Integrating mental health into primary care in Nigeria: report of a demonstration project using the mental health gap action programme intervention guide
Tóm tắt
The World Mental Health Surveys conducted by the World Health Organization (WHO) have shown that huge treatment gaps for severe mental disorders exist in both developed and developing countries. This gap is greatest in low and middle income countries (LMICs). Efforts to scale up mental health services in LMICs have to contend with the paucity of mental health professionals and health facilities providing specialist services for mental, neurological and substance use (MNS) disorders. A pragmatic solution is to improve access to care through the facilities that exist closest to the community, via a task-shifting strategy. This study describes a pilot implementation program to integrate mental health services into primary health care in Nigeria. The program was implemented over 18 months in 8 selected local government areas (LGAs) in Osun state of Nigeria, using the WHO Mental Health Gap Action Programme Intervention Guide (mhGAP-IG), which had been contextualized for the local setting. A well supervised cascade training model was utilized, with Master Trainers providing training for the Facilitators, who in turn conducted several rounds of training for front-line primary health care workers. The first set of trainings by the Facilitators was supervised and mentored by the Master Trainers and refresher trainings were provided after 9 months. A total of 198 primary care workers, from 68 primary care clinics, drawn from 8 LGAs with a combined population of 966,714 were trained in the detection and management of four MNS conditions: moderate to severe major depression, psychosis, epilepsy, and alcohol use disorders, using the mhGAP-IG. Following training, there was a marked improvement in the knowledge and skills of the health workers and there was also a significant increase in the numbers of persons identified and treated for MNS disorders, and in the number of referrals. Even though substantial retention of gained knowledge was observed nine months after the initial training, some level of decay had occurred supporting the need for a refresher training. It is feasible to scale up mental health services in primary care settings in Nigeria, using the mhGAP-IG and a well-supervised cascade-training model. This format of training is pragmatic, cost-effective and holds promise, especially in settings where there are few specialists.
Tài liệu tham khảo
Wang PS, Aguilar-Gaxiola S, Alonso J, Angermeyer MC, Borges G, Bromet EJ, et al. Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys. Lancet. 2007;370:841–50.
Mbuba CK, Ngugi AK, Newton CR, Carter JA. The epilepsy treatment gap in developing countries: a systematic review of the magnitude, causes, and intervention strategies. Epilepsia. 2008;49:1491–503.
Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, et al. Years lived with disability (YLDs) for 1160 sequealae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2163–96.
Gureje O, Lasebikan VO, Ephraim-Oluwanuga O, Olley BO, Kola L. Community study of knowledge of and attitude to mental illness in Nigeria. British J Psychiatry. 2005;186:436–41.
World Health Organization. Integrating mental health into primary care: a global perspective. Geneva: WHO Publication; 2008. ISBN 978 92 4 156368 o. 1211.
Lancet Global Mental Health Group, Chisholm D, Flisher AJ, Lund C, Patel V, Saxena S, Thornicroft G, Tomlinson M: Scale up services for mental disorders: a call for action. Lancet 2007; 370(9594):1241–52. doi:10.1016/50140-6736(07)61242-2.
Saraceno B, van Ommeren M, Batniji R, Cohen A, Gureje O, Mahoney J, et al. Barriers to improving mental health services in low and middle income countries. Lancet. 2007;370:1164–74.
Jenkins R, Kiima D, Njenga F, Okonji M, Kingora J, Kathuku D, et al. Integration of mental health into primary care in Kenya. World Psychiatry. 2010;9:118–20.
Ssebunnya J, Kigozi F, Kizza D, Ndyanabangi S. MHAPP Research Programme Consortium. Integration of mental health into primary health care in a rural district in Uganda. Afr J Psychiatry. 2010;13(2):128–31.
Petersen I, Ssebunnya J, Bhana A, Baillie K. MhaPP Research Programme Consortium. Lessons from case studies of integrating mental health into primary health care in South Africa and Uganda. Int J Mental Health Systems. 2011;5:8.
Jenkins R, Othieno C, Okeyo S, Aruwa J, Kingora J, Jenkins B. Health system challenges to integration of mental health delivery in primary care in Kenya–perspectives of primary care health workers. BMC Health Serv Res. 2013;13:368. doi:10.1186/1472-6963-13-368.
Sartorius N. Psychiatry in developed and developing countries. In: Bloch S, Green SA, Holman J, editors. Psychiatry: Past, present, and prospect. Oxford: Oxford University Press; 2014. p. 117–32.
Ventevogel P. Integration of mental health into primary health care in low-income countries: avoiding medicalization. International Review of Psychiatry 2014;26:in press.
Bhana A, Petersen I, Baillie KL, Flisher AJ. The Mhapp Research Programme Consortium Implementing the World Health Report 2001 recommendations for integrating mental health into primary care: a situational analysis of three African countries Ghana, South Africa and Uganda. Int Rev Psychiatry. 2010;22(6):599–610. doi:10.3109/09540261.2010.536152.
Federal Ministry of Health: Revised National Health Policy of Nigeria. Federal Ministry of Health, 2004, Abuja, Nigeria.
Makanjuola V, Doku V, Jenkins R, Gureje O. Impact of a one-week intensive ‘training of trainers’ workshop for community health workers in South-West Nigeria. Mental Health Family Med. 2012;9:33–8.
Odejide AO, Morakinyo JJ, Oshiname FO, Omigbodun O, Ajuwon AJ, Kola L. Integrating mental health into primary health care in Nigeria: management of depression in a local government (district) area as a paradigm. Seishin Shinkeigaku Zasshi. 2002;104(10):802–9.
Saxena S, Thornicroft G, Knapp M, et al. Resources for mental health: scarcity, inequity and inefficiency. Lancet. 2007;370:878–89.
World Health Organization Mental Health Gap Action Programme (mhGAP). scaling up care for mental, neurological and substance abuse disorders. Geneva: World Health Organization; 2008.
WHO. mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings: mental heatlh Gap Action Programme (mhGAP). Geneva: World Health Organization; 2010.
Abdulmalik J, Kola L, Fadahunsi W, Adebayo K, Yasamy MT, Musa E, et al. Country contextualization of the mental health gap action programme intervention guide: a case study from Nigeria. PLOS Med. 2013;10(8):e1001501. doi:10.1371/journal.pmed.1001501.Epub.
Kroenke K, Taylor-Vaisey A, Dietrich AJ, Oxman TE. Interventions to improve provider diagnosis and treatment of mental disorders in primary care. A critical review of the literature. Psychosomatics. 2000;41:39–5.
Ventevogel P, van de Put W, Faiz H, van Mierlo B, Siddiqi M, Komproe IH. Improving access to mental health care and psychosocial support within a fragile context: a case study from Afghanistan. PLoS Med. 2012;9(5):e1001225.