Implementing an mhGAP-based training and supervision package to improve healthcare workers' competencies and access to mental health care in Malawi.

BACKGROUND: It is now well established that the integration of mental health care into primary care is one of the most effective ways of reducing the substantial treatment gap for mental disorders which exists in most low- and middle-income countries. This study set out to determine whether a Mental Health Gap Action Programme (mhGAP) training and supervision package could be contextualised and implemented within the existing health care system in five districts in Southern Malawi. In addition, the study assessed the feasibility of holding community awareness events and establishing peer support groups in each district to further improve the access of the population to evidence-based mental health care. METHODS: A lead training team of experienced Malawian mental health professionals was appointed and mhGAP training materials were contextualised for use in Malawi. The lead team delivered a 4-day training package to district mental health teams in five districts covering three core conditions: psychosis, moderate-severe depression, and alcohol and substance use disorders. District mental health teams then delivered a 2-day training package and provided monthly supervision for 3 months to 500 non-specialist healthcare workers. Paired sample t-tests were used to compare knowledge, confidence and attitude scores before and immediately after training, and after 6 months in two districts. Case detection rates measured pre- and post-training in the pilot district were compared using Wilcoxon Rank Sum Test. Community awareness events were held and peer support groups were established in each of the five districts. The acceptability of the package was assessed through focus group discussions involving specialist and non-specialist healthcare workers, users and carers. RESULTS: Non-specialist healthcare workers' knowledge and confidence scores significantly increased immediately after training in comparison to pre-training. These scores were maintained at 6 months. However, no statistically significant change in attitude scores was detected. Case detection rates increased immediately after the training in comparison to pre-training. Responses from focus group discussion participants illustrated the programme's acceptability. CONCLUSIONS: This study demonstrated that, with minimal additional funding and working within existing structures, an mhGAP based training at primary and secondary health care levels is feasible in Southern Malawi.

Developing sustainable capacity-building in mental health research: implementation outcomes of training of trainers in systematic reviewing.

Less than 1% of biomedical research papers originate in Africa. Locally relevant mental health research, including synthesis of existing evidence, is essential for developing interventions and strengthening health systems, but institutions may lack the capacity to deliver training on systematic reviewing for publication in international journals. This paper describes the development and implementation of a training-of-trainers (ToT) course on systematic reviewing. The ToT prepared junior faculty ('trainers') from universities in Ethiopia, Malawi, and Zimbabwe to lead a five-day systematic reviewing workshop. Using an evaluation framework based on implementation science outcomes, the feasibility of the ToT was assessed by tracking the number of workshops the trainers subsequently conducted and the number of trainers and trainees who participated; acceptability was assessed through post-workshop surveys on trainee perspectives; impact was evaluated through trainee scores on a 15-item multiple choice test on systematic reviewing concepts; and sustainability was assessed based on whether the workshop was integrated into university curricula. Twelve trainers (86% of those trained) facilitated a total of seven workshops in their home countries (total 103 trainees). The first workshop run in each country was evaluated, and there was a significant improvement in mean knowledge scores between pre- and post-tests among trainees (MD= 3.07, t= 5.90, 95% CI 2.02-4.11). In two of the three countries, there are efforts to integrate the systematic review workshop into university curricula. The cost of the workshop led by the international trainer was $1480 per participant, whereas the trainer-led workshops cost approximately $240 per participant. Overall, ToT is relatively new to research capacity building, although it has been used widely in clinical settings. Our findings suggest ToT is a promising, low-cost way to develop both technical skills of individuals and the pedagogical capacity of universities, and to promote sustainability of research capacity building programs that often have time-limited grant funding.

Adverse drug reactions experienced by out-patients taking chlorpromazine or haloperidol at Zomba Mental Hospital, Malawi.

OBJECTIVE: Drugs for managing mental disorders can cause adverse drug reactions (ADRs) that have negative impacts on patients yet, in Malawi, epidemiological data on the drug-related problems are limited. This study assessed the prevalence and severity of ADRs in out-patients at Zomba Mental Hospital. RESULTS: Twenty-six of forty patients (65.0%) were taking haloperidol and 14 (35.0%) chlorpromazine. The commonest diagnosis was schizophrenia (n = 23, 57.5%) followed by epileptic psychosis (n = 4, 10.0%) and general psychosis (n = 4, 10.0%) with one of psychotic depression and one psychosis secondary to general medical condition. Comorbidities were also found with epilepsy being the commonest (n = 4, 10.0%). All patients reported at least one ADR of varying severity (mild, moderate and severe). Polydipsia was the most prevalent (24, 60.0%) followed by weight gain (20, 50.0%), spasm (15, 37.5%) and xerostomia (15, 37.5%). Some ADRs were gender specific and these included impotence (6/27, 29.6%) for males and menstrual changes (3/14, 21.4%) for females. Severe ADRs were more common in the older aged group (> 35 years 8.3% vs 7.1%), in males (11.1% vs 0.0%) and on chlorpromazine (14.3% vs 3.8%). Patients taking chlorpromazine and haloperidol are at risk of experiencing a wide range of ADRs with varying degrees of severity.

Pathway to care for psychiatric patients in a developing country: Malawi.

BACKGROUND: Paramedics dominate primary health care in Malawi where native healers also play a major role in the provision of health care and psychiatric nurses are the backbone of district mental health services. AIM: The aim is to improve understanding of prior care-seeking and treatment of new patients seen at mental health services in a developing country like Malawi. METHOD: For one calendar month, 128 newly referred patients to the mental health services in the three psychiatric units in Malawi were interviewed using an encounter form. RESULTS: Most of the patients went through a first carer before attending a psychiatric unit with only 11.7% going straight to a psychiatric unit. All patients who went straight to a psychiatric unit involved the private/Christian Health Association of Malawi (CHAM) unit in the northern region of Malawi. About 22.7% of the patients had a native healer as a first carer. Only 23% of all patients seen went through a second carer, with none going through a third carer. Over 8% of those who had a paramedic as their first carer had a native healer as their second carer. Duration of stay at different carers varied a lot with about half (48.2%) of all patients who saw a native healer as the first carer spending more than 2 weeks before referral while about 67.0% of those who saw convectional health workers spent 3 days or less before referral. CONCLUSION: The pathway to care for patients with psychological problems in Malawi is not very much different to pathways to care in other developing countries whereby native healers and paramedics play a significant role. With the high proportion of patients being seen by native healers and the fact that most patients stay longer at native healers before referral, there is need for official collaboration and training of native healers on mental health.

Malawi.

Malawi is a country with an approximate area of 118 000 km2. Its population is estimated at 13 million and the gender ratio (men per hundred women) is 98. The proportion of the population under the age of 15 years is 47% and the proportion above the age of 60 years is 5%. The literacy rate is 75.5% for men and 48.7% for women (World Health Organization, 2005).