Task sharing in rural Haiti: Qualitative assessment of a brief, structured training with and without apprenticeship supervision for community health workers.

Despite growing support for supervision after task sharing trainings in humanitarian settings, there is limited research on the experience of trainees in apprenticeship and other supervision approaches. Studying apprenticeships from trainees' perspectives is crucial to refine supervision and enhance motivation for service implementation. The authors implemented a multi-stage, transcultural adaptation for a pilot task sharing training in Haiti entailing three phases: 1) literature review and qualitative research to adapt a mental health and psychosocial support training; 2) implementation and qualitative process evaluation of a brief, structured group training; and 3) implementation and qualitative evaluation of an apprenticeship training, including a two year follow-up of trainees. Structured group training revealed limited knowledge acquisition, low motivation, time and resource constraints on mastery, and limited incorporation of skills into practice. Adding an apprenticeship component was associated with subjective clinical competency, increased confidence regarding utilising skills, and career advancement. Qualitative findings support the added value of apprenticeship according to trainees.

Reflechi twòp--thinking too much: description of a cultural syndrome in Haiti's Central Plateau.

A rich Haitian ethnopsychology has been described, detailing concepts of personhood, explanatory models of illness, and links between mind and body. However, little research has engaged explicitly with mental illness, and that which does focuses on the Kreyòl term fou (madness), a term that psychiatrists associate with schizophrenia and other psychoses. More work is needed to characterize potential forms of mild-to-moderate mental illness. Idioms of distress provide a promising avenue for exploring common mental disorders. Working in Haiti's Central Plateau, we aimed to identify idioms of distress that represent cultural syndromes. We used ethnographic and epidemiologic methods to explore the idiom of distress reflechi twòp (thinking too much). This syndrome is characterized by troubled rumination at the intersection of sadness, severe mental disorder, suicide, and social and structural hardship. Persons with "thinking too much" have greater scores on the Beck Depression Inventory and Beck Anxiety Inventory. "Thinking too much" is associated with 8 times greater odds of suicidal ideation. Untreated "thinking too much" is sometimes perceived to lead to psychosis. Recognizing and understanding "thinking too much" may allow early clinical recognition and interventions to reduce long-term psychosocial suffering in Haiti's Central Plateau.

Suicide in rural Haiti: clinical and community perceptions of prevalence, etiology, and prevention.

Suicide is a complex global public health problem, yet few studies have examined local socio-cultural explanatory models and other contextual factors surrounding suicide in low-and-middle-income countries. Such research is critical, as suicide frequency and etiology, as well as care-seeking in the case of distress, differ contextually and by sub-groups within a population. This is the first study of its kind to explore the dual perspectives of both healthcare workers and community members regarding suicide in Haiti. We conducted semi-structured, in-depth interviews between May and June 2011 with eight biomedical healthcare workers and 16 lay community members. Qualitative data analysis, drawing on interpretive phenomenological analysis, addressed themes including perceived suicide frequency, veracity of suicidal ideation claims, perceived causal factors, religious constructs related to suicide, and support resources for suicidality. Compared to community members, healthcare workers underestimated the frequency of suicide and were less likely to interpret suicide-related claims as representing true intent. Religious perspectives influenced attitudes toward suicide, albeit in different ways: Christian concern with the afterlife resulted in suicide being unacceptable and sinful, while Vodou explanatory frameworks displaced blame and stigma away from suicidal individuals. Healthcare workers' failure to recognize suicide as a serious problem suggests that the formal health system is currently ill-equipped to respond to suicide-related needs. Religious practice and community supports in rural Haiti may serve as essential resources for prevention programs.

Determinants of care seeking for mental health problems in rural Haiti: culture, cost, or competency.

OBJECTIVE: This study examined patterns, determinants, and costs of seeking care for mild to moderate psychiatric distress in order to determine optimal approaches for expanding mental health care in rural Haiti. METHODS: A cross-sectional, zone-stratified household survey of 408 adults was conducted in Haiti's Central Plateau. Multivariable logistic regression models were built to assess determinants of first-choice and lifetime health service use by provider type. RESULTS: Thirty-two percent of respondents endorsed God as their first choice for care if suffering from mental distress, and 29% of respondents endorsed clinics and hospitals as their first choice. Forty-seven percent of respondents chose potential providers on the basis of anticipated efficacy. Suicidal individuals were 7.6 times (95% confidence interval [CI]=1.4-42.0) as likely to prefer community-based providers (herbal healer, church priest or pastor, or Vodou priest) over hospitals or clinics. Depression severity was associated with increased odds (adjusted odds ratio [AOR]=1.8, CI=1.5-2.3) of ever having been to an herbal healer. Having a household member with mental health problems was associated with increased odds of ever having been to church pastors or priests (AOR=5.8, CI=2.8-12.0) and decreased odds of ever having been to hospitals or clinics (AOR=.3, CI=.1-.8). Median actual service costs were US $1 for hospitals or clinics, $6 for herbal healers, and $120 for Vodou priests. CONCLUSIONS: Three out of four rural Haitians said they would seek community resources over clinical care if suffering from mental distress. Therefore, isolated clinical interventions may have limited impact because of less frequent use. Efforts to expand mental health care should consider differential provider costs when selecting community resources for task shifting.

Depression, suicidal ideation, and associated factors: a cross-sectional study in rural Haiti.

BACKGROUND: Since the 2010 earthquake in Haiti, there has been increased international attention to mental health needs throughout the country. The present study represents one of the first epidemiologic studies of depression symptomatology, suicidal ideation, and associated factors in Haiti's Central Plateau. METHODS: We conducted a cross-sectional, zone-stratified household survey of 408 adults in Haiti's Central Plateau. Depression symptomatology was assessed with a culturally-adapted Kreyòl version of the Beck Depression Inventory (BDI). Multivariable linear and logistic regression models were built using backward elimination, with the outcomes being continuous BDI scores and endorsing suicidal ideation, respectively. RESULTS: The mean BDI score was 20.4 (95% confidence interval [CI]: 19.3-21.5), and 6.13% (N = 25) of participants endorsed current suicidal ideation. Factors associated with BDI scores were: continuous age (adjusted beta [aß]: 0.14, CI: 0.06-0.22), female gender (aß: 2.1, CI: 0.18-4.0), suicidal ideation (aß: 11.1, CI: 7.3-14.9), death in family (aß: 2.7, CI: 0.57-4.9), and prior life-threatening illness (aß: 2.6, CI: 0.77-4.5). Education was a risk factor for depression among women but not among men, and employment was a risk factor for both genders. Factors associated with endorsing suicidal ideation were: BDI score (ten point change) (adjusted odds ratio [aOR]: 2.5, CI: 1.7-3.6), lack of care if sick (aOR: 5.5, CI: 1.1-28.6), alcohol use (aOR: 3.3, CI: 1.3-8.2), and ever having been to a Vodou priest (aOR: 3.2, CI: 1.1-9.5). CONCLUSIONS: A large proportion of Haiti's Central Plateau may be experiencing high levels of depression symptomatology and/or current suicidal ideation. Screening could be conducted in biomedical, religious, and Vodou healing contexts. For prevention, poverty reduction and improved healthcare access are key elements. For treatment, general psychiatric services, psychosocial services for the medically ill and their families, and substance abuse interventions should be explored. Paradoxical associations related to education and employment require further exploration.