Browsing by Author "Hanlon, Charlotte"
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- ItemChallenges and opportunities for implementing integrated mental health care : a district level situation analysis from five low- and middle-income countries(PLoS, 2014-02-18) Hanlon, Charlotte; Luitel, Nagendra P.; Kathree, Tasneem; Murhar, Vaibhav; Shrivasta, Sanjay; Medhin, Girmay; Ssebunnya, Joshua; Fekadu, Abebaw; Shidhaye, Rahul; Petersen, Inge; Jordans, Mark; Kigozi, Fred; Thornicroft, Graham; Patel, Vikram; Tomlinson, Mark; Lund, Crick; Breuer, Erica; De Silva, Mary; Prince, MartinBackground: Little is known about how to tailor implementation of mental health services in low- and middle-income countries (LMICs) to the diverse settings encountered within and between countries. In this paper we compare the baseline context, challenges and opportunities in districts in five LMICs (Ethiopia, India, Nepal, South Africa and Uganda) participating in the PRogramme for Improving Mental health carE (PRIME). The purpose was to inform development and implementation of a comprehensive district plan to integrate mental health into primary care. Methods: A situation analysis tool was developed for the study, drawing on existing tools and expert consensus. Cross-sectional information obtained was largely in the public domain in all five districts. Results: The PRIME study districts face substantial contextual and health system challenges many of which are common across sites. Reliable information on existing treatment coverage for mental disorders was unavailable. Particularly in the low-income countries, many health service organisational requirements for mental health care were absent, including specialist mental health professionals to support the service and reliable supplies of medication. Across all sites, community mental health literacy was low and there were no models of multi-sectoral working or collaborations with traditional or religious healers. Nonetheless health system opportunities were apparent. In each district there was potential to apply existing models of care for tuberculosis and HIV or non-communicable disorders, which have established mechanisms for detection of drop-out from care, outreach and adherence support. The extensive networks of community-based health workers and volunteers in most districts provide further opportunities to expand mental health care. Conclusions: The low level of baseline health system preparedness across sites underlines that interventions at the levels of health care organisation, health facility and community will all be essential for sustainable delivery of quality mental health care integrated into primary care.
- ItemEnhancing mental health research capacity : emerging voices from the National Institute of Mental Health (NIMH) global hubs(BioMed Central, 2019-04-03) Da Silva, Andrea Tenorio Correia; Hanlon, Charlotte; Susser, Ezra; Rojas, Graciela; Claro, Heloisa Garcia; Quayle, Julieta; Habtamu, Kassahun; Burrone, Maria Soledad; Cavalcanti, Maria Tavares; Sharma, Mona; Schneider, Marguerite; Adhikari, Ramesh Prasad; Van de Water, Tanya; Mohammed, Yasmin; Ordonez, Anna E.; Seedat, SorayaBackground: Emerging researchers in low- and middle-income countries (LMIC) face many barriers, including inadequacies in funding, international exposure and mentorship. In 2012, the National Institute of Mental Health (NIMH) funded five research hubs aimed at improving the research core for evidence-based mental health interventions, enhancing research skills in global mental health, and providing capacity building (CB) opportunities for early career investigators in LMIC. In this paper emerging researchers contextualize their experiences. Case presentation: Each of the five hubs purposively selected an emerging researcher who had experienced more than one hub-related CB opportunity and actively participated in hub-related clinical trial activities. The five ‘voices’ were invited to contribute narratives on their professional backgrounds, CB experience, challenges and successes as an emerging mental health researcher, and suggestions for future CB activities. These narratives are presented as case studies. CB activities provided broader learning opportunities for emerging researchers. Benefits included the receipt of research funding, hands-on training and mentorship, as well as exposure to networks and collaborative opportunities on a global scale. To overcome ongoing challenges of access to funding, mentoring, networking and global exposure, the emerging voices recommend making mentorship and training opportunities available to a wider range of emerging mental health researchers. Conclusions: Investing in CB is not enough to ensure sustainability and leave a legacy unless it is accompanied by ongoing mentorship and international exposure. Financial investment in building research capacity, promotion of mentorship and supervision, and international networking are essential to yield well-prepared young investigators in LMIC as experienced by these rising stars. Governments and policymakers should prioritize educational policies to support the continuous development and international engagement of emerging researchers. This can advance strategies to deal with one of most important and costly problems faced by healthcare systems in LMIC: the mental health treatment gap.
- ItemHealth system governance to support scale up of mental health care in Ethiopia : a qualitative study(BMC (part of Springer Nature), 2017) Hanlon, Charlotte; Eshetu, Tigist; Alemayehu, Daniel; Fekadu, Abebaw; Semrau, Maya; Thornicroft, Graham; Kigozi, Fred; Marais, Debra Leigh; Petersen, Inge; Alem, AtalayBackground: Ethiopia is embarking upon a ground-breaking plan to address the high levels of unmet need for mental health care by scaling up mental health care integrated within primary care. Health system governance is expected to impact critically upon the success or otherwise of this important initiative. The objective of the study was to explore the barriers, facilitators and potential strategies to promote good health system governance in relation to scale-up of mental health care in Ethiopia. Methods: A qualitative study was conducted using in-depth interviews. Key informants were selected purposively from national and regional level policy-makers, planners and service developers (n = 7) and district health office administrators and facility heads (n = 10) from a district in southern Ethiopia where a demonstration project to integrate mental health into primary care is underway. Topic guide development and analysis of transcripts were guided by an established framework for assessing health system governance, adapted for the Ethiopian context. Results: From the perspective of respondents, particular strengths of health system governance in Ethiopia included the presence of high level government support, the existence of a National Mental Health Strategy and the focus on integration of mental health care into primary care to improve the responsiveness of the health system. However, both national and district level respondents expressed concerns about low baseline awareness about mental health care planning, the presence of stigmatising attitudes, the level of transparency about planning decisions, limited leadership for mental health, lack of co-ordination of mental health planning, unreliable supplies of medication, inadequate health management information system indicators for monitoring implementation, unsustainable models for specialist mental health professional involvement in supervision and mentoring of primary care staff, lack of community mobilisation for mental health and low levels of empowerment and knowledge undermining meaningful involvement of stakeholders in local mental health care planning. Conclusions: To support scale-up of mental health care in Ethiopia, there is a critical need to strengthen leadership and co-ordination at the national, regional, zonal and district levels, expand indicators for routine monitoring of mental healthcare, promote service user involvement and address widespread stigma and low mental health awareness.
- ItemHealth systems context(s) for integrating mental health into primary health care in six Emerald countries : a situation analysis(BMC (part of Springer Nature), 2017-01-05) Mugisha, James; Abdulmalik, Jibril; Hanlon, Charlotte; Petersen, Inge; Lund, Crick; Upadhaya, Nawaraj; Ahuja, Shalini; Shidhaye, Rahul; Mntambo, Ntokozo; Alem, Atalay; Gureje, Oye; Kigozi, FredBackground: Mental, neurological and substance use disorders contribute to a significant proportion of the world’s disease burden, including in low and middle income countries (LMICs). In this study, we focused on the health systems required to support integration of mental health into primary health care (PHC) in Ethiopia, India, Nepal, Nigeria, South Africa and Uganda. Methods: A checklist guided by the World Health Organization Assessment Instrument for Mental Health Systems (WHO-AIMS) was developed and was used for data collection in each of the six countries participating in the Emerging mental health systems in low and middle-income countries (Emerald) research consortium. The documents reviewed were from the following domains: mental health legislation, health policies/plans and relevant country health programs. Data were analyzed using thematic content analysis. Results: Three of the study countries (Ethiopia, Nepal, Nigeria, and Uganda) were working towards developing mental health legislation. South Africa and India were ahead of other countries, having enacted recent Mental Health Care Act in 2004 and 2016, respectively. Among all the 6 study countries, only Nepal, Nigeria and South Africa had a standalone mental health policy. However, other countries had related health policies where mental health was mentioned. The lack of fully fledged policies is likely to limit opportunities for resource mobilization for the mental health sector and efforts to integrate mental health into PHC. Most countries were found to be allocating inadequate budgets from the health budget for mental health, with South Africa (5%) and Nepal (0.17%) were the countries with the highest and lowest proportions of health budgets spent on mental health, respectively. Other vital resources that support integration such as human resources and health facilities for mental health services were found to be in adequate in all the study countries. Monitoring and evaluation systems to support the integration of mental health into PHC in all the study countries were also inadequate. Conclusion: Integration of mental health into PHC will require addressing the resource limitations that have been identified in this study. There is a need for up to date mental health legislation and policies to engender commitment in allocating resources to mental health services.
- ItemImpact of child emotional and behavioural difficulties on educational outcomes of primary school children in Ethiopia : a population-based cohort study(BMC (part of Springer Nature), 2020-05-16) Mekonnen, Habtamu; Medhin, Girmay; Tomlinson, Mark; Alem, Atalay; Prince, Martin; Hanlon, CharlotteBackground: The relationship between child emotional and behavioural difficulties (EBD) and educational outcomes has not been investigated in prospective, community studies from low-income countries. Methods: The association between child EBD symptoms and educational outcomes was examined in an ongoing cohort of 2090 mother–child dyads. Child EBD was measured when the mean age of children was 6.5 years, SD 0.04 (T0) and 8.4, SD 0.5 years (T1) using the Strength and Difficulties Questionnaire (SDQ). Educational outcomes were obtained from maternal report (drop-out) at T1 and from school records at when the mean age of the children was 9.3 (SD 0.5) years (T2). Result: After adjusting for potential confounders, child EBD symptoms at T1 were associated significantly with school absenteeism at T2: SDQ total score: Risk Ratio (RR) 1.01; 95% confidence interval (CI) 1.01, 1.02; SDQ high score (≥ 14) RR 1.36; 95% CI 1.24, 1.48; emotional subscale RR 1.03; 95% CI 1.01, 1.04; hyperactivity subscale RR 1.03; 95% CI 1.02, 1.04 and peer problems subscale (RR 1.02; 95% CI 1.00, 1.04). High SDQ (β = − 2.89; 95% CI − 5.73, − 0.06) and the conduct problems sub-scale (β = − 0.57; 95% CI − 1.02, − 0.12) had a significant negative association with academic achievement. There was no significant association between child EBD and school drop-out. Conclusion: Prospective associations were found between child EBD symptoms and increased school absenteeism and lower academic achievement, suggesting the need for child mental health to be considered in interventions
- ItemImpact of district mental health care plans on symptom severity and functioning of patients with priority mental health conditions : the Programme for Improving Mental Health Care (PRIME) cohort protocol(BioMed Central, 2018-03-06) Baron, Emily C.; Rathod, Sujit D.; Hanlon, Charlotte; Prince, Martin; Fedaku, Abebaw; Kigozi, Fred; Jordans, Mark; Luitel, Nagendra P.; Medhin, Girmay; Murhar, Vaibhav; Nakku, Juliet; Patel, Vikram; Petersen, Inge; Selohilwe, One; Shidhaye, Rahul; Ssebunnya, Joshua; Tomlinson, Mark; Lund, Crick; De Silva, MaryBackground: The Programme for Improving Mental Health Care (PRIME) sought to implement mental health care plans (MHCP) for four priority mental disorders (depression, alcohol use disorder, psychosis and epilepsy) into routine primary care in five low- and middle-income country districts. The impact of the MHCPs on disability was evaluated through establishment of priority disorder treatment cohorts. This paper describes the methodology of these PRIME cohorts. Methods: One cohort for each disorder was recruited across some or all five districts: Sodo (Ethiopia), Sehore (India), Chitwan (Nepal), Dr. Kenneth Kaunda (South Africa) and Kamuli (Uganda), comprising 17 treatment cohorts in total (N = 2182). Participants were adults residing in the districts who were eligible to receive mental health treatment according to primary health care staff, trained by PRIME facilitators as per the district MHCP. Patients who screened positive for depression or AUD and who were not given a diagnosis by their clinicians (N = 709) were also recruited into comparison cohorts in Ethiopia, India, Nepal and South Africa. Caregivers of patients with epilepsy or psychosis were also recruited (N = 953), together with or on behalf of the person with a mental disorder, depending on the district. The target sample size was 200 (depression and AUD), or 150 (psychosis and epilepsy) patients initiating treatment in each recruiting district. Data collection activities were conducted by PRIME research teams. Participants completed follow-up assessments after 3 months (AUD and depression) or 6 months (psychosis and epilepsy), and after 12 months. Primary outcomes were impaired functioning, using the 12-item World Health Organization Disability Assessment Schedule 2.0 (WHODAS), and symptom severity, assessed using the Patient Health Questionnaire (depression), the Alcohol Use Disorder Identification Test (AUD), and number of seizures (epilepsy). Discussion: Cohort recruitment was a function of the clinical detection rate by primary health care staff, and did not meet all planned targets. The cross-country methodology reflected the pragmatic nature of the PRIME cohorts: while the heterogeneity in methods of recruitment was a consequence of differences in health systems and MHCPs, the use of the WHODAS as primary outcome measure will allow for comparison of functioning recovery across sites and disorders.
- ItemImpact of maternal common mental disorders on child educational outcomes at 7 and 9 years : a population-based cohort study in Ethiopia(BMJ Publishing Group, 2018-01) Mekonnen, Habtamu; Medhin, Girmay; Tomlinson, Mark; Alem, Atalay; Prince, Martin; Hanlon, CharlotteObjectives To examine the association between exposure to maternal common mental disorders (CMD) in preschool and early school age children and subsequent child educational outcomes. Design A population-based cohort study. Setting The study was undertaken in the Butajira health and demographic surveillance site (HDSS), a predominantly rural area of south central Ethiopia. Participants Inclusion criteria are women aged between 15 and 49 years, able to speak Amharic, in the third trimester of pregnancy and resident of the HDSS. 1065 women were recruited between July 2005 and February 2006 and followed up. When the average age of children was 6.5 years old, the cohort was expanded to include an additional 1345 mothers and children who had been born in the 12 months preceding and following the recruitment of the original cohort, identified from the HDSS records. Data from a total of 2090 mother–child dyads were included in the current analysis. Measures Maternal CMD was measured when the children were 6–7 (6/7) and 7–8 (7/8) years old using the Self-reporting Questionnaire, validated for the setting. Educational outcomes (dropout) of the children at aged 7/8 years (end of 2013/2014 academic year) were obtained from maternal report. At age 8/9 years (end of 2014/2015 academic year), educational outcomes (academic achievement, absenteeism and dropout) of the children were obtained from school records. Results After adjusting for potential confounders, exposure to maternal CMD at 7/8 years was associated significantly with school dropout (OR 1.07; 95% CI 1.00 to 1.13, P=0.043) and absenteeism (incidence rate ratio 1.01; 95% CI 1.00 to 1.02 P=0.026) at the end of 2014/2015 academic year. There was no association between maternal CMD and child academic achievement. Conclusion Future studies are needed to evaluate whether interventions to improve maternal mental health can reduce child school absenteeism and dropout.
- ItemImpact of perinatal and repeated maternal common mental disorders on educational outcomes of primary school children in rural Ethiopia : population-based cohort study(Royal College of Psychiatrists, 2019) Mekonnen, Habtamu; Medhin, Girmay; Tomlinson, Mark; Alem, Atalay; Prince, Martin; Hanlon, CharlotteBackground: There have been no studies from low- or middle-income countries to investigate the long-term impact of perinatal common mental disorders (CMD) on child educational outcomes. Aims: To test the hypothesis that exposure to antenatal and postnatal maternal CMD would be associated independently with adverse child educational outcomes in a rural Ethiopian. Method: A population-based birth cohort was established in 2005/2006. Inclusion criteria were: age between 15 and 49 years, ability to speak Amharic, in the third trimester of pregnancy and resident of the health demographic surveillance site. One antenatal and nine postnatal maternal CMD assessments were conducted using a self-reporting questionnaire, validated for the local use. Child educational outcomes were obtained from the mother at T1 (2013/2014 academic year; mean age 8.5 years) and from school records at T2 (2014/2015 academic year; mean age 9.3 years). Results: Antenatal CMD (risk ratio (RR) = 1.06, 95% CI 1.05–1.07) and postnatal CMD (RR = 1.07, 95% CI 1.06–1.09) were significantly associated with child absenteeism at T2. Exposure to repeatedly high maternal CMD scores in the preschool period was not associated with absenteeism after adjusting for antenatal and postnatal CMD. Non-enrolment at T1 (odds ratio 0.75, 95% CI 0.62–0.92) was significantly but inversely associated with postnatal maternal CMD. There was no association between maternal CMD and child academic achievement or drop-out. Conclusions: Our findings support the hypothesis of a critical period for exposure to maternal CMD for adverse child outcomes and indicate that programmes to enhance regular school attendance in low-income countries need to address perinatal maternal CMD.
- ItemMaternal common mental disorders and infant development in Ethiopia : the P-MaMiE Birth Cohort(BioMed Central, 2010-11) Servili, Chiara; Medhin, Girmay; Hanlon, Charlotte; Tomlinson, Mark; Worku, Bogale; Baheretibeb, Yonas; Dewey, Michael; Alem, Atalay; Prince, MartinBackground: Chronicity and severity of early exposure to maternal common mental disorders (CMD) has been associated with poorer infant development in high-income countries. In low- and middle-income countries (LAMICs), perinatal CMD is inconsistently associated with infant development, but the impact of severity and persistence has not been examined. Methods: A nested population-based cohort of 258 pregnant women was identified from the Perinatal Maternal Mental Disorder in Ethiopia (P-MaMiE) study, and 194 (75.2%) were successfully followed up until the infants were 12 months of age. Maternal CMD was measured in pregnancy and at two and 12 months postnatal using the WHO Self-Reporting Questionnaire, validated for use in this setting. Infant outcomes were evaluated using the Bayley Scales of Infant Development. Results: Antenatal maternal CMD symptoms were associated with poorer infant motor development ( β ^ -0.20; 95% CI: -0.37 to -0.03), but this became non-significant after adjusting for confounders. Postnatal CMD symptoms were not associated with any domain of infant development. There was evidence of a dose-response relationship between the number of time-points at which the mother had high levels of CMD symptoms (SRQ ≥ 6) and impaired infant motor development ( β ^ = -0.80; 95%CI -2.24, 0.65 for ante- or postnatal CMD only, β ^ = -4.19; 95%CI -8.60, 0.21 for ante- and postnatal CMD, compared to no CMD; test-for-trend χ213.08(1), p < 0.001). Although this association became non-significant in the fully adjusted model, the β ^ coefficients were unchanged indicating that the relationship was not confounded. In multivariable analyses, lower socio-economic status and lower infant weight-for-age were associated with significantly lower scores on both motor and cognitive developmental scales. Maternal experience of physical violence was significantly associated with impaired cognitive development. Conclusions: The study supports the hypothesis that it is the accumulation of risk exposures across time rather than early exposure to maternal CMD per se that is more likely to affect child development. Further investigation of the impact of chronicity of maternal CMD upon child development in LAMICs is indicated. In the Ethiopian setting, poverty, interpersonal violence and infant undernutrition should be targets for interventions to reduce the loss of child developmental potential.
- ItemMaternal mental health in primary care in five low- and middle-income countries : a situational analysis(BioMed Central, 2016-02-16) Baron, Emily C.; Hanlon, Charlotte; Mall, Sumaya; Honikman, Simone; Breuer, Erica; Kathree, Tasneem; Luitel, Nagendra P.; Nakku, Juliet; Lund, Crick; Medhin, Girmay; Patel, Vikram; Petersen, Inge; Shrivastava, Sanjay; Tomlinson, MarkBackground: The integration of maternal mental health into primary health care has been advocated to reduce the mental health treatment gap in low- and middle-income countries (LMICs). This study reports findings of a cross-country situation analysis on maternal mental health and services available in five LMICs, to inform the development of integrated maternal mental health services integrated into primary health care. Methods: The situation analysis was conducted in five districts in Ethiopia, India, Nepal, South Africa and Uganda, as part of the Programme for Improving Mental Health Care (PRIME). The analysis reports secondary data on the prevalence and impact of priority maternal mental disorders (perinatal depression, alcohol use disorders during pregnancy and puerperal psychosis), existing policies, plans and services for maternal mental health, and other relevant contextual factors, such as explanatory models for mental illness. Results: Limited data were available at the district level, although generalizable data from other sites was identified in most cases. Community and facility-based prevalences ranged widely across PRIME countries for perinatal depression (3–50 %) and alcohol consumption during pregnancy (5–51 %). Maternal mental health was included in mental health policies in South Africa, India and Ethiopia, and a mental health care plan was in the process of being implemented in South Africa. No district reported dedicated maternal mental health services, but referrals to specialised care in psychiatric units or general hospitals were possible. No information was available on coverage for maternal mental health care. Challenges to the provision of maternal mental health care included; limited evidence on feasible detection and treatment strategies for maternal mental disorders, lack of mental health specialists in the public health sector, lack of prescribing guidelines for pregnant and breastfeeding women, and stigmatising attitudes among primary health care staff and the community. Conclusions: It is difficult to anticipate demand for mental health care at district level in the five countries, given the lack of evidence on the prevalence and treatment coverage of women with maternal mental disorders. Limited evidence on effective psychosocial interventions was also noted, and must be addressed for mental health programmes, such as PRIME, to implement feasible and effective services.
- ItemPartnerships in a global mental health research programme — the example of PRIME(Springer, 2019) Breuer, Erica; Hanlon, Charlotte; Bhana, Arvin; Chisholm, Dan; De Silva, Mary; Fekadu, Abebaw; Honikman, Simone; Jordans, Mark; Kathree, Tasneem; Kigozi, Fred; Luitel, Nagendra P.; Marx, Maggie; Medhin, Girmay; Murhar, Vaibhav; Ndyanabangi, Sheila; Patel, Vikram; Petersen, Inge; Prince, Martin; Raja, Shoba; Rathod, Sujit D.; Shidhaye, Rahul; Ssebunnya, Joshua; Thornicroft, Graham; Tomlinson, Mark; Wolde-Giorgis, Tedla; Lund, CrickCollaborative research partnerships are necessary to answer key questions in global mental health, to share expertise, access funding and influence policy. However, partnerships between low- and middle-income countries (LMIC) and high-income countries have often been inequitable with the provision of technical knowledge flowing unilaterally from high to lower income countries. We present the experience of the Programme for Improving Mental Health Care (PRIME), a LMIC-led partnership which provides research evidence for the development, implementation and scaling up of integrated district mental healthcare plans in Ethiopia, India, Nepal, South Africa and Uganda. We use Tuckman’s first four stages of forming, storming, norming and performing to reflect on the history, formation and challenges of the PRIME Consortium. We show how this resulted in successful partnerships in relation to management, research, research uptake and capacity building and reflect on the key lessons for future partnerships.
- ItemPRIME : a programme to reduce the treatment gap for mental disorders in five low- and middle-income countries(Public Library of Science, 2012-12-27) Lund, Crick; Tomlinson, Mark; De Silva, Mary; Fekadu, Abebaw; Shidhaye, Rahul; Jordans, Mark; Petersen, Inge; Bhana, Arvin; Kigozi, Fred; Prince, Martin; Thornicroft, Graham; Hanlon, Charlotte; Kakuma, Ritsuko; McDaid, David; Saxena, Shekhar; Chisholm, Dan; Raja, Shoba; Kippen-Wood, Sarah; Honikman, Simone; Fairall, Lara; Patel, VikramThe majority of people living with mental disorders in low- and middle-income countries do not receive the treatment that they need. There is an emerging evidence base for cost-effective interventions, but little is known about how these interventions can be delivered in routine primary and maternal health care settings.The aim of the Programme for Improving Mental Health Care (PRIME) is to generate evidence on the implementation and scaling up of integrated packages of care for priority mental disorders in primary and maternal health care contexts in Ethiopia, India, Nepal, South Africa, and Uganda.PRIME is working initially in one district or sub-district in each country, and integrating mental health into primary care at three levels of the health system: the health care organisation, the health facility, and the community.The programme is utilising the UK Medical Research Council complex interventions framework and the ‘‘theory of change’’ approach, incorporating a variety of qualitative and quantitative methods to evaluate the acceptability, feasibility, and impact of these packages.PRIME includes a strong emphasis on capacity building and the translation of research findings into policy and practice, with a view to reducing inequities and meeting the needs of vulnerable populations, particularly women and people living in poverty.