IMPROVING MENTAL HEALTH THROUGH COMMUNITY PARTICIPATION

IMPROVING MENTAL HEALTH THROUGH

COMMUNITY PARTICIPATION

Prof Inge PetersenSchool of Psychology

Community participation in Lancet Series 2007

• Interests of scaling up mental health services:– Strengthening & mobilization of user

and carer groups – advocacy purposes– Capacity building of community

members to supplement formal health care

– Inform the development of culturally congruent acceptable care

Gap• Broaden problem of poor mental health in

LMICs from purely increasing access to mental health services

• Increase access to mental health– Community control over mental health

• Public mental health efforts to address social determinants of mental ill-health

Focus of this presentation

• Case study - integrating a community participatory framework in service delivery systems

1. Implementation framework2. Benefits and challenges3. Human resource requirements &

cost

• Ghana, South Africa, Uganda, Zambia

Mental Health and Poverty Project (MHaPP)

http://www.map-of-africa.us/images/map-of-africa.gif





DISTRICT DEMONSTRATION SITE IN

SOUTH AFRICA

Hlabisa sub-district

Description of site

• Typical of rural areas in SA

• DSA area - 85 000 people

• Serviced by 6 primary health care clinics linked to a sub-district hospital.

Source: www.africacentre.ac.za

Situational Analysis

Petersen et al. 2009. Planning for district mental health services in South Africa. A situational analysis of a rural district site. Health Policy and Planning

Nationally

• Psychotropic drugs widely available1

• Treatment gap for CMDs of 75%2

• Unevenness in– outpatient psycho-

social interventions – human resources11Lund C, et al.. 2009. Public sector mental health

systems in South Africa: inter-provincial comparisons and policy implications. Soc Psychiat Epidemiol:

2Williams et al. 2008.12-month mental disorders in South Africa: prevalence, service use and demographic correlates in the population-based South African Stress and Health Study. Psychological Medicine

0

5

10

15

20

25

30

35

Lifetime Prevalence12-month prevalence

Focus on Common Mental Disorders

Emergency Manage-ment & observation

Symptom manage-ment of chronic

conditions

De-institutionalizedCare for SeriousMental Disorders

Disability grants

Integrated PrimaryMental Health

Care

Management of Common Mental

Disorders

Mental HealthPromotion and

Prevention

Psycho-social rehabVocational RehabHousing support

Interpersonal skills

Why focus on depression?

• Most prevalent 12 month individual disorder in South African adults (4.9%)1

• Pre/postnatal depression high - 34% (Khayelitsha)2

, 41% at attending ante-natal clinics (rural KZN)3

• Depression linked to physical ill-health4

• Cardiovascular disease• Diabetes• Poor maternal and child health• HIV

1.Williams et al. 2008.12-month mental disorders in South Africa: prevalence, Psychological Medicine 2 Cooper et al 1999 Post-partum depression and the mother-infant relationship. Brit J Psych 3. Rochat et al 2006 Depression among pregnant rural women in SA. JAMA. 4. Prince et al. 2007. No health without mental health . Lancet

PARTICIPATORY IMPLEMENTATION FRAMEWORK

1.Multi-sectoral community collaborative forum

• Increase public-health priority of mental health

• Mobilization of resources for MH

• Political support and legitimacy

• Ensure project addresses beneficiary needs

• Promote mental health literacy

Mental Health

Public Health sector

EducSector

SocialDev.

Private Health(TH)

Comm

Local &Tradgov

Criminal

Justice

2. Evidence-based community partnership research approach1

• Elements of health services research• improve access & quality of mental health

care & enhance sustainability• Community intervention research

• promotes cultural congruence and community competency and control over mental health

.Wells et al. 2004. Bridging community and health services research. American Jnl of Psychiatry

3.Capacitating community members to provide MHC

• Existing CHWs (30) were trained to:– Identify mental disorders– Refer– Provide basic counselling– Provide an adapted version of

Interpersonal Therapy (IPT) for depression

4.Peer facilitated groups • Community members trained (2)

• Facilitate groups for people with depression• Adapted manualized IPT & problem

solving approach.– Grief/bereavement, Interpersonal disputes,

Finding out your HIV+ status, Financial stress, Becoming a mother

1Petersen , Bhana , Baillie . under submission. Adapting Interpersonal Therapy (IPT) for the treatment of depression by community health workers within the context of task shifting in South Africa. A feasibility study

5.Support for community care-givers

• Technical and emotional support– Diversification of

roles of mental health specialists

– Introduction of a mental health counsellor (B.Psych qualification) at PHC clinic level

Tertiary Specialist ServicesP sych ia tris t, M ed ica l O ffice r,P sycho log ist, S ocia l W orke r,

P sych ia tric N urse , O ccupa tiona lTherap ist

Regional HospitalP sych ia tris t, M ed ica l O ffice r,

P sych ia tric N urses, P sycho log ist,S oc ia l W orke rs , O ccupa tiona l

Therap ists

Primary Health ClinicsP H C N urse

Men ta l H ea lth Counse llo r

CommunityC M H W s , T rad itiona l Hea le rs ,

P o lice , S p iritua l Leade rs, CH W s,P riva te P ractice G Ps, C B O s/N G O s/

D P O s, teachers

S hort-te rm acu te inpa tien t ca reO utpa tien t C are

S upport to d is tric t hosp ita lC onsu lta tion lia ison psych ia try

C om m un ity O u treach

Level of CareServices

S pecia lised trea tm en tA cu te inpa tien t C are

Long-te rm inpa tien t ca reO utpa tien t C are

S upport to R eg iona l H osp ita lsA lcoho l & d rug rehab lita tion

C om m un ity O u treach

A ssessm ent and A dm issions72 hr hosp ita l adm iss ions

O utpa tien t C areTra in ing , support & supervis ion o f P H C

personne l & counse llo rsP rogram m e In itia tion & coo rd ina tion

District Hospital(specia lis t M H team )

P sych ia tris t (P T), M ed ica l O ffice r,P sych ia tric N urses, P sycho log ist,

S oc ia l W orke rs , O ccupa tiona lTherap ists

E m ergency & sym ptom m anagem en t o facu te & ch ron ic psych ia tric cond itionsIden tif ica tion , m anagem ent & re fe rra l

o f com m on m en ta l d iso rde rsS upport & superv is ion to com m un ity tie r

P sycho-socia l rehab ilita tionCounse lling fo r specif ic d iso rders

P reven tion & p rom otion p rog ram m esP ove rty A llev ia tion P rogram m es

Iden tif ica tion & re fe rra l o f M H p robs

Petersen et al Submitted. A task-shifting approach to primary mental health care for adults in South Africa: Human resource requirements and costs. Health Policy & Planning

BENEFITS AND CHALLENGESEVALUATION

Methodology• Qualitative interviews

– 4 focus groups with CHWs (15)– 2 peer group facilitators– 9 group participants– Mental health counsellor– 4 PHC nurses– 2 psychiatric nurses– 2 health managers– 2 community leaders

26 community members

11 healthcare providers

Methodology (cont)• Quantitative outcome measures for

depression group intervention– Users screened by MHC for moderate to

severe depression– Participants placed in 4 x 12 week intervention

groups (30) or control group (30)– BDI and HSCL-25 administered at baseline, 12

weeks and 24 weeks

BENEFITSFINDINGS

Mobilization of resources for mental health

• Increased priority afforded to mental health in public health sector reflected in increased dedicated resources

• Mobilization of some resources from community e.g., community hall

You know we have allocated Sister S (an additional psychiatric nurse) to run with mental health… Sister K is also assisting and then of course the psychologist (newly appointed) is helping so there is more representation in general for mental health. Then of course we’ve also got Sister N who is helping out in the clinics with the mental health side of things (sub-district health manager).

Improved mental health literacy

• Community participation improved mental health literacy & help seeking

I found that it was very helpful to get together with the group; it really helped me because most times we black people don’t have the knowledge that mental and emotional problems can be treated. We just know them as things you just live with until it kills you… Most of them are hearing now how successful it was and are now asking ‘you really went there? What did you do there? How do you become part of it?’, and I tell them what we do and how it happens (group participants)

Decreased stigma

• Participation – potential to reduce stigmaSo the awareness was created at an individual level… (before) when you look at people who have got mental ill health, you wouldn’t bother much… But now, this has actually conscientized us that we really have to find means and ways of helping people who have got mental health disorders... It can have far reaching effects in terms of even changing the attitude and the mentality of the community towards mental health patients (community leader).

Improved access to care for CMDs – Feasibility of groups1

• Retention – 23 (77%) completed the programme

over the 12 week period• Dosage

– 23 participants attended 8-12 sessions– Over 50% attending all 11-12 sessions.


Results on outcome measures1

Group Time N Mean Std Dev F SignificanceBDI

ExperimentalControl Pretest

2022

34.8532.45

7.0587.539

ExperimentalControl 12 weeks

2022

17.8531.23

8.8337.880


2022

12.9026.86

10.0157.760 46.65* p = .0001

HSCL – 25


1722

74.8866.00

13.34615.657


1722

46.4766.91

13.77613.995


1722

40.1256.68

6.7638.828 34.55* p = .0001

HSCL (Anxiety sub-scale)


1822

28.7225.45

8.8646.773


1822

17.9424.68

5.5676.342


1822

16.7220.50

4.5743.569 22.51* p = .0001

HSCL (Depression sub-scale)


1822

43.9438.05

5.8868.899


1822

27.5638.95

9.5448.477


1822

24.6136.18

4.3946.638 24.09* p = .0001


BDI – comparison of scores on experimental versus control group: Baseline, 12 weeks, 6 months

HSCL-25 (anxiety) – comparison of scores on experimental versus control group: Baseline, 12 weeks, 24 weeks

Process evaluation – groups

• Social support afforded by group assisted through providing emotional, informational, appraisal and instrumental support

• Group participation facilitated more positive cognitions, improved interpersonal skills and improved personal agency amongst participants

The other woman in the group lost her son… he had been gone for a very long time. We started raising suggestions as to how she could start looking for him. She would try the suggestions and she would come back and tell us that she didn’t get help. Then we would come up with other suggestions as a group... At the end she came back and told us that she had …found her son at last.

When the group was almost finished, they would come with good news…Even when a person was no longer studying she would think of going back to school. You find that she has found a job. She is thinking of selling things for herself… They grew. Their minds are thinking differently. Like a person would come and say I am thinking of killing myself. You can see that that person’s mind is disturbed. But as time goes on, you ask her if she still has thoughts of killing herself and she doesn’t. She would explain that it’s because she can see that if she does this - things will be ok (Group facilitator)

Development of culturally competent services

• Consultative processes engaged with in the development of interventions promoted cultural congruence

• Community members best placed to understand and respond to cultural and existential realities

The manual was very helpful because it spoke about things that we have experienced…it went hand in hand with what we were dealing with…it was as if you saw what was in us and then put it in that book. It assisted us a lot (group participant).

I think this was the most appropriate way because when you had a problem, you would ask others for help and they will give you different ideas/ suggestions and that made it easy to find a solution to the problem… we came as a group (where) people’s problems are similar in life (group participant).

Improved community control

• CHW actions to promote mental health– Build social networks for people

• CHWs network people in crisis to gain help from other community members or government services‘Others they call us ambulances’

I would say that it (the training) helped me a lot in the community. We started a group for old people there at kwa(S). I found that old people have many different problems at their homes. Others have sick children, others their children died. Others are abused by their children. Then I used the knowledge I received from the training. I talked to them. I heard all about their problems. The group is still going on. We do handwork. We pray. They open up and we talk about their problems (CHW group 3).

CHALLENGES AND NEEDSFINDINGS

Challenges• CHWs capacity to engage in public

mental health activities constrained by their marginalized position as poor women

It’s difficult for us to enter family matters because it’s not safe for us. The man might turn around and hurt his family for reporting private matters to the care giver. It’s also not safe for us to report matters to the police... Because most of the times the thugs, if only one of them gets arrested and another one was left behind finds out that it’s the CHW that reported the case...we get scared because I and my family might die (CHW group 1).

Needs• Symbols of power

• Support

Even if we get a little difference like a name tag. So that we can be known that these people are doing work...You see, when someone comes wearing a uniform, it makes a difference... If we can also get that. To have something different that will highlight us in the community. That we are CHWs and we are also educated. (CHW group 1)

It (support) helps because you may find a house that has got problems. You take them and make them your own. Even when you are at home, you find these problems ringing in your head. You feel like this problem is facing you directly. (CHW group 4).

HUMAN RESOURCE REQUIREMENTS & COST

Estimated need for selected disorders per 100,000

Disorder

One year prevalence

(%)

ComorbidityAdjustments2

Total number

expectedin

population

MinimumCoverage3

Full Coverage4

Adults Schizophrenia 1 1 430 215 430Bipolar affective disorder 1 1 430 215 430

Major Depressive Disorder 4.9 4.2 1822 547 1822Posttraumatic stress disorder 0.6 0.5 223 67 223Maternal depression1 40 40 838 251 838

Total 7.5 6.7 2905 1044 2905

1 Maternal depression is calculated on 40% of pregnant women (Rochat et al, 2006) and assuming 4% of SA women give birth per year (Stats SA, 2008). Note: Maternal depression numbers are not included in the total.3For adults, minimum coverage is the minimal recommended service provision and represents a weighted percentage of schizophrenia (50%),Bipolar affective disorder (50%), major depressive disorder (50%), PTSD (30%), maternal depression (30%).


Staffing needs based in FTEs per 100,000 population

Type of

Community Tier PHC Clinic Tier District Hospital Tier Managerial Total (staff/population)

professional Min

cover Full

cover Min

cover Full

cover Min cover Full cover Min cover Full

cover Min cover Full cover

CMHWs 7.2 22.7

7.2 22.7 Nurse 1.8 3.8 0.1 0.2

1.8 4

Psych Nurse

0.4 0.9 1.2 4.5 1.6 5.4 MH Counselors 1 2.4

1 2.4

Social Workers*

0 0

Psychologists

0.3 0.6

0.3 0.6 Medical Officers

0.1 0.4

0.1 0.4

Psychiatrists

0.4 1

0.4 1 Info manager

0.5 2 0.5 2

Total 7.2 22.7 2.8 6.3 1.4 2.9 1.7 6.5 13.1 38.4 *Staffing needs for social workers were not calculated given that the case study site suggests that their involvement with mental health patients is minimal – they were found to only assist 3% of OPD patients in accessing grants.


Staff costs in pound sterling**

Health Type ofProvider

Community Tier

PHC ClinicTier

District HospitalTier

Managerial Total

Min cover Full cover Min cover Full cover Min cover Full cover Min cover Full cover Min cover Full cover

CMHWs £14 158.64 £44 389.73 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £14 158.64 £44 389.73

General nurse £0.00 £0.00 £13 032.58 £28 392.13 £497.73 £1 366.88 £0.00 £0.00 £13 530.31 £29 759.01

Psych nurse £0.00 £0.00 £0.00 £0.00 £5 425.71 £10 810.65 £14 755.03 £55 331.36 £20 180.73 £66 142.01

MH Counselors £0.00 £0.00 £14 298.38 £34 069.84 £0.00 £0.00 £0.00 £0.00 £14 298.38 £34 069.84

Social Workers* £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £0.00

Psychologists £0.00 £0.00 £0.00 £0.00 £4 671.89 £7 698.07 £0.00 £0.00 £4 671.89 £7 698.07

Medical Officers £0.00 £0.00 £0.00 £0.00 £3 746.14 £9 495.17 £0.00 £0.00 £3 746.14 £9 495.17

Psychiatrists £0.00 £0.00 £0.00 £0.00 £10 206.34 £24 984.86 £0.00 £0.00 £10 206.34 £24 984.86

Info manager £0.00 £0.00 £0.00 £0.00 £0.00 £0.00 £8 430.50 £33 722.00 £8 430.50 £33 722.00

Total £14 158.64 £44 389.73 £27 330.96 £62 461.97 £24 547.81 £54 355.63 £23 185.53 £89 053.36 £89 222.94 £250 60.69

*Staffing needs for social workers were not calculated given that the case study site suggests that their involvement with mental health patients is minimal – they were found to only assist 3% of OPD patients in accessing grants.**Rand to pound sterling was calculated at R12 to £1

Conclusion• Benefits of a community collaborative

participatory framework within district mental health services:• Mobilization of resources• Improving mental health literacy and help

seeking• Reducing stigma• Improving access at reduced cost• Culturally competent mental health services• Improved community control over mental

health

Recommendations• Community health workers well placed to

address social determinants of mental ill-health – Need symbolic and economic empowerment – Need to make greater use of CHWs as a

collective – improve collective agency

Acknowledgements• Prof Arvin Bhana (HSRC) Research collaborator• Kim Baillie (UKZN) Research officer• MHaPP consortium www.psychiatry.uct.ac.za/mhapp• Department of International Development• Africa Centre for Health and Population Studies, UKZN

http://www.psychiatry.uct.ac.za/mhapp

IMPROVING MENTAL HEALTH THROUGH COMMUNITY PARTICIPATION

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