‘Restoring the person's life’: a qualitative study to inform development of care for people with severe mental disorders in rural Ethiopia

Abstract

Aims.In low-income countries, care for people with severe mental disorders (SMDs) who manage to access treatment is usually emergency-based, intermittent or narrowly biomedical. The aim of this study was to inform development of a scalable district-level mental health care plan to meet the long-term care needs of people with SMD in rural Ethiopia.Methods.The present study was carried out as formative work for the Programme for Improving Mental health CarE which seeks to develop, implement and evaluate a district level model of integrating mental health care into primary care. Six focus group discussions and 25 in-depth interviews were conducted with service planners, primary care providers, traditional and religious healers, mental health service users, caregivers and community representatives. Framework analysis was used, with findings mapped onto the domains of the Innovative Care for Chronic Conditions (ICCC) framework.Results.Three main themes were identified. (1) Focused on ‘Restoring the person's life’, including the need for interventions to address basic needs for food, shelter and livelihoods, as well as spiritual recovery and reintegration into society. All respondents considered this to be important, but service users gave particular emphasis to this aspect of care. (2) Engaging with families, addressed the essential role of families, their need for practical and emotional support, and the importance of equipping families to provide a therapeutic environment. (3) Delivering collaborative, long-term care, focused on enhancing accessibility to biomedical mental health care, utilising community-based health workers and volunteers as an untapped resource to support adherence and engagement with services, learning from experience of service models for chronic communicable diseases (HIV and tuberculosis) and integrating the role of traditional and religious healers alongside biomedical care. Biomedical approaches were more strongly endorsed by health workers, with traditional healers, religious leaders and service users more inclined to see medication as but one component of care. The salience of poverty to service planning was cross-cutting.Conclusions.Stakeholders prioritised interventions to meet basic needs for survival and endorsed a multi-faceted approach to promoting recovery from SMD, including social recovery. However, sole reliance on this over-stretched community to mobilise the necessary resources may not be feasible. An adapted form of the ICCC framework appeared highly applicable to planning an acceptable, feasible and sustainable model of care.

Equitable access to mental healthcare integrated in primary care for people with severe mental disorders in rural Ethiopia: a community-based cross-sectional study

“…There is need for prospective evaluation of the equity of access to long-term care in people with SMD in this setting. As discussed, from our qualitative work [36, 38], we anticipate that poverty will be an important factor in sustained engagement with mental health care.…”

Implementing integrated services for people with epilepsy in primary care in Ethiopia: a qualitative study

“…The ICCCF approach requires health workers to work with patients as equal partners in their care, providing them with relevant and accessible information and promoting self-management of their condition. The need for the Ethiopian health system to adapt to the growing burden of people with chronic disorders has been highlighted previously [ 40 , 41 ].…”

“…Our findings are in keeping with previous studies describing the high level of emotional and financial burden experienced by family caregivers of people with MNS disorders in a rural Ethiopian setting [ 44 ] and the potential for locally accessible health care services to diminish the burden considerably [ 45 ]. However, most caregivers reported a lack of ongoing practical and emotional support, linking again with the ICCC framework approach that recognises the interconnectedness of patient and family health in this setting [ 40 ] . Interventions aimed at engaging families in care and providing ongoing support are needed.…”

Next steps for meeting the needs of people with severe mental illness in low- and middle-income countries

“…The ‘chronic care model’ is a health system configuration, which has been shown to improve outcomes for chronic disorders in high-income countries (Wagner et al 2001). This approach has been adapted for LMICs (as the ‘innovative care for chronic conditions framework’; ICCCF) (Epping-Jordan et al 2004) and formative work from Ethiopia indicates that ICCCF has the potential to address many of the system challenges with task-shared care for people with SMI (Mall et al 2015). The key elements of the ICCCF are as follows: equipping people affected by chronic disorders, their caregivers and communities with the information, access to treatment and support they need in order to maximise their health (‘informed, motivated and prepared’); shifting from delivery systems which are geared to respond to acute, infectious illness to those which promote long-term co-ordination and planning of person-centred care (‘delivery system design’ and information systems); integrating evidence-based guidelines into routine care, supporting access to expertise and orientating health care providers to the changes in clinician–patient relationship needed for long-term care (‘organised and well-equipped healthcare teams’); and ensuring conducive policies, legislation and financing to support good leadership and sustainable, quality care.…”