Caleb Othieno

Health system challenges to integration of mental health delivery in primary care in Kenya- perspectives of primary care health workers

BackgroundHealth system weaknesses in Africa are broadly well known, constraining progress on reducing the burden of both communicable and non-communicable disease (Afr Health Monitor, Special issue, 2011, 14-24), and the key challenges in leadership, governance, health workforce, medical products, vaccines and technologies, information, finance and service delivery have been well described (Int Arch Med, 2008, 1:27). This paper uses focus group methodology to explore health worker perspectives on the challenges posed to integration of mental health into primary care by generic health system weakness.MethodsTwo ninety minute focus groups were conducted in Nyanza province, a poor agricultural region of Kenya, with 20 health workers drawn from a randomised controlled trial to evaluate the impact of a mental health training programme for primary care, 10 from the intervention group clinics where staff had received the training programme, and 10 health workers from the control group where staff had not received the training).ResultsThese focus group discussions suggested that there are a number of generic health system weaknesses in Kenya which impact on the ability of health workers to care for clients with mental health problems and to implement new skills acquired during a mental health continuing professional development training programmes. These weaknesses include the medicine supply, health management information system, district level supervision to primary care clinics, the lack of attention to mental health in the national health sector targets, and especially its absence in district level targets, which results in the exclusion of mental health from such district level supervision as exists, and the lack of awareness in the district management team about mental health. The lack of mental health coverage included in HIV training courses experienced by the health workers was also striking, as was the intensive focus during district supervision on HIV to the detriment of other health issues.ConclusionGeneric health system weaknesses in Kenya impact on efforts for horizontal integration of mental health into routine primary care practice, and greatly frustrate health worker efforts.Improvement of medicine supplies, information systems, explicit inclusion of mental health in district level targets, management and supervision to primary care are likely to greatly improve primary care health worker effectiveness, and enable training programmes to be followed by better use in the field of newly acquired skills. A major lever for horizontal integration of mental health into the health system would be the inclusion of mental health in the national health sector reform strategy at community, primary care and district levels rather than just at the higher provincial and national levels, so that supportive supervision from the district level to primary care would become routine practice rather than very scarce activity.Trial registrationTrial registration ISRCTN%2053515024

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.

Trial designA pragmatic cluster randomised controlled trial.MethodsParticipants: Clusters were primary health care clinics on the Ministry of Health list. Clients were eligible if they were aged 18 and over. Interventions: Two members of staff from each intervention clinic received the training programme. Clients in both intervention and control clinics subsequently received normal routine care from their health workers. Objective: To examine the impact of a mental health inservice training on routine detection of mental disorder in the clinics and on client outcomes. Outcomes: The primary outcome was the rate of accurate routine clinic detection of mental disorder and the secondary outcome was client recovery over a twelve week follow up period. Randomisation: clinics were randomised to intervention and control groups using a table of random numbers. Blinding: researchers and clients were blind to group assignment.ResultsNumbers randomised: 49 and 50 clinics were assigned to intervention and control groups respectively. 12 GHQ positive clients per clinic were identified for follow up. Numbers analysed: 468 and 478 clients were followed up for three months in intervention and control groups respectively. Outcome: At twelve weeks after training of the intervention group, the rate of accurate routine clinic detection of mental disorder was greater than 0 in 5% versus 0% of the intervention and control groups respectively, in both the intention to treat analysis (p = 0.50) and the per protocol analysis (p =0.50). Standardised effect sizes for client improvement were 0.34 (95% CI = (0.01,0.68)) for the General Health Questionnaire, 0.39 ((95% CI = (0.22, 0.61)) for the EQ and 0.49 (95% CI = (0.11,0.87)) for WHODAS (using ITT analysis); and 0.43 (95% CI = (0.09,0.76)) for the GHQ, 0.44 (95% CI = (0.22,0.65)) for the EQ and 0.58 (95% CI = (0.18,0.97)) for WHODAS (using per protocol analysis). Harms: None identified.ConclusionThe training programme did not result in significantly improved recorded diagnostic rates of mental disorders in the routine clinic consultation register, but did have significant effects on patient outcomes in routine clinical practice.Trial registrationInternational Standard Randomised Controlled Trial Number Register ISRCTN53515024.

Depression among university students in Kenya: Prevalence and sociodemographic correlates

BACKGROUND Depression is a common cause of morbidity but prevalence levels among Kenyan university students are poorly understood. A better understanding of depression and its correlates is essential in planning for appropriate interventions in this population group. METHOD A random sample of 923 University of Nairobi students (525 male and 365 female) were interviewed using a questionnaire to record sociodemographic variables. Depressive symptoms were measured using Centre for Epidemiological Studies Short Depression Scale (CES - D 10). RESULTS The mean age was 23 (s.d. 4.0). Using a cut-off point of 10, the overall prevalence of moderate depressive symptoms was 35.7% (33.5% males and 39.0% females) and severe depression was 5.6% (5.3% males and 5.1% female). Depressive illness was significantly more common among the first year students, those who were married; those who were economically disadvantaged and those living off campus. Other variables significantly related to higher depression levels included year of study, academic performance, religion and college attended. Logistic regression showed that those students who used tobacco, engaged in binge drinking and those who had an older age were more likely to be depressed. No difference was noted with respect to gender. LIMITATIONS This was a cross sectional study relying on self report of symptoms and could therefore be inaccurate. Although the study was conducted in the largest university in the country that admits students from diverse backgrounds in the country there could still be regional differences in other local universities. CONCLUSION Depression occurs in a significant number of students. Appropriate interventions should be set up in higher institutions of learning to detect and treat these disorders paying particular attention to those at risk.

The Epidemiology of Addiction in Sub-Saharan Africa: A Synthesis of Reports, Reviews, and Original Articles

Use of alcohol and other psychoactive substances is associated with serious social and public health problems, but the extent of the problem in Sub-Saharan Africa is not well known. We set out to review epidemiological publications on alcohol and other psychoactive substances in Sub-Saharan Africa by performing a systematic search of electronic databases and paper records. Ten Sub-Saharan African countries are among the 22 in the world with the highest increase in per capita alcohol consumption. Cannabis, tobacco, and khat are widely used, and use of cocaine, stimulants, and heroin is increasing. More epidemiological research and implementation and evaluation of interventions is needed. Collaboration between African researchers and those in developed countries could help. 

Perspectives and concerns of clients at primary health care facilities involved in evaluation of a national mental health training programme for primary care in Kenya

BackgroundA cluster randomised controlled trial (RCT) of a national Kenyan mental health primary care training programme demonstrated a significant impact on the health, disability and quality of life of clients, despite a severe shortage of medicines in the clinics (Jenkins et al. Submitted 2012). As focus group methodology has been found to be a useful method of obtaining a detailed understanding of client and health worker perspectives within health systems (Sharfritz and Roberts. Health Transit Rev 4:81–85, 1994), the experiences of the participating clients were explored through qualitative focus group discussions in order to better understand the potential reasons for the improved outcomes in the intervention group.MethodsTwo ninety minute focus groups were conducted in Nyanza province, a poor agricultural region of Kenya, with 10 clients from the intervention group clinics where staff had received the training programme, and 10 clients from the control group where staff had not received the training during the earlier randomised controlled trial.ResultsThese focus group discussions suggest that the clients in the intervention group noticed and appreciated enhanced communication, diagnostic and counselling skills in their respective health workers, whereas clients in the control group were aware of the lack of these skills. Confidentiality emerged from the discussions as a significant client concern in relation to the volunteer cadre of community health workers, whose only training comes from their respective primary care health workers.ConclusionEnhanced health worker skills conferred by the mental health training programme may be responsible for the significant improvement in outcomes for clients in the intervention clinics found in the randomised controlled trial, despite the general shortage of medicines and other health system weaknesses. These findings suggest that strengthening mental health training for primary care staff is worthwhile even where health systems are not strong and where the medicine supply cannot be guaranteed.Trial registrationISRCTN 53515024.

Exploring the perspectives and experiences of health workers at primary health facilities in Kenya following training

BackgroundA cluster randomised controlled trial (RCT) of a national Kenyan mental health primary care training programme demonstrated a significant impact for health workers on the health, disability and quality of life of their clients, despite a severe shortage of medicines in the clinics (Jenkins et al.:37–47, 2012). In order to better understand the potential reasons for the improved outcomes in the intervention group, the experiences of the participating health workers were explored through qualitative focus group discussions, as focus group methodology has been found to be a useful method of obtaining a detailed understanding of client and health worker perspectives within health systems (Sharfritz and Roberts. Health Transition Review 4:81-85, 1994).MethodsTwo ninety minute focus groups were conducted in Nyanza province, a poor agricultural region of Kenya, with 10 health workers from the intervention group clinics where staff had received the training programme, and 10 health workers from the control group where staff had not received the training during the earlier randomised controlled trial.ResultsThese focus group discussions suggest that the health workers in the intervention group perceived an increase in their communication, diagnostic and counselling skills, and that the clients in the intervention group noticed and appreciated these enhanced skills, while health workers and clients in the control group were both aware of the lack of these skills.ConclusionEnhanced health worker skills conferred by the mental health training programme may be responsible for the significant improvement in outcome of patients in the intervention clinics found in the randomised controlled trial, despite the general shortage of medicines and other health system weaknesses. These findings suggest that strengthening mental health training for primary care staff is worthwhile even where health systems are not strong and where the medicine supply cannot be guaranteed.Trial registrationISRCTN53515024

Bullying in public secondary schools in Nairobi, Kenya

Background: The prevalence and frequency of bullying in Nairobi public secondary schools in particular and in Kenyan schools in general is not known. Knowledge of the extent of the problem is essential in developing effective interventions. Aim: To study the prevalence and frequency of bullying in Nairobi public secondary schools, Kenya. Methods: A self-report sociodemographic questionnaire and the Olweus Bullying Questionnaire of 1991 were administered to 1 012 students from a stratified sample of public secondary schools in Nairobi. Results: Between 63.2% (640) and 81.8% (828) of students reported various types of bullying, both direct and indirect, with significant variations found for sex, age, class and year of study, whether in day or boarding school, and the place where bullied. Being bullied was significantly associated with becoming a bully, in turn. Discussion: Bullying is highly prevalent in Kenyan schools. Further studies are needed to characterise bullies and victims in terms of personality and environmental factors that may be associated with or conducive to bullying, as well as to determine the long-term prognosis for both bullies and victims. Further research is also required to determine the most appropriate intervention.

PATTERNS OF SUBSTANCE ABUSE AMONG KENYAN STREET CHILDREN

Abstract A sample of 50 (36 male and 14 female) street children currently in a remand home at Kabete in Nairobi, Kenya, were interviewed using a predesigned questionnaire in order to estimate prevalence rates for use of selected substances. The lifetime prevalence rates of the drugs most commonly used were volatile hydrocarbons 42%, tobacco 32%, alcohol 14% cannabis 14% and Khat (catha edulis) 12%. Ten percent were habitual users of tobacco while 4% were regular users of cannabis or khat. The prevalence for use of hard drugs was low, cocaine 4 (8%) and Mandrax (methaqualone) 1 (2%). These findings are similar to those from Cameroon where solvent use was found mainly among street children.

Adult Psychotic Symptoms, Their Associated Risk Factors and Changes in Prevalence in Men and Women Over a Decade in a Poor Rural District of Kenya

There have been no repeat surveys of psychotic symptoms in Kenya or indeed subSaharan Africa. A mental health epidemiological survey was therefore conducted in a demographic surveillance site of a Kenyan household population in 2013 to test the hypothesis that the prevalence of psychotic symptoms would be similar to that found in an earlier sample drawn from the same sample frame in 2004, using the same overall methodology and instruments. This 2013 study found that the prevalence of one or more psychotic symptoms was 13.9% with one or more symptoms and 3.8% with two or more symptoms, while the 2004 study had found that the prevalence of single psychotic symptoms in rural Kenya was 8% of the adult population, but only 0.6% had two symptoms and none had three or more psychotic symptoms. This change was accounted for by a striking increase in psychotic symptoms in women (17.8% in 2013 compared with 6.9% in 2004, p < 0.001), whereas there was no significant change in men (10.6% in 2013 compared with 9.4% in 2004, p = 0.582). Potential reasons for this increase in rate of psychotic symptoms in women are explored.

Traumatic experiences, posttraumatic stress symptoms, depression, and health-risk behavior in relation to injury among University of Nairobi students in Kenya

Objective To describe the prevalence and types of injuries in relation to traumatic experiences, posttraumatic stress symptoms, depression, and health-risk behaviors among university students in Kenya. Method A cross-sectional study collected data on a random sample of university students using a questionnaire to record sociodemographic variables while injuries experiences recorded using the Centers for Disease control criteria and Breslau’s seven-item screener was used to identify post-traumatic stress disorder (PTSD) symptoms. Depressive symptoms were measured using Center for Epidemiological Studies Short Depression Scale. Results Nine hundred and twenty-three students (525 male and 365 female) were included in the study, mean age 23 years (SD 4.0). Serious injury in the previous 12 months was reported by 29.00% of the students. PTSD was present in 15.67% (men 15.39% and women 16.1%). Out of the total, 41.33% of the students had depressive symptoms (35.71% mild–moderate symptoms and 5.62% severe). In the multivariable logistic regression being poor, binge drinking, tobacco use, ever been diagnosed with HIV, physically abused as a child, high PTSD score, and depression (adjusted odds ratio 5.49, 95% confidence interval 4.32–13.21) were significantly (p value < 5%) associated with injury in the last 12 months. Conclusion Unintentional injuries and PTSD symptoms are common in this student population and are positively linked to depression and other risky behaviors. Measures aimed at improving the mental health, such as early identification and treatment of depression, may be useful in reducing the prevalence of such injuries among the youth.