Felix Kauye

Validation of a Chichewa version of the Self-Reporting Questionnaire (SRQ) as a brief screening measure for maternal depressive disorder in Malawi, Africa

BACKGROUND Depressive disorder affecting women during the perinatal period is common in low-income countries. The detection and study of maternal depression in a resource-poor setting requires a brief screening tool that is both accurate and practical to administer. METHOD A Chichewa version of the Self Reporting Questionnaire (SRQ) was developed through a rigorous process of forward and back translation, focus-group discussion and piloting. Criterion validation was conducted as part of a larger study in a sample of women who had brought their infants to a child health clinic in rural Malawi, using DSM-IV major and minor depressive episode as the gold standard diagnoses. RESULTS The criterion validation was conducted on 114 subjects who did not differ on health and sociodemographic characteristics from the total study sample (n=501). Test characteristics for each possible SRQ cut-off were calculated and Receiver Operator Characteristic (ROC) curves derived. Area under the ROC curve (AUROC) for detection of current major depressive disorder was 0.856 (95% CI 0.813 to 0.900), and for current major or minor depressive disorder was 0.826 (95% CI 0.783 to 0.869). Internal consistency of the SRQ was high (Cronbachs alpha 0.85). LIMITATION Inter-rater reliability testing was not conducted. CONCLUSION This Chichewa version of the SRQ shows utility as a brief screening measure for detection of probable maternal depression in rural Malawi.

Maternal common mental disorder and infant growth – a cross-sectional study from Malawi

The objective of the study was to investigate the association between maternal common mental disorder (CMD) and infant growth in rural Malawi. A cross-sectional study was conducted at a district hospital child health clinic. Participants were consecutive infants due for measles vaccination, and their mothers. Mean infant weight-for-age and length-for-age z-scores were compared between infants of mothers with and without CMD as measured using the self-reporting questionnaire (SRQ). Of 519 eligible infants/mothers, 501 were included in the analysis. Median infant age was 9.9 months. 29.9% of mothers scored 8 or above on the SRQ indicating CMD. Mean length-for-age z-score for infants of mothers with CMD (-1.50 SD 1.24) was significantly lower than for infants of mothers without CMD (-1.11 SD 1.12) Students t-test: P = 0.001. This association was confirmed in multivariate analysis. Mean weight-for-age z-score for infants of mothers with CMD (-1.77 SD 1.16) was lower than for infants of mothers without CMD (-1.59 SD 1.09) but this difference was not significant on univariate (Students t-test: P = 0.097) or multivariate analysis. The study demonstrates an association between maternal CMD and infant growth impairment in rural sub-Saharan Africa.

Developmental outcomes in Malawian children with retinopathy‐positive cerebral malaria

Objective  To assess children with retinopathy‐positive cerebral malaria (CM) for neurocognitive sequelae.

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.

Training primary health care workers in mental health and its impact on diagnoses of common mental disorders in primary care of a developing country, Malawi: a cluster-randomized controlled trial

BACKGROUND Mental health problems are common in primary care, with prevalence rates of up to 40% reported in developing countries. The study aim was to evaluate the impact of a specially designed toolkit used to train primary health care (PHC) workers in mental health on the rates of diagnosed cases of common mental disorders, malaria and non-specific musculoskeletal pains in primary care in Malawi. METHOD Clinics with out-patient services in the designated district were randomly divided into control and intervention arms. Using a two-phase sampling process, Self-Reporting Questionnaire scores, data on diagnoses made by PHC workers and results of the Structured Clinical Interview for DSM-IV for depression were collected from 837 consecutively attending adult patients in the pre-intervention study and 2600 patients in the post-intervention study. RESULTS The point prevalence rates for probable common mental disorder and depression were 28.8% and 19%, respectively. Rates for both anxiety and depression diagnoses by PHC workers at baseline were 0% in both arms. Following training, there were significant differences between the two arms in the rates of diagnosed cases of depression [9.2% v. 0.5%, odds ratio (OR) 32.1, 95% confidence interval (CI) 7.4-144.3, p ≤ 0.001], anxiety (1.2% v. 0%, p ≤ 0.001) and malaria (31% v. 40%, OR 0.62, 95% CI 0.43-0.89, p = 0.01). The intervention arm had more cases diagnosed with depression and anxiety while the control arm had more cases diagnosed with malaria. CONCLUSIONS Training of PHC workers in mental health with an appropriate toolkit will contribute significantly to the quality of detection and management of patients seen in primary care in developing countries.

Lack of appropriate treatment for people with comorbid HIV/AIDS and epilepsy in sub-Saharan Africa.

It is surprising how little we know regarding the optimal treatment for patients with epilepsy. This lack of information has been highlighted recently in this journal with respect to management of patients with newly diagnosed epilepsy (Glauser et al., 2006). There is probably even less evidence regarding the optimal management of patients who have failed the first drug tried (Kwan and Brodie, 2000). In this article, we propose a new approach to determining how patients with epilepsy should be managed.

A prospective study of psychological distress among mothers of children admitted to a nutritional rehabilitation unit in Malawi

OBJECTIVES Accompanying guardians (usually the mother) have a pivotal role in promoting recovery from childhood severe acute malnutrition on Nutritional Rehabilitation Units (NRUs). We describe the prevalence of maternal distress at an NRU in Malawi and identify factors associated with this. We tested the hypothesis that maternal distress during admission would be associated with reduced child weight gain over the 4-week post-discharge period. METHODS Maternal distress was measured using the Self Reporting Questionnaire (SRQ) administered to mothers of consecutive children during NRU admission. Repeat SRQ was administered to mothers attending a follow-up clinic 4 weeks post discharge. Maternal, child and psychosocial variables were also measured. Child weight change from discharge to follow-up was compared between children of mothers scoring SRQ ≥ 8 and those scoring SRQ < 8. FINDINGS A total of 244 mothers and their children were recruited. In total, 71% of mothers scored SRQ ≥ 8 during admission. In all, 155 of 222 mothers eligible to complete repeat SRQ did so, and 33.5% scored SRQ ≥ 8. Maternal distress at recruitment was associated with older child age, no confiding relationship with spouse, having had a previous child die, and the child having diarrhoea. Maternal distress at follow-up was associated with older child age, the child having diarrhoea or fever since discharge, and the child being HIV sero-positive. Maternal distress during admission was not associated with child weight gain at 4-week post-discharge follow-up. CONCLUSION Levels of maternal distress are very high during child admission to an NRU. Persistent distress is associated with child health factors including HIV. Nutritional rehabilitation programmes should pay increased attention to carer psychological wellbeing using targeted evidence-based interventions.

Integrating community mental health within primary care in southern Malawi: A pilot educational intervention to enhance the role of health surveillance assistants

Background: In response to the significant contribution of mental health problems to the global burden of disease, the World Health Organization (WHO, 2008) renewed its call for the integration of mental health services within primary care. The operationalization of this within resource-constrained settings such as rural Malawi, however, presents a challenge, not least the cultural acceptance of approaches to responding to psychological distress. Aim: This study reports on the development, implementation and evaluation of a mental health care training programme for 271 health surveillance assistants (HSAs) designed to overcome such challenges. Method: A structured evaluation of the impact of training on HSAs’ provision of mental health care was undertaken. Results: Results demonstrated a statistically significant positive effect on HSAs’ knowledge and confidence in providing care and analysis of patient records revealed considerable mental health care and health promotion activity wherein HSAs initiated a new dialogue with the community on mental health and human rights concerns. Conclusion: The HSAs’ focus on the psychosocial concerns of individuals’ ‘distress’ and ‘risk’ prepared the way for a practical set of culturally sensitive and therapeutic interventions and offers a potential path towards increasing the capacity of primary care mental health provision that is responsive to local understandings and experiences of distress.

Health service utilization by patients with common mental disorder identified by the Self-Reporting Questionnaire in a primary care setting in Zomba, Malawi: A descriptive study

Background: There has been no study carried out to assess health service utilization by people with common mental disorder (CMD) in Malawi. Aim: The aim of the study was to evaluate health service utilization patterns of patients with CMD in primary health care (PHC) clinics. Methods: The study was conducted in two PHC clinics in one of the 28 districts in Malawi. Face-to-face interviews with the Self-Reporting Questionnaire (SRQ-20) were conducted in a sample of 323 PHC attendees aged 18 years and older who attended the PHC clinics for any reason. Results: The prevalence of probable CMD in the sample was 20.1%. People with probable CMD had a higher mean number of health facility visits in the previous three months compared to those without probable CMD (1.6 vs 1.19, p = .02). Conclusion: The study reveals high utilization of health services for people with CMD in the PHC setting. There is a need for PHC workers to improve skills in diagnosing patients with CMD to make PHC services more effective by reducing re-attendance and improving patient outcomes.

Pathway to care for psychiatric patients in a developing country: Malawi

Background: Paramedics dominate primary health care in Malawi where native healers also play a major role in the provision of health care and psychiatric nurses are the backbone of district mental health services. Aim: The aim is to improve understanding of prior care-seeking and treatment of new patients seen at mental health services in a developing country like Malawi. Method: For one calendar month, 128 newly referred patients to the mental health services in the three psychiatric units in Malawi were interviewed using an encounter form. Results: Most of the patients went through a first carer before attending a psychiatric unit with only 11.7% going straight to a psychiatric unit. All patients who went straight to a psychiatric unit involved the private/Christian Health Association of Malawi (CHAM) unit in the northern region of Malawi. About 22.7% of the patients had a native healer as a first carer. Only 23% of all patients seen went through a second carer, with none going through a third carer. Over 8% of those who had a paramedic as their first carer had a native healer as their second carer. Duration of stay at different carers varied a lot with about half (48.2%) of all patients who saw a native healer as the first carer spending more than 2 weeks before referral while about 67.0% of those who saw convectional health workers spent 3 days or less before referral. Conclusion: The pathway to care for patients with psychological problems in Malawi is not very much different to pathways to care in other developing countries whereby native healers and paramedics play a significant role. With the high proportion of patients being seen by native healers and the fact that most patients stay longer at native healers before referral, there is need for official collaboration and training of native healers on mental health.