Access to Child and Adolescent Mental Health services in Uganda: Investigating the role of Primary Health Care and Traditional Healers
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Introduction: Up to 20% of children and adolescents globally suffer from a debilitating mental illness and up to 50% of adult mental illness begins in adolescence. Early detection and management of Child and Adolescent Mental Health (CAMH) disorders reduces the likelihood of long term ill-health and minimizes stress on individuals, families, communities and health systems. Robust health systems are required for optimizing CAMH. However, the coverage of CAMH services in most low-income and middle-income countries (LMIC) is low and health system responses to CAMH have been weak. To increase the coverage of CAMH services, the WHO and others recommend the integration of CAMH into primary health care (PHC) in LMIC. The Mental Health Gap Action Program (mhGAP) and intervention guide (IG) were developed for this purpose. To increase entry into CAMH systems, recent studies recommend collaboration between traditional healers and mental health professionals. The main objective of this research was to investigate access to mental health services for children and adolescents in Uganda through PHC workers and traditional healers. Methods: This concurrent mixed-methods study was conducted in two districts of Eastern Uganda. The qualitative studies utilized key informant interviews with all public officials (n=7) responsible for supervision of CAMH services (Paper I) and in-depth interviews with 20 purposively selected traditional healers (Paper II). The quantitative studies comprised a pre-test/post-test study (Paper III) nested within a pragmatic randomized controlled trial (RCT). The quantitative sub-studies included nurses, midwives and clinical officers who provide PHC services to children and adolescents in level-3 health centers (HC III) in both districts, and who had not previously undergone CAMH training. The RCT (paper IV) intervention consisted of 1) training 36 PHC providers from 18 randomly selected HC III for five days using a curriculum based on the mhGAP- IG version 1.0; and 2) provision of training handouts as job-aids. The RCT compared the proportion of intervention (n=18) to control (n=18) clinics with a non-epilepsy CAMH diagnosis recorded in the clinic registries over three consecutive months following training. Qualitative data were analysed using thematic analysis. Analysis in paper III was based on two-tailed t-tests to assess differences in mean pre-test and post-test scores between the cadres; hierarchical linear regression tested the association between cadre and post test scores; and logistic regression evaluated the relationship between cadre and knowledge gain at three pre-determined cut off points. Fisher’s exact test and logistic regression based on Intention to Treat principles were applied for paper IV. The trial is registered at clinicaltrials.gov registration NCT02552056. Results: Existing CAMH national laws and policies were found to be sufficient. Insufficient public financing for CAMH services and inadequate quality and quantity of CAMH services was cited by all health managers. CAMH services at lower health centers and integration of mental health and CAMH into other health sector services was absent. The health workforce was insufficient in number and skills. Epistemologies of mental illness in children and adolescents were shared between traditional healers and bio-medical providers, but traditional healers had limited interactions with the biomedical health system for mental illness. Traditional healers expressed distrust in biomedical health systems and believed their treatments were superior to medical therapies. They expressed willingness to collaborate with biomedical providers. However, traditional healers believe clinicians disregard them and would not be willing to collaborate with them (paper II). Thirty-three participants completed both pre-and post-tests. There was an improvement in the mean scores from pre- to post-test for both clinical officers (20% change) and nurse/midwives (18% change). Clinical officers had significantly higher mean test scores than nurses and midwives (p < 0.05) but cadre was not significantly associated with improvement in CAMH knowledge at three cut-off points of knowledge gain: 10% (AOR 0.08; 95 CI [0.01, 1.19]; p = 0.066), 15% (AOR 0.16; 95% CI [0.01, 2.21]; p = 0.170), or 25% (AOR 0.13; 95% CI [0.01, 1.74]; p = 0.122) levels. The proportion of clinics with a non-epilepsy CAMH diagnosis prior to training was 27·7% (10/36, similar between study arms). Following training, nearly two thirds (63·8%, 23/36) of all clinics identified and recorded at least one nonepilepsy CAMH diagnosis from 40,692 clinic visits of patients aged 1-18 recorded.. Training did not significantly improve intervention clinics’ nonepilepsy 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: The CAMH system in Uganda is weak. CAMH workforce development to address the human resource gap; and increased integration of CAMH into primary health care and other sectors are suggestions for improving the availability and quality of CAMH services. Collaboration between traditional healers and biomedical providers is possible but is undermined by a prevailing mutual mistrust and competition between traditional healers and clinicians, calling for the implementation of strategies that harness the complementarity of traditional and biomedical providers. PHC providers are important actors in improving access to CAMH services within Uganda’s CAMH system. PHC provider training using mhGAP-IG v1 improves CAMH knowledge; and learning outcomes are independent on the cadre of the provider being trained. Therefore, an option for integrating CAMH into PHC in Uganda is to proceed without cadre differentiation. However, training alone does not result in significant improvements in clinics’ identification and reporting of nonepilepsy CAMH cases. Further task-sharing studies integrating CAMH into a larger sample of PHC clinics are suggested, including a community mobilization component in the intervention to improve CAMH clinic attendance.
Består avPaper 1: Akol A, Engebretsen IMS, Skylstad V, Nalugya J, Ndeezi G, Tumwine J. 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. 2015; 9(1):54. The article is available at: http://hdl.handle.net/1956/12566
Paper 2: Akol A, Moland, KM, Babirye, JN, Engebretsen, IMSE. “We are like cowives”: Traditional healers’ views on collaborating with the formal Child and Adolescent Mental Health System. BMC health services research. 2018. Dec; 18(1):258. The article is available at: http://hdl.handle.net/1956/18870
Paper 3: Akol, A, Nalugya, J, Nshemereirwe, S, Babirye JN and Engebretsen, IMSE. Does Child and Adolescent Mental Health in-service training result in homogenous knowledge gain among cadres of non-specialist health workers in Uganda? A pre-test post-test study. International journal of mental health systems. 2017 Dec; 11(1):50. The article is available at: http://hdl.handle.net/1956/16928
Paper 4: Akol A, Makumbi F, Babirye, JN, Nalugya-Sserunjogi J, Nshemereirwe S, Engebretsen, IMSE. 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. Global Mental Health. 2018; 5:e29. The article is available at: http://hdl.handle.net/1956/18871