"Like a doctor, like a brother": Achieving competence amongst lay health workers delivering community-based rehabilitation for people with schizophrenia in Ethiopia.

BACKGROUND: There are gaps in our understanding of how non-specialists, such as lay health workers, can achieve core competencies to deliver psychosocial interventions in low- and middle-income countries. METHODS: We conducted a 12-month mixed-methods study alongside the Rehabilitation Intervention for people with Schizophrenia in Ethiopia (RISE) pilot study. We rated a total of 30 role-plays and 55 clinical encounters of ten community-based rehabilitation (CBR) lay workers using an Ethiopian adaptation of the ENhancing Assessment of Common Therapeutic factors (ENACT) structured observational rating scale. To explore factors influencing competence, six focus group discussions and four in-depth interviews were conducted with 11 CBR workers and two supervisors at three time-points. We conducted a thematic analysis and triangulated the qualitative and quantitative data. RESULTS: There were improvements in CBR worker competence throughout the training and 12-month pilot study. Therapeutic alliance competencies (e.g., empathy) saw the earliest improvements. Competencies in personal factors (e.g., substance use) and external factors (e.g., assessing social networks) were initially rated lower, but scores improved during the pilot. Problem-solving and giving advice competencies saw the least improvements overall. Multimodal training, including role-plays, field work and group discussions, contributed to early development of competence. Initial stigma towards CBR participants was reduced through contact. Over time CBR workers occupied dual roles of expert and close friend for the people with schizophrenia in the programme. Competence was sustained through peer supervision, which also supported wellbeing. More intensive specialist supervision was needed. CONCLUSION: It is possible to equip lay health workers with the core competencies to deliver a psychosocial intervention for people with schizophrenia in a low-income setting. A prolonged period of work experience is needed to develop advanced skills such as problem-solving. A structured intervention with clear protocols, combined with peer supervision to support wellbeing, is recommended for good quality intervention delivery. Repeated ENACT assessments can feasibly and successfully be used to identify areas needing improvement and to guide on-going training and supervision.

Community-based rehabilitation intervention for people with schizophrenia in Ethiopia (RISE): a 12 month mixed methods pilot study.

BACKGROUND: Community-based rehabilitation (CBR), or community-based inclusive development, is an approach to address the complex health, social and economic needs of people with schizophrenia in low and middle-income countries. Formative work was undertaken previously to design a culturally appropriate CBR intervention for people with schizophrenia in Ethiopia. The current study explored the acceptability and feasibility of CBR in practice, as well as how CBR may improve functioning among people with schizophrenia. METHODS: This mixed methods pilot study took place in rural Ethiopia between December 2014 and December 2015. Ten people with schizophrenia who were unresponsive to treatment with medication alone, and their caregivers, participated in CBR. CBR was led by lay workers with five weeks training and involved home visits (education, family intervention and support returning to work) and community mobilisation. Theory of change was used to guide the pilot evaluation. Qualitative and quantitative data were collected at baseline, six months and 12 months. Forty in-depth interviews and two focus group discussions were conducted with 31 individuals comprising people with schizophrenia, caregivers, CBR workers, supervisors, health officers and community members. RESULTS: The RISE CBR intervention may have a positive impact on functioning through the pathways of enhanced family support, improved access to health care, increased income and improved self-esteem. CBR was acceptable to CBR workers, community leaders and health officers. Some CBR workers found it challenging to accept the choices of people with schizophrenia. These concerns were felt to be resolvable with supplementary training for CBR workers. The intervention was feasible but further evaluation is needed on a larger scale. CONCLUSION: In low and middle-income countries, CBR may be an acceptable and feasible adjuvant approach to facility-based care for people with schizophrenia. However, contextual factors, including poverty and inaccessible anti-psychotic medication, remain substantial challenges. There were indications that CBR can impact on functioning but the RISE trial will determine effectiveness.

Developing a measure of mental health service satisfaction for use in low income countries: a mixed methods study.

BACKGROUND: Service satisfaction is integral to quality of care and measures are therefore considered important indicators of quality. Patient's responses to their experiences of using services are under-researched in the context of mental healthcare in low income countries. Our aim was to use mixed methods to develop a new measure of satisfaction for use among consumers of the new models of mental healthcare which are currently being scaled-up. METHODS: We used qualitative methods to explore the concept of service satisfaction. On the basis of these findings, we developed a new 'Mental health service satisfaction scale' (MHSSS v0.0) by adapting existing measures of service satisfaction. We evaluated psychometric properties of the new measure, among a sample of service users with severe mental disorder (SMD) (n = 200) and caregivers (n = 200). Following expert review, a modified version of the measure was developed (MHSSS v1.0) and psychometric properties were examined with data from a second independent sample (n = 150 service users with SMD and n = 150 caregivers). RESULTS: Factors identified in analysis of the first quantitative sample coincide with core concepts of service satisfaction as reported in the literature and were reflected in the key themes which emerged from our qualitative study: interpersonal factors, efficacy, communication, technical competency and adequacy of facilities. There was generally consensus among caregivers and service users regarding dimensions of satisfaction. However there was evidence of some differences in prioritization. Revisions made to version 0.0 of the Mental Health Service Satisfaction Scale (MHSSS) led to an improved instrument, with excellent internal consistency, convergent validity and factor loadings indicative of a uni-dimensional construct. CONCLUSIONS: Our findings suggest that conceptions of service satisfaction among people accessing a service for SMD are broadly similar with those established in the literature. Our findings indicate that the MHSSS might be a useful candidate for inclusion in the new toolkit of measures needed to facilitate monitoring of service satisfaction which will be crucial to quality improvement.

Participatory planning of a primary care service for people with severe mental disorders in rural Ethiopia.

Little is understood about the feasibility and acceptability of primary care-based models of task-sharing care for people with severe mental disorders (SMDs) in low- and middle-income countries (LMICs). A participatory planning approach was adopted in preparation for the transition from hospital-delivered psychiatric care for SMD to a primary care-based, task-sharing model in a rural Ethiopian community. In this article, we present findings from community consultation meetings (n = 4), focus group discussions (n = 7) and in-depth interviews (n = 11) with key stakeholders (healthcare administrators and providers, caregivers, service-users and community leaders) which were carried out over a 2-year period in the context of ongoing dialogue with the community. The principle of local delivery of mental health services was agreed upon by all stakeholder groups. Key reasons for supporting local delivery were increased access for the majority due to proximity, reduced cost and reduced stress related to transportation. However, acceptance of the new service was qualified by concerns about the competence of staff to deliver a comprehensive and dependable service of equal quality to that currently provided at the hospital. Adequate training and support, as well as ensuring consistency of medication supply were identified as key components to ensure success. Encouragingly, our results suggest that there is significant support for the service change and an interest for the mobilization of community resources to support this. One of the study strengths was that we were able to present the different perspectives of multiple stakeholder groups. By nesting the study in an ongoing community-based cohort of people with SMD we were able to interview a more representative and empowered group of caregivers and service users than is often available in LMICs. Despite this, the extent to which service-users are able to express their opinions is likely limited by their marginalized role in rural Ethiopian society.