Perspectives on competency-based feedback for training non-specialists to deliver psychological interventions: multi-site qualitative study of the EQUIP competency-based approach.

BACKGROUND: The use of feedback to address gaps and reinforce skills is a key component of successful competency-based mental health and psychosocial support intervention training approaches. Competency-based feedback during training and supervision for personnel delivering psychological interventions is vital for safe and effective care. AIMS: For non-specialists trained in low-resource settings, there is a lack of standardised feedback systems. This study explores perspectives on competency-based feedback, using structured role-plays that are featured on the Ensuring Quality in Psychosocial and Mental Health Care (EQUIP) platform developed by the World Health Organization and United Nations Children's Fund. METHOD: Qualitative data were collected from supervisors, trainers and trainees from multiple EQUIP training sites (Ethiopia, Kenya, Lebanon, Peru and Uganda), from 18 key informant interviews and five focus group discussions (N = 41 participants). Qualitative analysis was conducted in Dedoose, using a codebook with deductively and inductively developed themes. RESULTS: Four main themes demonstrated how a competency-based structure enhanced the feedback process: (a) competency-based feedback was personalised and goal-specific, (b) competency-based feedback supported a feedback loop, (c) competency-based feedback supported a comfortable and objective feedback environment, and (d) competency-based feedback created greater opportunities for flexibility in training and supervision. CONCLUSIONS: A better understanding of the role of feedback supports the implementation of competency-based training that is systematic and effective for trainers and supervisors, which ultimately benefits the learning process for trainees.

Effectiveness of a mindfulness and acceptance-based intervention for improving the mental health of adolescents with HIV in Uganda: An open-label trial.

Adolescents with HIV (AWH) face the double burden of dealing with challenges presented by their developmental phase while coping with stigma related to HIV, affecting their mental health. Poor mental health complicates adherence to daily treatment regimens, requiring innovative psychosocial support strategies for use with adolescents. We assessed the effectiveness of a mindfulness and acceptance-based intervention on the mental health of AWH in Uganda. One hundred and twenty-two AWH, mean age 17 ±1.59 (range 15 to 19 years), 57% female, receiving care at a public health facility in Kampala were enrolled in an open-label randomized trial (ClinicalTrials.gov: NCT05010317) with assessments at pre-and post-intervention. The mindfulness and acceptance-based intervention involved weekly 90-minute group sessions for four consecutive weeks facilitated by two experienced trainers. Sessions involved clarifying values, skillfully relating to thoughts, allowing and becoming aware of experiences non-judgmentally, and exploring life through trial and error. The control group received the current standard of care. Three mental health domains (depression, anxiety, and internalized stigma) were compared between the intervention and control groups. A linear mixed effects regression was used to analyze the effect of the intervention across the two time points. Results showed that the intervention was associated with a statistically significant reduction in symptoms of depression (ß = -10.72, 95%CI: 6.25, -15.20; p < .0001), anxiety (ß = -7.55, 95%CI: 2.66, -12.43; p = .0003) and stigma (ß = -1.40, 95%CI: 0.66 to -2.15; p = .0004) over time. Results suggest that mindfulness and acceptance-based interventions have the potential to improve the mental health of AWH.

The Effect of a Group-Based Mindfulness and Acceptance Training on Psychological Flexibility and Adherence to Antiretroviral Therapy Among Adolescents in Uganda: An Open-Label Randomized Trial.

Adherence to antiretroviral therapy (ART) is lower in adolescents with HIV (AWH) than in any other age group, partly due to self-regulatory challenges during development. Mindfulness and acceptance training have been shown to support psychological flexibility, a self-regulatory skill that potentially improves adolescent adherence to medication. We assessed the effect of weekly group-based mindfulness and acceptance training sessions on ART adherence among older adolescents (15-19 years) in Kampala, Uganda. One hundred and twenty-two AWH (median age 17, range 15-19 years, 57% female) receiving care at a public health facility in Kampala were randomized 1:1 to receive 4 weekly 90-min group sessions facilitated by experienced trainers or standard-of-care ART services. The training involved (Session 1) clarifying values, (Session 2) skillfully relating to thoughts, (Session 3) allowing and becoming aware of experiences non-judgmentally, and (Session 4) exploring life through trial and error. At baseline, postintervention, and 3-month follow-up, psychological flexibility was measured using the Avoidance and Fusion Questionnaire for Youth (AFQ-Y8), and self-reported ART adherence was assessed using the Morisky Medication Adherence Scale (MMAS-8). At baseline, the intervention and standard-of-care arms had similar psychological flexibility (AFQ-Y8 score:15.45 ± 0.82; 15.74 ± 0.84) and ART adherence (MMAS-8 score: 5.32 ± 0.24; 5.13 ± 0.23). Retention through the study was moderate (71%). Completion of mindfulness and acceptance training was associated with a significant reduction in psychological inflexibility at the 3-month follow-up (AFQ-Y8 score: 12.63 ± 1.06; 14.05 ± 1.07, P = .006). However, no significant differences were observed in self-reported adherence to ART at the 3-month follow-up (MMAS-8 score: 5.43 ± 0.23; 4.90 ± 0.33, P = .522). Group-based mindfulness and acceptance training improved psychological flexibility in this population of adolescents on ART in Uganda but did not significantly improve ART adherence. Future research should explore integrated approaches that combine behavioral management training with other empowerment aspects to improve ART adherence among AWH.

A mixed methods evaluation of a World Health Organization competency-based training package for foundational helping skills among pre-service and in-service health workers in Nepal, Peru and Uganda.

Health systems globally demand more competent workers but lack competency-based training programs to reach their goals. This study evaluates the effectiveness of a competency-based curriculum (EQUIP-FHS) for trainers and supervisors to teach foundational helping knowledge, attitudes and skills, guided by the WHO/UNICEF EQUIP platform, to improve the competency of in-service and pre-service workers from various health and other service sectors. A mixed-methods, uncontrolled before-and-after trial was conducted in Nepal, Peru, and Uganda from 2020 to 2021. Trainees' (N = 150) competency data were collected during 13 FHS trainings. Paired t-tests assessed pre- to post-change in ENACT competency measures (e.g., harmful, helpful). Qualitative data was analyzed using thematic analysis. EQUIP-FHS trainings, on average, were 20 h in duration. Harmful behaviors significantly decreased, and helpful behaviors significantly increased, across and within sites from pre-to post-training. Qualitatively, trainees and trainers promoted the training and highlighted difficult competencies and areas for scaling the training. A brief competency-based curriculum on foundational helping delivered through pre-service or in-service training can reduce the risk that healthcare workers and other service providers display harmful behaviors. We recommend governmental and nongovernmental organizations implement competency-based approaches to enhance the quality of their existing workforce programming and be one step closer to achieving the goal of quality healthcare around the globe.

Mental health awareness programmes to promote mental well-being at the workplace among workforce in the low-income and middle-income countries: a scoping review protocol.

INTRODUCTION: An understanding of the mental health awareness programmes among workforces in low/middle-income countries (LMICs) is lacking significantly in literature. Such understanding is crucial for the employers, government agencies and other stakeholders to initiate strategies to promote mental health and well-being at the workplace. OBJECTIVE: The main aim of this study is to conduct a scoping review to systematically map the research on the mental health awareness programmes among workforces in LMICs. METHODS: A comprehensive search strategy for the articles published between 2000 and 2022 will be conducted in MEDLINE, PubMed, EBSCOhost, Wiley Online Library, Cochrane and JSTOR. Various study designs such as randomised control trials, non-randomised control trials, systematic reviews, scoping reviews and observational studies that report evidence on mental health awareness programmes among workforce in LMICs will be identified through specific strategy. Search outcomes will be exported to Endnote and duplication of studies will be removed. From the list of included studies, data such as characteristics of mental health programmes, common outcome measures and domains, and motivations underlying the establishment of existing mental health awareness programmes will be extracted and analysed. ANALYSIS: The search outcomes will be presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart. The characteristics of the research studies on mental health programmes will be outlined using tables. The various outcome domains and outcome measures reported in the studies will be presented in a bubble chart showing different outcome measures categorised and collated under a specific outcome domain. The findings on the motivations and justifications underlying the establishment of mental health awareness programmes will be summarised using a thematic analysis. TRIAL REGISTRATION NUMBER: https://doi.org/10.17605/OSF.IO/WPURK.

Acceptability of an adapted mindfulness and acceptance-based intervention to support adolescents with HIV: A qualitative study with Ugandan health care providers.

While the adaptation of evidence-based psychosocial support tailors the intervention components to the targeted context, minimizing the associated costs of developing new interventions for low-income contexts, the acceptability of such adapted interventions is important for augmenting successful implementation and sustainability. Given that psychosocial support to persons living with HIV is mostly rendered by healthcare providers, their acceptance of adapted interventions before implementation is crucial. This study explored healthcare providers' acceptance of an adapted mindfulness and acceptance-based intervention supporting adolescents with HIV. Ten healthcare providers at two urban clinics in Kampala, Uganda attended a three-day training on using the adapted intervention and gave feedback on its appropriateness during in-depth interviews conducted thereafter. Semi-structured interviews were based on the Theoretical Framework of Acceptability and findings were analyzed abductively within the seven components of the framework. Overall, the adapted intervention was perceived to be acceptable and appropriate for use with adolescents. Benefits included the intervention offering support beyond a focus on adherence to drugs, refocusing adolescents on aspects in their lives that matter most, and being easy to integrate into providers' work processes. Providers however expressed concern about the time the intervention requires and the possibility of increasing their workload. These findings will support further adaptation and implementation.

Community based sociotherapy for depressive symptomatology of Congolese refugees in Rwanda and Uganda (CoSTAR): a protocol for a cluster randomised controlled trial.

Background: Conflict in the Democratic Republic of Congo has led to large numbers of refugees fleeing to Uganda and Rwanda. Refugees experience elevated levels of adverse events and daily stressors, which are associated with common mental health difficulties such as depression. The current cluster randomised controlled trial aims to investigate whether an adapted form of Community-based Sociotherapy (aCBS) is effective and cost-effective in reducing depressive symptomatology experienced by Congolese refugees in Uganda and Rwanda.Methods: A two-arm, single-blind cluster randomised controlled trial (cRCT) will be conducted in Kyangwali settlement, Uganda and Gihembe camp, Rwanda. Sixty-four clusters will be recruited and randomly assigned to either aCBS or Enhanced Care As Usual (ECAU). aCBS, a 15-session group-based intervention, will be facilitated by two people drawn from the refugee communities. The primary outcome measure will be self-reported levels of depressive symptomatology (PHQ-9) at 18-weeks post-randomisation. Secondary outcomes will include levels of mental health difficulties, subjective wellbeing, post-displacement stress, perceived social support, social capital, quality of life, and PTSD symptoms at 18-week and 32-week post-randomisation. Cost effectiveness of aCBS will be measured in terms of health care costs (cost per Disability Adjusted Life Year, DALY) compared to ECAU. A process evaluation will be undertaken to investigate the implementation of aCBS.Conclusion: This cRCT will be the first investigating aCBS for mental health difficulties experienced by refugees and will contribute to knowledge about the use of psychosocial interventions for refugees at a time when levels of forced migration are at a record high.Trial registration: ISRCTN.org identifier: ISRCTN20474555.

There is a need to evaluate community-based psychosocial interventions for refugees.Community-based sociotherapy has been used to support communities in post-conflict situations but has not been evaluated in a randomised controlled trial.This protocol outlines a proposed randomised controlled trial of community-based sociotherapy adapted for Congolese refugees in Uganda and Rwanda.

Culturally adapting a mindfulness and acceptance-based intervention to support the mental health of adolescents on antiretroviral therapy in Uganda.

The dual burden of living with HIV and negotiating life stage changes has been identified as a contributing factor to lapsed adherence among adolescents with HIV in sub-Saharan Africa. While psychosocial support can promote medication adherence, most interventions in use with adolescents were originally developed for the general population creating a gap in appropriate support. Life-stage-appropriate, evidence-based psychosocial support interventions have been used with young people in high-income contexts, prompting interest in their use in low-income contexts. However, many interventions are less effective when implemented outside of their original settings, hence the need for modifications before implementation. We aimed to culturally adapt an evidence-based psychosocial support intervention designed to improve the mental health of young people for use among adolescents with HIV in a sub-Saharan African context and to explore the acceptability of the adapted intervention among adolescents. We engaged thirty stakeholders (n = 30) in Kampala, Uganda including psychologists, psychiatrists, social workers, HIV counselors, religious leaders and adolescent peers from December 2021 to April 2022 to modify an evidence-based intervention for adolescents. Key adaptations included simplifying the language, adding local practices, integrating locally relevant slang and stories into therapy, introducing racially-congruent visuals and cards representing emotions, and adjusting therapy materials for use in resource-constrained settings. We then tested the acceptability of the intervention in a small sample of service users using a qualitative approach. We recruited nine adolescents with HIV from a participating clinic in Kampala, delivered six 90-minute sessions of the adapted intervention across three weeks and conducted in-depth interviews to assess the acceptability of the intervention. We used thematic analysis to analyze the qualitative data. The adapted intervention was perceived as acceptable among adolescents with HIV, with many stating that it helped them overcome fears, increased their self-acceptance, and gave them the confidence to make careful health-enhancing decisions.

Training of interventionists and cultural adaptation procedures: A systematic review of culturally adapted evidence-based parenting programs in Africa.

There has been an increase in the implementation of evidence-based parenting programs from high-income countries to several African countries. In this review, we systematically evaluated intervention studies of culturally adapted parenting programs in nine African countries with the objective of examining the quality of training for interventionists and cultural adaptation procedures. A total of 18 studies, obtained from an electronic search of 6 databases, met the inclusion criteria and were evaluated following PRISMA guidelines. The Ecological Validity Model was adopted to organize data on cultural adaptation procedures. Sixteen of the 18 studies reported information regarding the clinical training of interventionists and the cultural adaptations undertaken. Live and interactive workshops were the most common format used to train interventionists in the focal intervention. Overall, cultural adaptations in most studies included translation of intervention protocols into the local language. However, studies varied in the way cultural adaptation procedures were reported with some studies failing to report on cultural adaptation procedures. Concurring with previous literature, attending to issues of culture, power, privilege, access, sustainability, and other relevant concepts to increase the cultural relevance is highly encouraged in parent intervention studies in Africa. This review provides a baseline upon which future training and adaptation procedures can be built.

Translating, contextually adapting, and pilot testing of psychosocial and mental health assessment instruments for Congolese refugees in Rwanda and Uganda.

BACKGROUND: Forcibly displaced people are at elevated risk of experiencing circumstances that can adversely impact on mental health. Culturally and contextually relevant tools to assess their mental health and psychosocial needs are essential to inform the development of appropriate interventions and investigate the effectiveness of such interventions. METHODS: We conducted two related studies: (1) to translate and contextually adapt the Patient Health Questionnaire (PHQ-9), a measure of depressive symptomatology, along with assessment instruments measuring levels of daily stress (Checklist for Daily & Environmental Stressors; CDES), social capital (Shortened and Adapted Social Capital Assessment Tool; SASCAT) and perceived social support (Multidimensional Scale of Perceived Social Support; MSPSS) for use with Congolese refugees; (2) to conduct pilot testing of the assessment instruments (including cognitive interviewing about participants' views of completing them) and a validation of the adapted PHQ-9 using a 'known group' approach by recruiting Congolese refugees from refugee settings in Rwanda (n = 100) and Uganda (n = 100). RESULTS: Study 1 resulted in the translation and adaptation of the assessment instruments. No substantive adaptations were made to the SASCAT or MSPSS, while notable linguistic and contextual adaptations were made in both sites to the CDES and the PHQ-9. The cognitive interviewing conducted in Study 2 indicated that the adapted assessment instruments were generally well received by members of the refugee communities. Participants recruited on the basis that local informants adjudged them to have high levels of depressive symptoms had significantly higher PHQ-9 scores (M = 11.02; SD = 5.84) compared to those in the group adjudged to have low levels of depressive symptoms (M = 5.66; SD = 5.04). In both sites, the adapted versions of the PHQ-9 demonstrated concurrent validity via significant positive correlations with levels of daily stressors. Each of the four adapted assessment instruments demonstrated at least adequate levels of internal consistency in both sites. CONCLUSIONS: The adapted versions of the PHQ-9, CDES, SASCAT and MSPSS are appropriate for use amongst Congolese refugees in Rwanda and Uganda. We recommend further application of the approaches used in the current studies for contextually adapting other assessment instruments in humanitarian settings.

The 'good life', personal appearance, and mental health of Congolese refugees in Rwanda and Uganda.

RATIONALE: Research into mental health and wellbeing recognises the role of positive mental health to enable people to lead healthy and emotionally fulfilling lives. Mental health difficulties continue to be associated with high levels of disability worldwide, and refugees fleeing conflict are known to suffer from poor mental health for years after their forced migration. METHOD: Informed by Sen's Capability Approach and as part of a wider research project, we used semi-structured interviews to engage with 60 men and women in two refugee communities in Uganda and Rwanda to explore their aspirations and what a 'good life' meant to them. FINDINGS: While aspects of what constituted a good life were gendered, both men and women struggled to achieve their aspirations within their communities. Following the basic needs of food and shelter, the complex needs of being dressed well and being clean were consistently associated with be able to achieve a 'good life' by women and men across age groups. Looking good and being clean were highly valued and associated with gaining the respect of others, achieving good relationships with neighbours, and avoiding conflict. Participants identified personal appearance and related social status as critical precursors to their successful engagement with other gendered dimensions of social and economic life in their communities, such as finding employment and being well regarded in their religious communities. CONCLUSIONS: Our findings suggest that without the means to present a good appearance, people living in refugee communities may experience feelings of shame and isolation and are unable to gain self-respect and the respect of others needed to achieve the positive mental and physical health they associate with leading 'a good life'.

Why don't children in Uganda have tics? A mixed-methods study of beliefs, knowledge, and attitudes of health professionals.

BACKGROUND: Tourette syndrome (TS) is reported in all cultures, although is speculated to be rare among those of Sub-Saharan African descent. A lack of research exploring TS in the context of Sub-Saharan Africa has meant that it is not yet established whether this apparent rarity is due to a true low prevalence or if identification of the condition merely is unrecognized. The present study aimed to explore health professionals' knowledge and attitudes of the identification, diagnosis and management of TS in Uganda. METHOD: A mixed-methods design was used to collect data from 152 Ugandan healthcare professionals by survey. Of these, 6 professionals took part in semi-structured interviews. Data gathered were analyzed with descriptive statistics and qualitatively using thematic analysis. RESULTS: Professionals' views and experiences led to conclusions addressing (a) perceived challenges in diagnosing and treating TS in a Ugandan healthcare setting, (b) the role of cultural factors in help-seeking behaviors, and (c) ways by which efforts can be made to build capacity in awareness and clinical care. CONCLUSIONS: The findings suggest that TS is present in Uganda, but a number of factors hinder detection rates causing it to be under-reported in the population. This study highlights the need for more focused and adequate training for all healthcare professionals in Uganda and education campaigns to increase awareness among the general public. KEY PRACTITIONER MESSAGE: Little is currently known about the presentation of or understanding by professionals around Tourette syndrome in Sub-Saharan Africa. This study found health professionals in Uganda indicated a number of factors which interact and negatively impact recognition rates of tic disorders. This included limited training, exposure, and misconceptions, contributing to a lack of clinical awareness and attention. They also reported a lack of help-seeking behaviors due to parental perceptions and Ugandan traditional, cultural and religious beliefs. Professionals perceive that there are likely large numbers of undiagnosed and untreated children with Tourette syndrome in Uganda. This supports existing literature regarding the diagnostic challenges of neurodevelopmental disorders in Africa and provides an alternative explanation for the assumption that tic disorders may be rare and possible absent in Sub-Saharan Africa. There is a need to develop adequate training regarding tic disorders for all healthcare professionals working in Uganda as well as education campaigns for the general public to increase awareness.

Exploring the mental health and psychosocial problems of Congolese refugees living in refugee settings in Rwanda and Uganda: a rapid qualitative study.

BACKGROUND: Refugees fleeing conflict often experience poor mental health due to experiences in their country of origin, during displacement, and in new host environments. Conditions in refugee camps and settlements, and the wider socio-political and economic context of refugees' lives, create structural conditions that compound the effects of previous adversity. Mental health and psychosocial support services must address the daily stressors and adversities refugees face by being grounded in the lived reality of refugee's lives and addressing issues relevant to them. METHODS: We undertook a rapid qualitative study between March and May 2019 to understand the local prioritisation of problems facing Congolese refugees living in two refugee settings in Uganda and Rwanda. Thirty free list interviews were conducted in each setting, followed by 11 key informant interviews in Uganda and 12 in Rwanda. RESULTS: Results from all interviews were thematically analysed following a deductive process by the in-country research teams. Free list interview findings highlight priority problems of basic needs such as food, shelter, and healthcare access; alongside contextual social problems including discrimination/inequity and a lack of gender equality. Priority problems relating to mental and psychosocial health explored in key informant interviews include discrimination and inequity; alcohol and substance abuse; and violence and gender-based violence. CONCLUSIONS: Our findings strongly resonate with models of mental health and psychosocial wellbeing that emphasise their socially determined and contextually embedded nature. Specifically, findings foreground the structural conditions of refugees' lives such as the physical organisation of camp spaces or refugee policies that are stigmatising through restricting the right to work or pursue education. This structural environment can lead to disruptions in social relationships at the familial and community levels, giving rise to discrimination/inequity and gender-based violence. Therefore, our findings foreground that one consequence of living in situations of pervasive adversity caused by experiences of discrimination, inequity, and violence is poor mental health and psychosocial wellbeing. This understanding reinforces the relevance of feasible and acceptable intervention approaches that aim to strengthening familial and community-level social relationships, building upon existing community resources to promote positive mental health and psychosocial wellbeing among Congolese refugees in these settings.

Exploring mental health needs and services among affected population in a cyclone affected area in costal Bangladesh: a qualitative case study.

BACKGROUND: Bangladesh, one of the most densely populated countries in the world has been ranked 9th on the Climate Risk Index for 2017: the 10 most affected countries & 7th on the Long-Term Climate Risk Index: the 10 countries most affected from 1998 to 2017. Every year it is afflicted with various climatic disasters including floods, hurricanes and cyclones. Apart from the obvious devastation of lives and property, there is a huge increase in clinical diseases when these disasters occur. Mental health of affected persons after these disasters is a topic that is often neglected by local and national level. METHODS: A qualitative case study was conducted on perceived need on mental health support & availability of such services in a cyclone affected area in rural Bangladesh. Ten (10) key informant interviews (KIIs) with different stakeholders and ten (10) in-depth interviews (IDIs) with affected people were taken. FINDINGS: We found that cyclones had numerous psychosocial impacts on the population including acute stress disorder, sleep disorder, post-traumatic stress disorders (PTSDs), generalized anxiety disorders, suicidal ideation and depression. The survivors had specific needs for receiving support. Children, elderly and women were perceived to be more vulnerable. The government and NGOs had no specific action plans and initiatives to address these issues and support the mental health of affected population. There was a visible gap in finding effective ways to provide affected people with the required mental health & psycho-social services (MHPSS). CONCLUSION: Resilient, responsive and self-sustaining health systems for this vulnerable population are required. Implementation of effective mental health programs and strong mental health policies remain a challenge in Bangladesh where there is a cultural fatalistic acceptance of mental health issues.

Clinical supervision for clinical psychology students in Uganda: an initial qualitative exploration.

BACKGROUND: Burn out in clinical psychologists working in low income countries has been reported. Clinical supervisory structures do not yet exist in Uganda. A way to decrease levels of burn out and increase quality of care for people with mental illness is through clinical supervision. The aim of this study was to explore the initial experiences of supervision for clinical psychology students in Uganda to ascertain whether or not clinical supervision is culturally appropriate, and what aspects of supervision had been helpful and unhelpful. METHODS: A qualitative design with thematic analysis was utilized. A focus group was held with 12 second year clinical psychology students to ask their experiences of receiving supervision. RESULTS: Data analysis created five themes. Firstly, the negative emotions that resulted from the training processed were discussed, and how supervision helped and did not help the students to manage these. Secondly, the students voiced that supervision helped them to learn through observational experiences, co-therapist roles and parallel processes within the supervisory relationship. Thirdly, supervision had taught the clinical psychology students their role as a clinical psychology student, how to act within the Ugandan mental health system and skills to conduct therapy. Fourthly, suggestions for the future of supervision were given, with the students requesting for it to start earlier in the training, for supervisors who can meet with the students on a regular basis to be selected and for the training the students receive at university to match the skills required on their placements, with a request for more practical techniques rather than theory. The final theme related to left over miscellaneous data, such as the students agreeing with each other. CONCLUSIONS: The students stated that supervision was helpful overall, implying that clinical supervision is culturally appropriate for clinical psychology students in Uganda. Suggestions for future supervision were given. In order to decrease high levels of staff burn out in the mental health systems in Uganda, supervisory structures with an emphasis on self care need to be established.