Innovation summary

Mental disorders represent a substantial and growing proportion of the burden of disease in sub-Saharan Africa,1 but there is a lack of mental health professionals to address this burden. This research project assesses the effectiveness and cost-effectiveness of task sharing of two interventions:

  1. Counseling for maternal depression by community health workers in South Africa
  2. Care of stabilised persons with severe mental disorders by primary health care workers in Ethiopia

The broader AFFIRM project (AFrica Focus on Intervention Research for Mental health) is a US National Institute of Mental Health (NIMH) Hub carrying out four core activities:

  1. Randomised controlled trials in South Africa and Ethiopia to investigate task sharing delivered by lay health care workers to patients with mental illnesses
  2. A shared research project on task sharing with the three other NIMH funded Hubs
  3. Building individual and institutional capacity for intervention research in mental health in sub-Saharan Africa
  4. Networking with researchers, NGOs, government agencies and other NIMH Hubs

Impact summary

  • MPhil course attended by 5 AFFIRM fellows annually
  • Approximately 270 participants recruited into projects as of April 2014
  • Effectiveness and cost-effectiveness of task-sharing interventions currently under evaluation through RCTs​

“People who live with mental disorders are among the most poor, the most marginalised and the most disenfranchised members of our society, not just in South Africa but across the African continent... And we know that at least 75% of people living with mental disorders in South Africa don't receive any form of evidence-based care.”

 

-Crick Lund, Centre for Public Mental Health, University of Cape Town

Innovation details

AFFIRM is one of four collaborative Hubs funded by the US National Institute of Mental Health (NIMH), focused on global research in mental health. The Hub includes research institutions and Ministries of Health from sub-Saharan Africa (Ethiopia, Ghana, Malawi, South Africa, Uganda and Zambia), and academic centers in the US (Columbia University and Johns Hopkins School of Public Health) and the UK (King’s College London). The Hub is coordinated through the University of Cape Town, South Africa. There are 4 components to the project:

1. Research

Randomised Controlled Trials (RCT) of task-sharing interventions are being carried out in South Africa and Ethiopia. Both sites have completed successful formative research, retrieving qualitative information on task sharing and local understandings of mental illness. This has also contributed to the development of locally valid Functional Assessment Tools in Butajira, Ethiopia and Khayelitsha, Cape Town.

Khayelitsha, Cape Town​, South Africa: The objective of this randomised controlled trial (RCT) is to determine the effectiveness and cost-effectiveness of a task sharing counseling intervention for maternal depression in South Africa. We wish to determine whether such care can be delivered by non-specialist health workers more cost-effectively than enhanced usual care in South Africa.

Butajira, Gurage Zone, Southern Nations Nationalities and People’s Region (SNNPR), Ethiopia: The main aim of the proposed RCT is to determine the effectiveness and cost-effectiveness of task sharing care of persons with severe mental disorders (SMD) with Primary Health Care Workers, compared to a model of specialist mental health care in Ethiopia.

2. Shared Project

As part of the group of four NIMH Hubs involving task sharing for mental health, AFFIRM is conducting a mixed-methods evaluation of the barriers and facilitators to task-sharing, from the perspectives of health and community workers, mental health professionals, clients, and other relevant persons in the health care system. This is based in Ethiopia.

3. Capacity Building

AFFIRM has a capacity building component that aims to build individual and institutional capacity for intervention research in mental health, in sub-Saharan Africa. This is addressed through:

  • MPhil programme on Public Mental Health at UCT and Stellenbosch University
  • Support for PhD students linked to the trials or shared project
  • Provision of short courses covering topics such as Randomised Controlled Trials and policy making and planning for mental health

4. Networking

AFFIRM collaborates with researchers, NGOs, government agencies, and other NIMH Hubs, to facilitate the translation of research knowledge into policy and practice. This is addressed through on-going discussions and meetings and through sharing experiences in the capacity building and research components.

Key drivers

Continuous reporting to the funders at NIMH, the ethics review boards, and the participating clinics.

Challenges

South Africa 

Finding space for recruitment and counseling sessions at the clinics, and getting buy-in from the nursing staff at the clinics.

Ethiopia 

The process of obtaining ethical approval from the Ethiopian Ethics councils has proven lengthy. Explaining and rationalising the randomisation process to participants has also been difficult.

Continuation

AFFIRM has a ready-made platform to influence policy development, through ongoing close working relationships with the Ministries of Health and NGOs, in both Ethiopia and South Africa. Amongst other things, members of AFFIRM have contributed to the formation of the Ethiopian National Mental Health Strategic Plan (2012), South African National Mental Health Policy and Action Plan (July 2013), and the WHO AFRO Regional Mental Health Action Plan.

Partners

Evaluation methods

The intervention will be evaluated on a number of levels, through both qualitative and quantitative analysis. The main study designs are randomised controlled trials, conducted in South Africa and Ethiopia.

The primary outcome measure of the study is the 17-Item Hamilton Depression Rating Scale (HDRS-17).

The secondary outcomes are:

  • Edinburgh Postnatal Depression Scale (EPDS)
  • Mini International Neuropsychiatric Interview (MINI) 6.0.0, Section A (Major Depressive Episode) and Section B (Suicidality)
  • Health Care Utilization questionnaire (HCUQ)World Health Organization Disability Assessment Schedule (WHO-DAS) 2.0
  • Cape Town Functional Assessment Instrument for Maternal Depression
  • Household Food Insecurity Assessment scale (HFIAS)
  • Multidimensional Scale of Perceived Social Support (MSPSS)
  • AUDIT Alcohol Use Disorders Identification Test
  • Obstetric and child outcome measures at 3 and 12 month postnatal follow-up assessments

Qualitative interviews were conducted at the beginning of the study with service users and service providers regarding the feasibility and viability of the intervention. At the end of the intervention, more interviews will be conducted with a random selection of participants from the study, as well as with the counselors involved in the intervention and other service providers, again regarding perceptions of effectiveness and feasibility of the counseling and of task sharing itself.

Cost of implementation

The total grant is approximately $2,500,000 USD over two years. Evidence on cost-effectiveness is not yet available.

Impact details

  • 200 depressed pregnant women recruited into the study as of March 2014. (Total aim of 420 depressed pregnant participants in South Africa and 324 participants with severe mental disorders in Ethiopia.)
  • 25 Masters students trained through AFFIRM fellowships over 5 years of MPhil courses in Public Mental Health
  • 6 counselors trained in structured counseling for maternal depression in Cape Town

References

  1. Lim, S. S. Vos, T. et al. (2012). "A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010." Lancet 380(9859): 2224-2260.

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Ethiopia, Ghana, Malawi, South Africa, Uganda, Zimbabwe

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