Ethical issues of involving people with intellectual disabilities in genomic research: a scoping review protocol.

Background: Psychiatric genomic research is a growing field of research in Africa that is looking at epigenetics of psychiatric disorders; within which a specific focus is neurodevelopmental disorders including intellectual disability (ID). Conducting this type of research is important to identify etiologies and possible interventions or areas for further research. However, genomic research generally, and psychiatric genomic research, faces many social, ethical, cultural, and legal issues; research involving people with ID is particularly challenging. All research stakeholders - researchers, research review bodies, regulators, patient groups - generally agree that involving people with ID require several considerations, including extra protection. It is also recognized that not involving people with ID in research that is relevant to them means that opportunities to learn on specific issues including lived experiences are missed. In this scoping review, we aim to describe the range of ethical and social-cultural issues concerning involvement of people with intellectual disability in genomic research from existing literature. Methods: This scoping review will be conducted based on the Joanna Briggs Institute guidance for scoping review and reported using the PRISMA-ScR guidelines. Iterative review stages will include systematic search of six databases (Embase, Ovid Global Health, PubMed, Scopus, PsycInfo and Web of Science core collection), screening, charting and synthesis of the data. Forward and backward citation screening will also be done for the articles included in the final review. We will include peer reviewed journal articles, guidance documents and reports. Screening and selection of studies based on the eligibility criteria will be done independently by three reviewers; conflicts will be resolved through discussion with a third reviewer and other experts. Results: The results will be included in the scoping review publication. Conclusions: This scoping review will identify key areas of ethical tensions and possible solutions and inform opportunities for empirical ethics studies.

Effectiveness of participatory video in lowering stigma against people with mental, neurological and substance use disorders in Kenya.

BACKGROUND: Globally, stigma associated with mental, neurological and substance use (MNS) disorders is rampant and a barrier to good health and overall well-being of people with these conditions. Person-centred digital approaches such as participatory video may reduce stigma, but evidence on their effectiveness in Africa is absent. AIMS: To evaluate the effectiveness of participatory video in reducing mental health-related stigma in a resource-limited setting. METHOD: We evaluated the effectiveness of using participatory video and face-to-face interaction between people with MNS disorders and a target audience in lowering stigma among 420 people living in Kilifi, Kenya. Changes in knowledge, attitudes and behaviour (KAB) were measured by comparing baseline scores with scores immediately after watching the participatory videos and 4 months after the intervention. Sociodemographic correlates of stigma scores were examined using multivariable linear regression models. RESULTS: Compared with baseline, KAB scores significantly improved at both time points, suggesting reduced stigma levels. At 4 months, the changes in scores were: knowledge (ß = 0.20, 95% CI 0.16-0.25; P < 0.01), liberal attitude (ß = 1.08, 95% CI 0.98-1.17; P < 0.01), sympathetic attitude (ß = 0.52, 95% CI 0.42-0.62; P < 0.01), tolerant attitude (ß = 0.72, 95% CI 0.61-0.83; P < 0.01) and behaviour (ß = 0.37, 95% CI 0.31-0.43; P < 0.01). Sociodemographic variables were significantly correlated with KAB scores; the correlations were not consistent across the domains. CONCLUSIONS: Participatory video is a feasible and effective strategy in improving knowledge, attitudes and intended behaviour in a resource-limited setting. Further studies are required to understand the mechanisms through which it lowers stigma and to examine long-term sustainability and the effectiveness of multicomponent interventions.

Perspectives on reasons for suicidal behaviour and recommendations for suicide prevention in Kenya: qualitative study.

BACKGROUND: Little is known about the reasons for suicidal behaviour in Africa, and communities' perception of suicide prevention. A contextualised understanding of these reasons is important in guiding the implementation of potential suicide prevention interventions in specific settings. AIMS: To understand ideas, experiences and opinions on reasons contributing to suicidal behaviour in the Coast region of Kenya, and provide recommendations for suicide prevention. METHOD: We conducted a qualitative study with various groups of key informants residing in the Coast region of Kenya, using in-depth interviews. Audio-recorded interviews were transcribed and translated from the local language before thematic inductive content analysis. RESULTS: From the 25 in-depth interviews, we identified four key themes as reasons given for suicidal behaviour: interpersonal and relationship problems, financial and economic difficulties, mental health conditions and religious and cultural influences. These reasons were observed to be interrelated with each other and well-aligned to the suggested recommendations for suicide prevention. We found six key recommendations from our thematic content analysis: (a) increasing access to counselling and social support, (b) improving mental health awareness and skills training, (c) restriction of suicide means, (d) decriminalisation of suicide, (e) economic and education empowerment and (f) encouraging religion and spirituality. CONCLUSIONS: The reasons for suicidal behaviour are comparable with high-income countries, but suggested prevention strategies are more contextualised to our setting. A multifaceted approach in preventing suicide in (coastal) Kenya is warranted based on the varied reasons suggested. Community-based interventions will likely improve and increase access to suicide prevention in this study area.

Changes in rates of psychiatric beds and prison populations in sub-Saharan Africa from 1990 to 2020.

Background: Psychiatric bed numbers (general, forensic, and residential) and prison populations have been considered indicators of institutionalization. The present study aimed to assess changes of those indicators across sub-Saharan Africa (SSA) from 1990 to 2020. Methods: We retrospectively obtained data on psychiatric bed numbers and prison populations from 46 countries in SSA between 1990 and 2020. Mean and median rates, as well as percentage changes between first and last data points were calculated for all of SSA and for groups of countries based on income levels. Results: Primary data were retrieved from 17 out of 48 countries. Data from secondary sources were used for 29 countries. From two countries, data were unavailable. The median rate of psychiatric beds decreased from 3.0 to 2.2 per 100 000 population (median percentage change = -16.1%) between 1990 and 2020. Beds in forensic and residential facilities were nonexistent in most countries of SSA in 2020, and no trend for building those capacities was detected. The median prison population rate also decreased from 77.8 to 71.0 per 100 000 population (-7.8%). There were lower rates of psychiatric beds and prison populations in low-income and lower-middle income countries compared with upper-middle income countries. Conclusions: SSA countries showed, on average, a reduction of psychiatric bed rates from already very low levels, which may correspond to a crisis in acute psychiatric care. Psychiatric bed rates were, on average, about one twenty-fifth of countries in the Organization for Economic Co-operation and Development (OECD), while prison population rates were similar. The heterogeneity of trends among SSA countries over the last three decades indicates that developments in the region may not have been based on coordinated policies and reflects unique circumstances faced by the individual countries.

Sociocultural perspectives on suicidal behaviour at the Coast Region of Kenya: an exploratory qualitative study.

OBJECTIVES: To explore perceived sociocultural factors that may influence suicidality from key informants residing in coastal Kenya. DESIGN: We used an exploratory qualitative study design. SETTING: Mombasa and Kilifi Counties of Coastal Kenya. PARTICIPANTS: 25 key informants including community leaders, professionals and community members directly and indirectly affected by suicidality. METHODS: We conducted in-depth interviews with purposively selected key informants to collect data on sociocultural perspectives of suicide. Thematic analysis was used to identify key themes using both inductive and deductive processes. RESULTS: Four key themes were identified from the inductive content analysis of 25 in-depth interviews as being important for understanding cultural perspectives related to suicidality: (1) the stigma of suicidal behaviour, with suicidal victims perceived as weak or crazy, and suicidal act as evil and illegal; (2) the attribution of supernatural causality to suicide, for example, due to sorcery or inherited curses; (3) the convoluted pathway to care, specifically, delayed access to biomedical care and preference for informal healers; and (4) gender and age differences influencing suicide motivation, method of suicide and care seeking behaviour for suicidality. CONCLUSIONS: This study provides an in depth understanding of cultural factors attributed to suicide in this rural community that may engender stigma, discrimination and poor access to mental healthcare in this community. We recommend multipronged and multilevel suicide prevention interventions targeted at changing stigmatising attitudes, beliefs and behaviours, and improving access to mental healthcare in the community.

Cross-country variations in the reporting of psychotic symptoms among sub-Saharan African adults: A psychometric evaluation of the Psychosis Screening Questionnaire.

BACKGROUND: Self-reporting of psychotic symptoms varies significantly between cultures and ethnic groups. Yet, limited validated screening instruments are available to capture such differences in the African continent. METHODOLOGY: Among 9,059 individuals participating as controls in a multi-country case-control study of the genetic causes of psychosis, we evaluated the psychometric properties of the Psychosis Screening Questionnaire (PSQ). We applied multi-group confirmatory factor analysis and item response theory to assess item parameters. RESULTS: The overall positive endorsement of at least one item assessing psychotic symptoms on the PSQ was 9.7%, with variability among countries (Uganda 13.7%, South Africa 11%, Kenya 10.2%, and Ethiopia 2.8%). A unidimensional model demonstrated good fit for the PSQ (root mean square error of approximation = 0.009; comparative fit index = 0.997; and Tucker-Lewis Index = 0.995). Hypomania had the weakest association with single latent factor (standardized factor loading 0.62). Sequential multi-group confirmatory factor analysis demonstrated that PSQ items were measured in equivalent ways across the four countries. PSQ items gave more information at higher levels of psychosis, with hypomania giving the least discriminating information. LIMITATIONS: Participants were recruited from general medical facilities, so findings may not be generalizable to the general population. CONCLUSION: The PSQ demonstrated a unidimensional factor structure in these samples. Items were measured equivalently across all study settings, suggesting that differences in prevalence of psychotic symptoms between countries were less likely to represent measurement artifact. The PSQ is more reliable in screening for psychosis in individuals with higher degrees of psychotic experiences-hypomania excluded-and might decrease the false-positive rate from mild nonspecific psychotic experiences.

Validating measures of stigma against those with mental illness among a community sample in Kilifi Kenya.

Background: Stigma against persons with mental illness is a universal phenomenon, but culture influences the understanding of etiology of mental illness and utilization of health services. Methods: We validated Kiswahili versions of three measures of stigma which were originally developed in the United Kingdom: Community Attitudes Toward the Mentally Ill Scale (CAMI), Reported and Intended Behaviors Scale (RIBS) and Mental Health Awareness Knowledge Schedule (MAKS) and evaluated their psychometric properties using a community sample (N = 616) in Kilifi, Kenya. Results: Confirmatory factor analysis confirmed the one-factor solution for RIBS [root mean-squared error of approximation (RMSEA) < 0.01, comparative fit index (CFI) = 1.00, Tucker-Lewis index (TLI) = 1.01] and two-factor solution for MAKS (RMSEA = 0.04, CFI = 0.96, TLI = 0.95). A 23-item, three-factor model provided the best indices of goodness of fit for CAMI (RMSEA = 0.04, CFI = 0.90, TLI = 0.89). MAKS converged with both CAMI and RIBS. Internal consistency was good for the RIBS and acceptable for CAMI and MAKS. Test-retest reliabilities were excellent for RIBS and poor for CAMI and MAKS, but kappa scores for inter-rater agreement were relatively low for these scales. Results support validity of the original MAKS and RIBS scale and a modified CAMI scale and suggest that stigma is not an enduring trait in this population. The low kappa scores are consistent with first kappa paradox which is due to adjustment for agreements by chance in case of marginal prevalence values. Conclusions: Kiswahili versions of the MAKS, RIBS and a modified version of the CAMI are valid for use in the study population. Stigma against people with mental illness may not be an enduring trait in this population.

Validity and reliability of the Neurodevelopmental Screening Tool (NDST) in screening for neurodevelopmental disorders in children living in rural Kenyan coast.

Background: There are no data on the precise burden of neurodevelopmental disorders (NDD) in Africa, despite high incidence of risk factors. Ten Questions Questionnaire (TQQ) has been used extensively in Africa to screen neurological impairments but not autism spectrum disorders (ASD) and attention-deficit hyperactivity disorders (ADHD). The Neurodevelopmental Screening Tool (NDST) has reliably assessed NDD in Asia; its validity in Africa is unknown. Methods: Using NDST and TQQ, we screened 11,223 children aged 6-9 years in Kilifi, Kenya. We invited all screen-positives and a proportion of screen-negative children for confirmatory diagnosis of NDD using clinical history, neuropsychological assessments and interviews. Results: In total, 2,245 (20%) children screened positive for NDD. Confirmatory testing was completed for 1,564 (69.7%) screen-positive and 598 (6.7%) screen-negative children. NDST's sensitivity was 87.8% (95%CI: 88.3-88.5%) for any NDD, 96.5% (95%CI:96.1-96.8%) ASD and 89.2% (95%CI: 88.7-89.8%) for ADHD. Moderate/severe neurological impairments' sensitivities ranged from 85.7% (95%CI: 85.1-86.3%) for hearing impairments to 100.00% (100.0-100.0%) for motor impairments. NDST had higher sensitivities than TQQ for epilepsy (88.8 vs 86.7), motor impairments (100.0 vs 93.7) and cognitive impairment (88.2 vs 84.3). Sensitivities for visual and hearing impairments were comparable in both tools. NDST specificity was 82.8% (95%CI: 82.1-83.5%) for any NDD, 94.5% (95%CI: 94.0-94.9%) for ASD and 81.7% (95%CI: 81.0-82.4%) for ADHD. The specificities range for neurological impairments was 80.0% (95%CI: 79.3-80.7%) for visual impairments to 93.8% (95%CI: 93.4-94.3%) for epilepsy. Negative predictive values were generally very high (≤100%), but most positive predictive values (PPV) were low (≤17.8%). Domain specific internal consistency ranged from 0.72 (95%CI: 0.70-0.74) for ADHD to 0.89 (95%CI: 0.87-0.90) for epilepsy. Conclusions: NDST possesses high sensitivity and specificity for detecting different domains of NDD in Kilifi. Low PPV suggest that positive diagnoses should be confirmed when samples are drawn from a population with low disease prevalence.

The Africa Ethics Working Group (AEWG): a model of collaboration for psychiatric genomic research in Africa.

The Africa Ethics Working Group (AEWG) is a South-South-North collaboration of bioethics and mental health researchers from sub-Saharan Africa, working to tackle emerging ethical challenges in global mental health research. Initially formed to provide ethical guidance for a neuro-psychiatric genomics research project, AEWG has evolved to address cross cutting ethical issues in mental health research aimed at addressing equity in North-South collaborations. Global South refers to economically developing countries (sub-Saharan Africa in this context) and Global North to economically developed countries (primarily Europe, UK and North America). In this letter we discuss lessons that as a group we have learnt over the last three years; lessons that similar collaborations could draw on. With increasing expertise from Global South as an outcome of several capacity strengthening initiatives, it is expected that the nature of scientific collaborations will shift to a truly equitable partnership. The AEWG provides a model to rethink contributions that each partner could make in these collaborations.

Contextualizing and pilot testing the Mental Health Gap Action Programme Intervention Guide (mhGAP-IG) to primary healthcare workers in Kilifi, Kenya.

BACKGROUND: Little data exists about the methodology of contextualizing version two of the Mental Health Gap Action Programme Intervention Guide (mhGAP-IG) in resource-poor settings. This paper describes the contextualisation and pilot testing of the guide in Kilifi, Kenya. METHODS: Contextualisation was conducted as a collaboration between the KEMRI-Wellcome Trust Research Programme (KWTRP) and Kilifi County Government's Department of Health (KCGH) between 2016 and 2018. It adapted a mixed-method design and involved a situational analysis, stakeholder engagement, local adaptation and pilot testing of the adapted guide. Qualitative data were analysed using content analysis to identify key facilitators and barriers to the implementation process. Pre- and post-training scores of the adapted guide were compared using the Wilcoxon signed-rank test. RESULTS: Human resource for mental health in Kilifi is strained with limited infrastructure and outdated legislation. Barriers to implementation included few specialists for referral, unreliable drug supply, difficulty in translating the guide to Kiswahili language, lack of clarity of the roles of KWTRP and KCGH in the implementation process and the unwillingness of the biomedical practitioners to collaborate with traditional health practitioners to enhance referrals to hospital. In the adaptation process, stakeholders recommended the exclusion of child and adolescent mental and behavioural problems, as well as dementia modules from the final version of the guide. Pilot testing of the adapted guide showed a significant improvement in the post-training scores: 66.3% (95% CI 62.4-70.8) v. 76.6% (95% CI 71.6-79.2) (p < 0.001). CONCLUSION: The adapted mhGAP-IG version two can be used across coastal Kenya to train primary healthcare providers. However, successful implementation in Kilifi will require a review of new evidence on the burden of disease, improvements in the mental health system and sustained dialogue among stakeholders.

Investigating assumptions of vulnerability: A case study of the exclusion of psychiatric inpatients as participants in genetic research in low- and middle-income contexts.

Psychiatric genetic research investigates the genetic basis of psychiatric disorders with the aim of more effectively understanding, treating, or, ultimately, preventing such disorders. Given the challenges of recruiting research participants into such studies, the potential for long-term benefits of such research, and seemingly minimal risk, a strong claim could be made that all non-acute psychiatric inpatients, including forensic and involuntary patients, should be included in such research, provided they have capacity to consent. There are tensions, however, regarding the ethics of recruiting psychiatric inpatients into such studies. In this paper our intention is to elucidate the source of these tensions from the perspective of research ethics committee interests and decision-making. We begin by defining inpatient status and outline some of the assumptions surrounding the structures of inpatient care. We then introduce contemporary conceptions of vulnerability, including Florencia Luna's account of vulnerability which we use as a framework for our analysis. While psychiatric inpatients could be subject to consent-related vulnerabilities, we suggest that a particular kind of exploitation-related vulnerability comes to the fore in the context of our case study. Moreover, a subset of these ethical concerns takes on particular weight in the context of genetic research in low- and middle-income countries. At the same time, the automatic exclusion of inpatients from research elicits justice-related vulnerabilities.

Evaluation of Psychometric Properties and Factorial Structure of ADHD Module of K-SADS-PL in Children From Rural Kenya.

Objective: We determined the reliability of The Kiddie-Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime (K-SADS-PL) for screening and diagnosing ADHD in children. Method: K-SADS-PL was administered to 2,074 children in the community. Psychometric properties, factorial structure, and clinical validity of K-SADS-PL in screening or diagnosis of ADHD were examined. Results: Internal consistency was excellent for items in the screening interview (Macdonald's Omega [ω] = 0.89; 95% confidence interval [CI] [0.87, 0.94]) and diagnostic supplement (ω = 0.95; 95% CI [0.92, 0.99]). The standardized coefficients for items in the screening interview were acceptable (0.59-0.85), while fit indices for single factorial structure reached acceptable levels. Screening items were associated with high sensitivity (97.8%; 95% CI [97.2, 98.5%]) and specificity (94.0%; 95% CI [93.0, 95.0%]) for diagnosis of ADHD in the supplement. The test-retest and interinformant reliability as measured by intraclass correlation coefficient was good for most of the items. Conclusion: This large study shows that K-SADS-PL can be reliably used to screen and diagnose ADHD in children in Kenya.

Priority mental, neurological and substance use disorders in rural Kenya: Traditional health practitioners' and primary health care workers' perspectives.

BACKGROUND: Over 75% of people with mental neurological and substance use disorders (MNSD) live in low and middle-income countries with limited access to specialized care. The World Health Organization's Mental Health Gap Action Program (mhGAP) aims to address the human resource gap but it requires contextualization. AIMS: We conducted a qualitative study in rural coastal Kenya to explore the local terms, perceived causes and management modalities of priority MNSD listed in the mhGAP, to inform implementation in this setting. METHODS: We conducted 8 focus group discussions with primary health care providers and traditional health practitioners and used the framework method to conduct thematic analysis. We identified local terms, perceived causes and treatment options for MNSD. We also explored possibilities for collaboration between the traditional health practitioners and primary health care providers. RESULTS: We found local terms for depression, psychoses, epilepsy, disorders due to substance use and self-harm/ suicide but none for dementia. Child and adolescent mental and behavioral problems were not regarded as MNSD but consequences of poor parenting. Self-harm/suicide was recognized in the context of other MNSD. Causes of MNSD were broadly either biological or supernatural. Treatment options were dependent on perceived cause of illness. Most traditional health practitioners were willing to collaborate with primary health care providers mainly through referring cases. Primary health care providers were unwilling to collaborate with traditional health practitioners because they perceived them to contribute to worsening of patients' prognoses. CONCLUSIONS: Local terms and management modalities are available for some priority MNSD in this setting. Community level case detection and referral may be hindered by lack of collaboration between traditional health practitioners and primary health care providers. There is need for training on the recognition and management of all priority MNSD.

Suicide in a rural area of coastal Kenya.

BACKGROUND: Suicide accounts for approximately 1.4% of deaths globally and is the 15th leading cause of death overall. There are no reliable data on the epidemiology of completed suicide in rural areas of many developing countries, yet suicide is an indicator of the sustainable development goals on health. METHODS: Using data collected between 2008 and 2016 from the Kilifi Health and Demographic Surveillance System in rural Kenya, we retrospectively determined the incidence rate and risk factors for completed suicide. RESULTS: During the period, 104 people died by suicide, contributing to 0.78% (95% CI = 0.74-1.10) of all deaths. The mean annual incidence rate of suicide was 4.61 (95% CI = 3.80-5.58) per 100,000 person years of observation (pyo). The annual incidence rate for men was higher than that of women (IRR = 3.05, 95% CI = 1.98-4.70, p < 0.001) and it increased with age (IRR = 2.73, 95% CI = 2.30-3.24, p < 0.001). People aged > 64 years had the highest mean incidence rate of 18.58 (95% CI = 11.99-28.80) per 100,000 pyo. Completed suicide was associated with age, being male, and living in a house whose wall is made of scrap material, which is a proxy marker of extreme poverty in this region (OR = 5.5, 95% CI = 4.0-7.0, p = 0.02). Most cases (76%) completed suicide by hanging themselves. Spatial heterogeneity of rates of suicides was observed across the enumeration zones of the KHDSS. CONCLUSIONS: Suicide is common in this area, but the incidence of completed suicide in rural Kenya may be an underestimate of the true burden. Like in other studies, suicide was associated with older age, being male and poverty, but other medical and neuropsychiatric risk factors should be investigated in future studies.

Antimalarial drugs and the prevalence of mental and neurological manifestations: A systematic review and meta-analysis.

Background: Antimalarial drugs affect the central nervous system, but it is difficult to differentiate the effect of these drugs from that of the malaria illness. We conducted a systematic review to determine the association between anti-malarial drugs and mental and neurological impairment in humans.  Methods: We systematically searched online databases, including Medline/PubMed, PsychoInfo, and Embase, for articles published up to 14th July 2016. Pooled prevalence, heterogeneity and factors associated with prevalence of mental and neurological manifestations were determined using meta-analytic techniques.  Results: Of the 2,349 records identified in the initial search, 51 human studies met the eligibility criteria. The median pooled prevalence range of mental and neurological manifestations associated with antimalarial drugs ranged from 0.7% (dapsone) to 48.3% (minocycline) across all studies, while it ranged from 0.6% (pyrimethamine) to 42.7% (amodiaquine) during treatment of acute malaria, and 0.7% (primaquine/dapsone) to 55.0% (sulfadoxine) during prophylaxis. Pooled prevalence of mental and neurological manifestations across all studies was associated with an increased number of antimalarial drugs (prevalence ratio= 5.51 (95%CI, 1.05-29.04); P=0.045) in a meta-regression analysis. Headaches (15%) and dizziness (14%) were the most common mental and neurological manifestations across all studies. Of individual antimalarial drugs still on the market, mental and neurological manifestations were most common with the use of sulphadoxine (55%) for prophylaxis studies and amodiaquine (42.7%) for acute malaria studies. Mefloquine affected more domains of mental and neurological manifestations than any other antimalarial drug.  Conclusions: Antimalarial drugs, particularly those used for prophylaxis, may be associated with mental and neurological manifestations, and the number of antimalarial drugs taken determines the association. Mental and neurological manifestations should be assessed following the use of antimalarial drugs.

An overview of mental health care system in Kilifi, Kenya: results from an initial assessment using the World Health Organization's Assessment Instrument for Mental Health Systems.

BACKGROUND: Little is known about the state of mental health systems in Kenya. In 2010, Kenya promulgated a new constitution, which devolved national government and the national health system to 47 counties including Kilifi County. There is need to provide evidence from mental health systems research to identify priority areas in Kilifi's mental health system for informing county health sector decision making. We conducted an initial assessment of state of mental health systems in Kilifi County and documented resources, policy and legislation and spectrum of mental, neurological and substance use disorders. METHODS: This was a pilot study that used the brief version of the World Health Organization's Assessment Instrument for Mental Health Systems Version 2.2 to collect data. Data collection was based on the year 2014. RESULTS: Kilifi county has two public psychiatric outpatient units that are part of general hospitals. There is no standalone mental hospital in Kilifi. There are no inpatients or community based facilities for people with mental health problems. Although the psychiatric facilities in Kilifi have an essential drugs list, supply of drugs is erratic with frequent shortages. There is no psychiatrist or psychologist in Kilifi with only two psychiatric nurses for a population of approximately 1.2 million people. Schizophrenia was the commonest reason for visiting outpatient facilities (47.1%) while suicidal ideation was the least common (0.4%). Kenya's mental health policy, which is being used by Kilifi County, is outdated and does not cater for the current mental health needs of Kilifi. There is no specific legislation to protect the rights of people with mental health problems. No budget exists specifically for mental health care. There have been no efforts to integrate mental health care into primary care in Kilifi, and there is no empirical research work to evaluate its feasibility. CONCLUSION: There is an urgent need to increase resources allocated for mental health in particular infrastructure and human resource. Policy and legislations need to be established to protect the rights of people with mental illnesses, and mental health should be integrated with primary care to increase access to services.

Burden of neurodevelopmental disorders in low and middle-income countries: A systematic review and meta-analysis.

Background: Childhood mortality from infectious diseases has declined steadily in many low and middle-income (LAMIC) countries, with increased recognition of non-communicable diseases such as neurodevelopmental disorders (NDD). There is lack of data on the burden of NDD in LAMIC. Current global burden of these disorders are largely extrapolated from high-income countries. The main objective of the study was therefore to estimate the burden of NDD in LAMIC using meta-analytic techniques. Methods: We systematically searched online databases including Medline/PubMed, PsychoInfo, and Embase for studies that reported prevalence or incidence of NDD. Pooled prevalence, heterogeneity and risk factors for prevalence were determined using meta-analytic techniques.   Results: We identified 4,802 records, but only 51 studies met the eligibility criteria. Most studies were from Asia (52.2%) and most were on neurological disorders (63.1%). The median pooled prevalence per 1,000 for all NDD was 7.6 (95%CI 7.5-7.7), being 11.3 (11.7-12.0) for neurological disorders and 3.2 (95%CI 3.1-3.3) for mental conditions such as attention-deficit hyperactivity disorder (ADHD). The type of NDD was significantly associated with the greatest prevalence ratio in the multivariable model (PR=2.6(95%CI 0.6-11.6) (P>0.05). Incidence was only reported for epilepsy (mean of 447.7 (95%CI 415.3-481.9) per 100,000). Perinatal complications were the commonest risk factor for NDD. Conclusion: The burden of NDD in LAMIC is considerable. Epidemiological surveys on NDD should screen all types of NDD to provide reliable estimates.