≤18), and fear of being judged (14%). Concern about side effects was the most common reason for not using FP methods. Survey respondents said having VHTs of the same sex was important, particularly those in the youngest age group (OR = 4.45; 95%CI: 1.24, 16.00) and those who were unmarried (OR = 5.02; 95%CI: 2.42, 10.39). However, FGD participants (who were older than survey respondents on average) often preferred older VHTs of the opposite sex, whom they viewed as more professional and trustworthy. Respondents said the primary deciding factors for using VHTs were whether privacy would be respected, the proximity of care, and the respectfulness of care.ConclusionsVHTs are a known source of FP services but not widely used by youth due to privacy and quality of care concerns. VHT messaging and training should increase focus on ensuring privacy, protecting confidentiality, providing respectful care, and addressing concerns about contraceptive side effects. Preferences for VHTs of similar age and sex may be more important for younger adolescents than older youths for whom quality concerns predominate.

Project description:BackgroundVillage health workers (VHWs) can serve as a valuable resource to address public health needs in resource-limited settings such as Uganda. However, the successful implementation of VHW programs can be limited by poor acceptability among community members. Kisoro District Hospital (KDH) in Kisoro District, Uganda operates a VHW program and, at the time of the study, was expanding its services to 11 additional villages.ObjectiveThe objective of this study was to evaluate community perceptions of VHWs in villages of Kisoro District with no prior exposure to the KDH VHW program in order to improve community acceptance when expanding the program to additional villages.MethodsWe administered surveys to 658 community members from 11 villages to evaluate their perceptions of VHWs prior to receiving VHW services. Additionally, we conducted focus group discussions among 97 participants to explore perceptions of VHWs in further depth.FindingsCommunity members were generally accepting of VHWs. They preferred that VHWs provide both curative and preventive services across a broad range of health domains as opposed to a single disease. Expectations of the responsibilities of a VHW were influenced by agricultural occupational and household responsibilities, particularly for women. Participants expressed a preference to be actively involved in the selection and oversight of VHWs and that VHWs receive compensation.Conclusions1) Community members' expectations of VHWs are shaped by environmental, cultural, and social factors. 2) Active community engagement in the VHW program is key. 3) Aligning a VHW program with community perceptions may improve acceptance, in turn influencing effectiveness and sustainability. These findings were used to expand the KDH VHW Program into the participating villages in a manner consistent with community preferences. Our findings may provide guidance on enhancing the uptake of community-based VHW programs for VHW stakeholders and policymakers in other settings.

Project description:BackgroundAchieving maternal health outcomes in the SDGs requires the implementation of more targeted policies and strategies. While the MDGs may have deepened our understanding in this regard, we know little about the trends in maternal health services utilisation among primigravidas, and how age and geographical regions could have influenced these trends. In this study, we examined utilisation of antenatal and skilled delivery services among primigravidas in Uganda, a country with one of the highest maternal mortality ratios, and where early childbearing and its attendant challenges are common.MethodsGuided by Andersen's Behavioural Model, we fitted multivariate regression models to a pooled dataset of the 2006, 2011 and 2016 Ugandan Demographic and Health Survey (n = 3477) to understand the dynamics in Antenatal Care (ANC) and Skilled Birth Attendance (SBAs) utilisation among primigravidas. Post-estimation margins were employed to further highlight the effect of age and geographical regions.ResultsThe analyses show an improvement in access to maternal health services among primigravidas from 2006 to 2016. Compared to 2006, primigravidas in 2016 were 48%, 24% and 2.98 times more likely to have early ANC, four or more ANC visits, and SBAs, respectively. Altogether, a primigravida in 2016 relative to 2006 was 42% more likely to meet all three maternal health service indicators. Post-estimation margins analyses on age and geographical disparities revealed that younger primigravidas have lower probability, while primigravidas in Eastern Region, one of the most deprived in the country, have the lowest probability of accessing maternal health services. Also, the study found education, wealth, women's household decision-making power, place of residence as important determinants of ANC visits and SBAs.ConclusionsBased on our findings, it is important to address the vulnerabilities of primigravidas, particularly younger individuals, in accessing early ANC. Uganda should scale-up decentralisation and integration of maternal health delivery in local communities as a strategy of addressing lingering geographical disparities, and ultimately improve maternal health outcomes in the SDGs period.

Project description:BACKGROUND:In low-resource settings, a significant proportion of fetal, neonatal, and maternal deaths can be attributed to intrapartum-related complications. Certain risk factors, such as non-cephalic presentation, have a particularly high risk of complications. This qualitative study describes experiences around non-cephalic births and highlights existing perceptions and care-seeking behavior specific to non-cephalic presentation in rural Sarlahi District, Nepal. METHODS:We conducted in-depth interviews with 34 individuals, including women who recently gave birth to a non-cephalic infant and female decision-makers in their households. We also conducted two focus groups with mothers (have two or more children, with at least one child under age five) and two focus groups with grandmothers in the community. RESULTS:Several women described scenes of obstructed labor and practices like provision of unspecified injections early in labor to assist with the delivery. There were reports of arduous care-seeking processes from primary health centers to tertiary facilities, and mixed quality of care among home birth attendants and facility-based health workers respectively. Very few women were aware of the fetal presentation prior to delivery, and we identified no consistent understanding among participants of the risks of and care strategies for non-cephalic births. Risk perception around non-cephalic presentation varied widely. Some participants were acutely aware of potential dangers, while others had not heard of non-cephalic birth. Many interviewees said that the position in which a pregnant woman sleeps could impact the fetal position. Several participants had either taken or heard of medication intended to rotate the fetus into the correct position. CONCLUSIONS:Our findings suggest the mixed quality of and access to care associated with non-cephalic birth and a lack of consistent understanding of the risk of and care for non-cephalic births in rural Nepal. The high risk of the condition and the recommended tertiary care present a dilemma in low-resource settings; the logistical difficulties and the mixed quality of care make care-seeking and referral decisions complex. While public health stakeholders strive to improve the quality of and access to the formal health system, those players must also be sensitive to the potential negative implications of promoting institutional care-seeking.

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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.

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