Mental health in the era of HIV. Investigating mental distress, its determinants, conceptual models and the impact of HIV in Zambia
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The world health organisation drew attention to the growing global burden of mental disorders. Current estimates comprised 12% of the Global Burden of Disease and estimated to rise to 15% by the year 2020 which would then make them the second leading cause of health disability in the world. This burden is thought to be worse in low income countries where poverty and other communicable diseases abounds. It is thought that in these regions, the poor are particularly vulnerable through a mechanism mediated by high intensity of social stressors, social marginalisation and the overwhelming burden of communicable and noncommunicable diseases. Additionally, mental distress is known to interact and alter the course of many other diseases. Of particular interest to this thesis is it interaction with HIV. HIV is currently considered to be among the major cause of deaths in the most affected sub-Saharan countries. Here HIV infection is compounded by poor access to health services and high stigmatisation. Changes in socioeconomic transmission patterns are interesting in this regard. In the early stages of the epidemic HIV transmission appeared highest among the highest socioeconomic groups. However, this pattern changed dramatically over years, and HIV transmission rates are now highest among the low socio-economic position groups. Assuming that HIV has a negative impact on mental distress, it would suggest that the two disease entities are entangled in a self-perpetuating cycle of increasing morbidity where; poor mental health prevents people from engaging productively in their own lives and also might predispose them to risky sexual behaviour and substance abuse while in turn HIV increases the risk for poor mental health via its biological and psychological impact thereby impeding access to preventive, promotive and even curative health interventions. This ushers in the need for routine screening for mental distress in general medical patients and especially among HIV-infected patients. However, due to inadequacies in medical staffing, providing mental health services in Primary Health Care centres involves diagnosing and treating people with mental distress within the currently existing general framework of the available services and personnel. Therefore there is need for a valid screening instrument that is psychometrically sound and sufficiently short (less time consuming) and can be used without specialised training to achieve routine screening. Furthermore, it is imperative that explanatory models for mental distress are explored so as to compare them to those of health care providers as well as for purposes of examining how they are related to help-seeking, coping mechanisms and treatment preferences. This thesis examined all these factors in four scientific papers. Paper I was based on a population based survey conducted in 2003 in selected urban and rural communities in Zambia which examined the prevalence of mental distress, its distribution patterns and the mechanism by which HIV impacts on mental distress. The HIV prevalence was 13.6% vs. 18% in the rural and urban populations, respectively. The prevalence of mental distress was substantially higher among women than men and among groups with low educational attainment. The structural equation model revealed that HIV infection had both direct and indirect impact on mental distress. Further, it showed that the indirect effects of self-rated health and self-perceived HIV risk and worry of being HIV infected were important mediators between socio-demographic factors, HIV infection and mental distress. In paper II and paper IV, the validation of different well established screening instruments was under taken among a sample of primary health care clinic attendees in Lusaka, Zambia. This was aimed at assessing their face, content and criterion validity alongside determining the most commonly reported symptoms for mental distress. Results showed that all three instruments (Self-Reporting Questionnaire: SRQ-20. SRQ-10, SRQ-5) had acceptable sensitivity and specificity for identifying mental distress correctly. There were no differences noted by residence, age or gender and so there was no need to have different cut-off points for those categories. The papers established the utility of the all three instruments as easy-to-use screening instruments for detecting probable cases of mental distress. The abbreviated instruments had an added advantage of being shorter and so less time consuming. In paper IV we aimed at identifying explanatory models employed by HIV-infected and uninfected individuals and to compare them with those employed by local health care providers. Furthermore, we aimed to build a theoretical model linking the perception of mental distress to treatment preferences and coping mechanisms. The results showed that mental distress was expressed primarily as somatic complaints and as autonomic symptoms. Economic difficulties and interpersonal relationship problems were identified as commonest causes of mental distress among the HIV-uninfected individuals. Among the HIV positive, the newly diagnosed HIV patients presented with the highest degree of hopelessness which was linked to poor help-seeking for their symptoms. Poor health seeking behavior was also seen among the HIV-infected patients who were not receiving anti-retroviral drugs (ARV). In contrast, patients already commenced on ARV were best adjusted to their status, expressed hope and valued counseling and support groups. Comparison of explanatory models for the patients and health care providers revealed that the conceptualization was somewhat different. The findings in this thesis underscore the importance of validating screening instruments to fit the local context and thus to improve the epidemiological knowledgebase on mental health. They also advocate for the adoption and integration of the SRQ in the routine screening for mental distress in Primary health care, and especially in HIV-infected patients. The findings also reinforce the need for Health care providers to be sensitive to patients’ explanatory models as they were critical to treatment-seeking decisions and coping.
Paper I: BMC Public Health 9(298), Chipimo, P. J.; Fylkesnes, K., Mental distress in the general population in Zambia: impact of HIV and social factors. Copyright 2009 Chipimo and Fylkesnes; licensee BioMed Central. Reproduced with permission. Published version. The published version is also available at: http://dx.doi.org/10.1186/1471-2458-9-298Paper II: Clinical Practice & Epidemiology in Mental Health 6, Chipimo, P. J.; Fylkesnes, K., Comparative validity of screening instruments for Mental Distress in Zambia, pp. 4-15. Copyright Chipimo and Fylkesnes; Licensee Bentham Open. Reproduced with permission. Published version.Paper III: BMC Health Services Research 11(7), Chipimo, P. J.; Tuba, M.; Fylkesnes, K., Conceptual models for Mental Distress among HIV-infected and uninfected individuals: A contribution to clinical practice and research in primary-health-care centers in Zambia. Copyright 2011 Chipimo et al; licensee BioMed Central. Reproduced with permission. Published version. The published version is also available at: http://dx.doi.org/10.1186/1472-6963-11-7Paper IV: Chipimo, P. J.; Fylkesnes, K., 2011, Case-finding for Mental Distress in Primary Health Care: an evaluation of the performance of a five-item screening instrument. Submitted version.