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Health system constraints in integrating mental health services into primary healthcare in rural Uganda: perspectives of primary care providers.

ABSTRACT: Background:The World Health Organization issued recommendations to guide the process of integrating mental health services into primary healthcare. However, there has been general as well as context specific shortcomings in the implementation of these recommendations. In Uganda, mental health services are intended to be decentralized and integrated into general healthcare, but, the services are still underutilized especially in rural areas. Purpose:The purpose of this study was to explore the health systems constraints to the integration of mental health services into PHC in Uganda from the perspective of primary health care providers (PHCPs). Methods:This was a cross sectional qualitative study guided by the Supporting the Use of Research Evidence (SURE) framework. We used a semi-structured interview guide to gain insight into the health systems constraints faced by PHCPs in integrating mental health services into PHC. Results:Key health systems constraints to integrating mental health services into PHC identified included inadequate practical experience during training, patient flow processes, facilities, human resources, gender related factors and challenges with accessibility of care. Conclusion:There is need to strengthen the training of healthcare providers as well as improving the health care system that supports health workers. This would include periodic mental healthcare in-service training for PHCPs; the provision of adequate processes for outreach, and receiving, referring and transferring patients with mental health problems; empowering PHCPs at all levels to manage and treat mental health problems and adequately provide the necessary medical supplies; and increase the distribution of health workers across the health facilities to address the issue of high workload and compromised quality of care provided.

SUBMITTER: Wakida EK

PROVIDER: S-EPMC6429816 | biostudies-literature | 2019

REPOSITORIES: biostudies-literature

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Health system constraints in integrating mental health services into primary healthcare in rural Uganda: perspectives of primary care providers.

Wakida Edith K EK Okello Elialilia S ES Rukundo Godfrey Z GZ Akena Dickens D Alele Paul E PE Talib Zohray M ZM Obua Celestino C

International journal of mental health systems 20190322

<h4>Background</h4>The World Health Organization issued recommendations to guide the process of integrating mental health services into primary healthcare. However, there has been general as well as context specific shortcomings in the implementation of these recommendations. In Uganda, mental health services are intended to be decentralized and integrated into general healthcare, but, the services are still underutilized especially in rural areas.<h4>Purpose</h4>The purpose of this study was to ...[more]

PMID: 30949234

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Project description:BackgroundIn response to an increased health burden from non-communicable diseases (NCDs), primary health care (PHC) is effective platform to support NCDs prevention and control. This study aims to assess Thailand's PHC capacity in providing NCDs services, identify enabling factors and challenges and provide policy recommendations for improvement.MethodsThis cross-sectional mixed-method study was conducted between October 2019 and May 2020. Two provinces, one rich and one poor, were randomly selected and then a city and rural district from each province were randomly selected. From these 4 sites in the 2 provinces, all 56 PHC centres responded to a self-administrative questionnaire survey on their capacities and practices related to NCDs. A total of 79 participants from Provincial and District Health Offices, provincial and district hospitals, and PHC centres who are involved with NCDs participated in focus group discussions or in-depth interviews.ResultsStrong health infrastructure, competent staff (however not with increased workload), essential medicines and secured budget boost PHC capacity to address NCDs prevention, control, case management, referral and rehabilitation. Community engagement through village health volunteers improves NCDs awareness, supports enrolment in screening and raises adherence to interventions. Village health volunteers, the crucial link between the health system and the community, are key in supporting health promotion and NCDs prevention and control. Collaboration between provincial and district hospitals in providing resources and technical support enhance the capacity of PHC centres to provide NCDs services. However, inconsistent national policy directions and uncertainty related to key performance indicators hamper progress in NCDs management at the operational level. The dynamic of urbanization and socialization, especially living in obesogenic environments, is one of the greatest challenges for dealing with NCDs.ConclusionPHC centres play a vital role in NCDs prevention and control. Adequate human and financial resources and policy guidance are required to improve PHC performance in managing NCDs. Implementing best buy measures at national level provides synergies for NCDS control at PHC level.

Project description:IntroductionPatient-centered care (PCC) is an approach to involve patients in health care delivery, to contribute to quality of care, and to strengthen health systems responsiveness. This article aims to highlight patient perspectives by showcasing their perceptions of their experience of PCC at primary health facilities in two districts in Uganda.MethodsA mixed methods cross-sectional study was conducted in three public and two private primary health care facilities in rural eastern Uganda. In total, 300 patient exit survey questionnaires, 31 semi-structured Interviews (SSIs), 5 Focus Group Discussions (FGDs) and 5 feedback meetings were conducted. Data analysis was guided by a conceptual framework focusing on (1) understanding patients' health needs, preferences and expectations, (2) describing patients perceptions of their care experience according to five distinct PCC dimensions, and (3) reporting patient reported outcomes and their recommendations on how to improve quality of care.ResultsPatient expectations were shaped by their access to the facility, costs incurred and perceived quality of care. Patients using public facilities reported doing so because of their proximity (78.3% in public PHCs versus 23.3% in private PHCs) and because of the free services availed. On the other hand, patients attending private facilities did so because of their perception of better quality of care (84.2% in private PHCs versus 21.7% in public PHCs). Patients expectations of quality care were expressed as the availability of medication, shorter waiting times, flexible facility opening hours and courteous health workers. Analysis of the 300 responses from patients interviewed on their perception of the care they received, pointed to higher normalized scores for two out of the five PCC dimensions considered: namely, exploration of the patient's health and illness experience, and the quality of the relationship between patient and health worker (range 62.1-78.4 out of 100). The qualitative analysis indicated that patients felt that communication with health workers was enhanced where there was trust and in case of positive past experiences. Patients however felt uncomfortable discussing psychological or family matters with health workers and found it difficult to make decisions when they did not fully understand the care provided. In terms of outcomes, our findings suggest that patient enablement was more sensitive than patient satisfaction in measuring the effect of interpersonal patient experience on patient reported outcomes.Discussion and conclusionOur findings show that Ugandan patients have some understanding of PCC related concepts and express a demand for it. The results offer a starting point for small scale PCC interventions. However, we need to be cognizant of the challenges PCC implementation faces in resource constrained settings. Patients' expectations in terms of quality health care are still largely driven by biomedical and technical aspects. In addition, patients are largely unaware of their right to participate in the evaluation of health care. To mitigate these challenges, targeted health education focusing on patients' responsibilities and patient's rights are essential. Last but not least, all stakeholders must be involved in developing and validating methods to measure PCC.

Project description:INTRODUCTION:The burden of childhood mortality continues to be born largely by low-income and middle-income countries. The critical postdischarge period has been largely neglected despite evidence that mortality rates during this period can exceed inpatient mortality rates. However, there is a paucity of data on the paediatric discharge process from the perspective of the healthcare provider. Provider perspectives may be important in the development of an improved understanding of the barriers and facilitators to improving the transition from hospital to home. OBJECTIVES:To explore healthcare providers' and facility administrators' perspectives of the paediatric discharge process with respect to: (1) current procedures, (2) barriers and challenges, (3) ideas for change, (4) facilitators for change and (5) the importance of discharge planning. DESIGN:A qualitative exploratory approach using focus groups (14) and in-depth interviews (7). SETTING:This study was conducted at seven hospitals providing paediatric care in Uganda. RESULTS:Current discharge procedures are largely based on hospital-specific protocols or clinician opinion, as opposed to national guidelines. Some key barriers to an improved discharge process included caregiver resources and education, critical communication gaps, traditional practices, and a lack of human and physical resources. Teamwork and motivation to see improved paediatric transitions to home were identified as facilitators to implementing the ideas for change proposed by participants. The need for a standardised national policy guiding paediatric discharges, implemented through education at many levels and coupled with appropriate community referral and follow-up, was broadly perceived as essential to improving outcomes for children. CONCLUSIONS:Although significant challenges and gaps were identified within the current health system, participants' ideas and the identified facilitators provide a significant basis from which change may occur. This work can facilitate the development of sustainable and effective interventions to improve postdischarge outcomes in Uganda and other similar settings.

Project description:BackgroundDecreasing or flattening funding for vertical HIV services means that new and innovative ways of providing care are necessary. This study aimed to assess the determinants of readiness for integration of Antiretroviral Therapy (ART) services at the departmental level among primary health care providers (PHCP) at selected health facilities in Lira District.MethodsA cross-sectional survey employing mixed methods approaches was conducted between January and February 2022 among 340 primary healthcare practitioners (PHCP) at selected health facilities in Lira district. An interviewer-administered questionnaire was used to collect quantitative data. Quantitative data was analyzed using Stata version 15. and presented as proportions, means, percentages, frequencies, and odds ratios. Logistic regression was used to determine associations of the factors with readiness for ART integration at a 95% level of significance. Thematic analysis was used to analyze qualitative data.ResultsThe majority 75.2% (95% CI; 0.703-0.795) of the respondents reported being ready for the integration of ART services. PHCPs who were aware of the integration of services and those who had worked in the same facility for at least 6 years had higher odds of readiness for integration of ART, compared with their counterparts [aOR = 7.36; 95% CI = 3.857-14.028, p-value <0.001] for knowledge and duration at the current facility [aOR = 2.92; 95% CI = 1.293-6.599, p-value < 0.05] respectively. From the qualitative data, the dominant view was that integration is a good thing that should be implemented immediately. However, several challenges were noted, key among which include limited staffing and drug supplies at the facilities, coupled with limited space.ConclusionsThe study reveals a high level of readiness for the integration of ART services at departmental levels among Primary Healthcare Providers. Notably, PHCPs knowledgeable about integration and those who spent at least six years at the current health facility of work, were strong determinants for the integration of ART services in resource limited settings. In light of these findings, we recommend that policymakers prioritize the implementation of training programs aimed at upskilling healthcare workers. Furthermore, we advocate that a cluster randomized controlled trial be conducted, to evaluate the long-term effects of this integration on overall health outcomes.

Project description:Despite the rising burden of noncommunicable diseases, access to quality decentralized noncommunicable disease services remain limited in many low- and middle-income countries. Here we describe the strategies we employed to drive the process from adaptation to national endorsement and implementation of the 2016 Botswana primary healthcare guidelines for adults. The strategies included detailed multilevel assessment with broad stakeholder inputs and in-depth analysis of local data; leveraging academic partnerships; facilitating development of supporting policy instruments; and embedding noncommunicable disease guidelines within broader primary health-care guidelines in keeping with the health ministry strategic direction. At facility level, strategies included developing a multimethod training programme for health-care providers, leveraging on the experience of provision of human immunodeficiency virus care and engaging health-care implementers early in the process. Through the strategies employed, the country's first national primary health-care guidelines were endorsed in 2016 and a phased three-year implementation started in August 2017. In addition, provision of primary health-care delivery of noncommunicable disease services was included in the country's 11th national development plan (2017-2023). During the guideline development process, we learnt that strong interdisciplinary skills in communication, organization, coalition building and systems thinking, and technical grasp of best-practices in low- and middle-income countries were important. Furthermore, misaligned agendas of stakeholders, exaggerated by a siloed approach to guideline development, underestimation of the importance of having policy instruments in place and coordination of the processes initially being led outside the health ministry caused delays. Our experience is relevant to other countries interested in developing and implementing guidelines for evidence-based noncommunicable disease services.

Project description:ObjectiveProviding services to rural dwelling minority cultural groups with serious chronic disease is challenging due to access to care and cultural differences. This study aimed to describe service providers' perspectives on health services delivery for Aboriginal people receiving haemodialysis for end-stage kidney disease in rural Australia.DesignSemistructured interviews, thematic analysisSettingA health district in rural New South Wales, AustraliaParticipantsUsing purposive sampling, 29 renal and allied service providers were recruited, including nephrologists, renal nurses, community nurses, Aboriginal health workers, social workers and managers. Six were Aboriginal and 23 non-Aboriginal.ResultsImproving cultural understanding within the healthcare system was central to five themes identified: rigidity of service design (outreach, inevitable home treatment failures, pressure of system overload, limited efficacy of cultural awareness training and conflicting priorities in acute care); responding to social complexities (respecting but challenged by family obligations, assumptions about socioeconomic status and individualised care); promoting empowerment, trust and rapport (bridging gaps in cultural understanding, acknowledging the relationship between land, people and environment, and being time poor); distress at late diagnosis (lost opportunities and prioritise prevention); and contending with discrimination and racism (inherent judgement of lifestyle choices, inadequate cultural awareness, pervasive multilevel institutionalised racism and managing patient distrust).ConclusionsService providers believe current services are not designed to address cultural needs and Aboriginality, and that caring for Aboriginal patients receiving haemodialysis should be family focused and culturally safer. An Aboriginal-specific predialysis pathway, building staff cultural awareness and enhancing cultural safety within hospitals are the measures recommended. Increasing patient support for home haemodialysis may improve health and the quality of care outcomes.

Project description:BackgroundTransitioning from pediatric care to adult-oriented care at age 18 (the age of transfer in most countries and jurisdictions) is a complex process for adolescents and young adults affected by chronic physical health and/or mental health conditions. The role of primary health care (PHC) providers for this population is poorly understood. Perspectives from these providers, such as family physicians and other members of the primary care team, have not been explored in depth.MethodsA total of 18 participants (e.g., family physicians, social workers, nurses) were recruited from 6 Primary Care Networks in Calgary, Alberta, Canada. Semi-structured individual interviews were conducted, and transcribed verbatim. A qualitative description approach was used to analyze the data, and included thematic analysis.ResultsFive distinct, yet overlapping, roles of primary health care providers for adolescents and young adults transitioning to adult care resulted from our analysis: (1) being the "common thread" (continuous accessible care); (2) caring for the "whole patient" (comprehensive care); (3) "knowing families" (family-partnered care); (4) "empowering" adolescents and young adults to develop "personal responsibility" (developmentally-appropriate care); and (5) "quarterbacking" care (coordination of specialist and/or community-based care). Participants identified potential benefits of these roles for adolescents and young adults transitioning to adult care, and barriers in practice (e.g., lack of time, having minimal involvement in pediatric care).ConclusionsInput from family physicians, who follow their patients across the lifespan and provide the majority of primary care in Canada, are critical for informing and refining recommended transition practices. Our findings provide insights, from PHC providers themselves, to bolster the rationale for primary care involvement during transitions from pediatric specialty and community-based care for AYAs. Solutions to overcome barriers for integrating primary care and specialty care for adolescents and young adults need to be identified, and tested, with input from key stakeholders.

Dataset Information

Health system constraints in integrating mental health services into primary healthcare in rural Uganda: perspectives of primary care providers.

Publications

Health system constraints in integrating mental health services into primary healthcare in rural Uganda: perspectives of primary care providers.

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