Prevalence of Mental Health Disorders and Their Associated Risk Factors Among People Living with HIV in Rwanda: A Cross-Sectional Study.

While life expectancy of people living with HIV is increasing, their burden of non-communicable diseases, including mental health disorders, is growing as well. The aim of this study is to investigate the prevalence and identify the risk factors associated with mental health disorders among this population in Rwanda. This cross-sectional study enrolled people living with HIV from 12 HIV clinics across Rwanda using random sampling. Trained HIV nurses conducted the Mini International Neuropsychiatric Interview to estimate the prevalence of major depressive episode, post-traumatic stress disorder, and generalized anxiety disorder. Sociodemographic, psychosocial, and HIV-related data were also collected. Associated risk factors for being diagnosed with one of the mental health disorders were assessed using modified Poisson regression with robust error variance. Of 428 participants, 70 (16.4%) had at least one mental health disorder with major depressive episode being most prevalent (n = 60, 14.0%). Almost all participants were adherent to antiretroviral therapy (n = 424, 99.1%) and virally suppressed (n = 412, 96.9%). Of those diagnosed with a mental health disorder, only few were aware of (n = 4, 5.7%) or under treatment for this mental health disorder (n = 5, 7.2%). Mental health disorders were associated with experiences of HIV-related stigma and discrimination (aRR = 2.14, 95%CI 1.30-3.53, p = 0.003). The results demonstrate underdiagnosis and undertreatment of mental health disorders among Rwandan People Living with HIV. Using HIV nurses to diagnose mental health disorders could serve as a low-cost strategy for integrating mental health care with existing HIV services and could inspire the implementation in other low-resource settings.

Prevalence of mental disorders, associated co-morbidities, health care knowledge and service utilization in Rwanda - towards a blueprint for promoting mental health care services in low- and middle-income countries?

BACKGROUND: In order to respond to the dearth of mental health data in Rwanda where large-scale prevalence studies were not existing, Rwanda Mental Health Survey was conducted to measure the prevalence of mental disorders, associated co-morbidities and knowledge and utilization of mental health services nationwide within Rwanda. METHODS: This cross-sectional study was conducted between July and August 2018, among the general population, including survivors of the 1994 Genocide against the Tutsi. Participants (14-65 years) completed the Mini-International Neuropsychiatric Interview (Version 7.0.2), sociodemographic and epilepsy-related questionnaires. General population participants were selected first by random sampling of 240 clusters, followed by systematic sampling of 30 households per cluster. Genocide survivors within each cluster were identified using the 2007-2008 Genocide Survivors Census. RESULTS: Of 19,110 general survey participants, most were female (n = 11,233; 58.8%). Mental disorders were more prevalent among women (23.2%) than men (16.6%) (p < 0.05). The most prevalent mental disorders were major depressive episode (12.0%), panic disorder (8.1%) and post-traumatic stress disorder (PTSD) (3.6%). Overall, 61.7% had awareness of mental health services while only 5.3% reported to have used existing services. Of the 1271 genocide survivors interviewed, 74.7% (n = 949) were female; prevalence of any mental disorder was 53.3% for women and 48.8% for men. Most prevalent disorders were major depressive episode (35.0%), PTSD (27.9%) and panic disorder (26.8%). Among genocide survivors, 76.2% were aware of availability of mental health services, with 14.1% reported having used mental health services. CONCLUSIONS: Despite high prevalence of mental disorders among the general population and genocide survivors, utilization of available mental health services was low. A comprehensive approach to mental health is needed for prevention of mental illness and to promote mental healthcare services.

Co-creation and Evaluation of Nationwide Remote Training Service for Mental Health Education of Community Health Workers in Rwanda.

Objective: Johnson & Johnson Global Public Health and the Ministry of Health of Rwanda strengthened the mental health awareness by providing an innovative, low-cost, easily accessible, and scalable remote training service (RTS) on mental health for Community Health Workers (CHWs). Methods: The RTS consisted of eight training modules shared via simple feature phones over a 4-week period. Quiz questions and baseline/endline assessments were included to assess the feasibility and acceptability of the training platform, the knowledge and self-confidence gained by the CHWs, and prospects for the sustainability of the platform. Results: Ninety-three percent of the CHWs completed at least four of the eight training modules, and 42% of the CHWs improved with a higher end score. The training content was considered interesting, easy to understand, and helpful to intervene appropriately to refer patients with signs of mental illness to a hospital and to provide community and family education on mental health topics. Conclusion: The RTS is feasible and acceptable for the delivery of mental health training on a large scale and contributed to strengthening the capacity in delivering mental health care at community level.

Outcomes of a primary care mental health implementation program in rural Rwanda: A quasi-experimental implementation-effectiveness study.

INTRODUCTION: To address the know-do gap in the integration of mental health care into primary care in resource-limited settings, a multi-faceted implementation program initially designed to integrate HIV/AIDS care into primary care was adapted for severe mental disorders and epilepsy in Burera District, Rwanda. The Mentoring and Enhanced Supervision at Health Centers (MESH MH) program supported primary care-delivered mental health service delivery scale-up from 6 to 19 government-run health centers over two years. This quasi-experimental study assessed implementation reach, fidelity, and clinical outcomes at health centers supported by MESH MH during the scale up period. METHODS: MESH MH consisted of four strategies to ensure the delivery of the priority care packages at health centers: training; supervision and mentorship; audit and feedback; and systems-based quality improvement (QI). Implementation reach (service use) across the 19 health centers supported by MESH MH during the two year scale-up period was described using routine service data. Implementation fidelity was measured at four select health centers by comparing total clinical supervisory visits and checklists to target goals, and by tracking clinical observation checklist item completion rates over a nine month period. A prospective before and after evaluation measured clinical outcomes in consecutive adults presenting to four select health centers over a nine month period. Primary outcome assessments at baseline, 2 and 6 months included symptoms and functioning, measured by the General Health Questionnaire (GHQ-12) and the World Health Organization Disability Assessment Scale (WHO-DAS Brief), respectively. Secondary outcome assessments included engagement in income generating work and caregiver burden using a quantitative scale adapted to context. RESULTS: A total of 2239 mental health service users completed 15,744 visits during the scale up period. MESH MH facilitated 70% and 76% of supervisory visit and clinical checklist utilization target goals, respectively. Checklist item completion rates significantly improved overall, and for three of five checklist item subgroups examined. 121 of 146 consecutive service users completed outcome measurements six months after entry into care. Scores improved significantly over six months on both the GHQ-12, with median score improving from 26 to 10 (mean within-person change 12.5 [95% CI: 10.9-14.0] p< 0.0001), and the WHO-DAS Brief, with median score improving from 26.5 to 7 (mean within-person change 16.9 [95% CI: 14.9-18.8] p< 0.0001). Over the same period, the percentage of surveyed service users reporting an inability to work decreased significantly (51% to 6% (p < 0.001)), and the proportion of households reporting that a caregiver had left income-generating work decreased significantly (41% to 4% (p < 0.001)). CONCLUSION: MESH MH was associated with high service use, improvements in mental health care delivery by primary care nurses, and significant improvements in clinical symptoms and functional disability of service users receiving care at health centers supported by the program. Multifaceted implementation programs such as MESH MH can reduce the evidence to practice gap for mental health care delivery by nonspecialists in resource-limited settings. The primary limitation of this study is the lack of a control condition, consistent with the implementation science approach of the study. STUDY REGISTRATION: ISRCTN #37231.

Evaluating process and clinical outcomes of a primary care mental health integration project in rural Rwanda: a prospective mixed-methods protocol.

INTRODUCTION: Integrating mental healthcare into primary care can reduce the global burden of mental disorders. Yet data on the effective implementation of real-world task-shared mental health programmes are limited. In 2012, the Rwandan Ministry of Health and the international healthcare organisation Partners in Health collaboratively adapted the Mentoring and Enhanced Supervision at Health Centers (MESH) programme, a successful programme of supported supervision based on task-sharing for HIV/AIDS care, to include care of neuropsychiatric disorders within primary care settings (MESH Mental Health). We propose 1 of the first studies in a rural low-income country to assess the implementation and clinical outcomes of a programme integrating neuropsychiatric care into a public primary care system. METHODS AND ANALYSIS: A mixed-methods evaluation will be conducted. First, we will conduct a quantitative outcomes evaluation using a pretest and post-test design at 4 purposively selected MESH MH participating health centres. At least 112 consecutive adults with schizophrenia, bipolar disorder, depression or epilepsy will be enrolled. Primary outcomes are symptoms and functioning measured at baseline, 8 weeks and 6 months using clinician-administered scales: the General Health Questionnaire and the brief WHO Disability Assessment Scale. We hypothesise that service users will experience at least a 25% improvement in symptoms and functioning from baseline after MESH MH programme participation. To understand any outcome improvements under the intervention, we will evaluate programme processes using (1) quantitative analyses of routine service utilisation data and supervision checklist data and (2) qualitative semistructured interviews with primary care nurses, service users and family members. ETHICS AND DISSEMINATION: This evaluation was approved by the Rwanda National Ethics Committee (Protocol #736/RNEC/2016) and deemed exempt by the Harvard University Institutional Review Board. Results will be submitted for peer-reviewed journal publication, presented at conferences and disseminated to communities served by the programme.