There is growing international consensus that a task sharing approach is required to narrow the treatment gap for mental disorders in low and middle-income countries (LMIC). This means essentially that general health workers need to deliver mental health interventions through routine health care delivery systems, supervised by mental health specialists.
WHO (2008) notes that “by reorganizing the workforce in this way, task sharing presents a viable solution for improving health care coverage by making more efficient use of the human resources already available and by quickly increasing capacity while training and retention programmes are expanded”. (See http://www.who.int/mediacentre/events/meetings/task_shifting/en/index.html)
AFrica Focus on Intervention Research for Mental Health (AFFIRM) evaluated task sharing through the use of Community Health Workers in South Africa, and Primary Health Care workers in Ethiopia. In South Africa the focus is on pregnant women who are depressed, and in Ethiopia the focus is on people with severe mental disorders. This research and capacity development hub was established in 6 countries: Ethiopia, Ghana, Malawi, South Africa, Uganda and Zimbabwe.
AFFIRM aimed to investigate cost effective interventions for mental health disorders, through task-sharing by Community Health Workers in South Africa, and Primary Health Care workers in Ethiopia.
AFFIRM was led from the University of Cape Town, and funded by the National Institute of Mental Health (NIMH), USA. It included four components to address the specific aims:
1) Two randomised controlled trials on task shifting: one each in Ethiopia and South Africa; 2) A capacity building component primarily focused on the MPhil programme in Public Mental Health and a series of short courses, offered by UCT and Stellenbosch University; 3) A shared project across all NIMH hubs, examining scalability and replicability of task shifting interventions, and 4) Regular meetings to establish a network of collaborators in mental health research within sub-Saharan Africa, between AFFIRM, other hubs, the NIMH, and local researchers and mental health specialists.
The project’s specific aims included:
1. Investigating strategies for narrowing the treatment gap for mental disorders in sub-Saharan Africa by:
- Assessing the feasibility and acceptability of low cost task sharing interventions in Ethiopia and South Africa; and
- Conducting randomised controlled trials (RCTs) of low cost task sharing interventions for severe mental disorders in Ethiopia and maternal depression in South Africa.
2. Building individual and institutional capacity for intervention research in sub- Saharan Africa by:
- Providing fellowship and mentorship programmes for candidates in Ethiopia, Ghana, Malawi, Uganda and Zimbabwe to develop capacity for mental health intervention research;
- Offering short courses in mental health intervention research in sub-Saharan Africa; and
- Providing supervision to Masters, PhD and post-doctoral students, who wish to base their research in either of the AFFIRM research sites in Ethiopia and South Africa.
3. Establishing a network of collaboration between researchers, NGOs and government agencies that facilitates the
translation of research knowledge into policy and practice by:
- Establishing knowledge exchange with Ministries of Health in all partner countries, regarding steps for evaluating and later scaling up task sharing interventions for mental health disorders; and
- Producing communication materials, such as policy briefs and annual newsletters, on intervention research for mental health in sub-Saharan Africa, to be disseminated to partner Ministries of Health and NGOs.
4. Collaborating with other NIMH hubs by:
- Designing and executing shared research projects related to task sharing and narrowing the treatment gap; and
- Pooling research knowledge from all hubs to contribute to global advocacy initiatives to narrow the treatment gap for mental disorders in Low and Middle Income Countries (LMIC)
AFFIRM is one of 4 hubs funded by the National Institute of Mental Health (part of the National Institutes of Health in the USA). These are:
AFFIRM: Sub-Saharan Africa (Ethiopia, Ghana, Malawi, South Africa, Uganda and Zimbabwe).
SHARE: the South Asian Hub for Advocacy, Research and Education on Mental Health (Bangladesh, India, Pakistan, Sri Lanka). See the SHARE Brochure for more information.
RedeAmericas: Network for Mental Health Research in the Americas (Argentina, Brazil, Chile, Colombia and USA). Click here for more information.
PaM-D: Partnerships for Mental Health Development in sub-Saharan Africa (Nigeria, Ghana, Kenya, Liberia and South Africa).
The first annual meeting of the hubs was held in Cape Town from 8 – 11 August 2012 (participants shown in the photo below), and the second one in Santiago, Chile, from 4-7 September 2013. The meetings provided a good forum for sharing ideas and developing networks.
Crick Lund, University of Cape Town
Atalay Alem, Addis Ababa University
Ezra Susser, Columbia University
Charlotte Hanlon, Addis Ababa University
Principal Investigator: Ethiopian Trial
Abebaw Fekadu, Addis Ababa University
Girmay Medhin, Addis Ababa University
Teshome Shibre, Addis Ababa University
Frank Nyanator, Health Services
Peter Yaro, Basic Needs
Margie Schneider, UCT
Songelwa Mobo, UCT
Thandi Davies, UCT
Memory Nyatsanza, UCT
Simone Honikman, UCT
Inge Petersen, UKZN
Arvin Bhana, UKZN
John Joska, UCT
Dan Stein, UCT
Landon Myer, UCT
Leslie Swartz, SU
Ashraf Kagee, SU
Mark Tomlinson, SU
Jonathan Burns, UKZN
Melvyn Freeman, Department of Health
Sifiso Phakhati, Department of Health
Seggane Musisi, Makerere University
Fred Kigozi, Makerere University
Tina Ntulo, Basic Needs
Graham Thornicroft, King’s College London
Martin Prince, King’s College London
Melanie Abas, King’s College London
Ezra Susser, Columbia University
Judy Bass, Johns Hopkins University
Paul Bolton, Johns Hopkins University
Larry Wissow, Johns Hopkins University
AFFIRM Partner Institutions
Alan J Flisher Centre for Public Mental Health
The Perinatal Mental Health Project
Programme for Improving Mental Health Care (PRIME)
Centre for Global Mental Health, King’s College London
Mailman School of Public Health, Columbia University, New York
Bloomberg School of Public Health, Johns Hopkins University, Baltimore
Philani Child Health and Nutrition Project
The Parent Centre
Cape Mental Health
Re-engineered Primary Health Care for South Africa
AFFIRM Capacity Building
The capacity building component aimed to build individual and institutional capacity for intervention research in mental health, in sub-Saharan Africa. This was addressed in part through the MPhil programme on Public Mental Health at UCT/Stellenbosch University, which sponsored 5 MPhil students from each of the 5 African countries other than South Africa. Other strategies include support for PhD students linked to the trials or shared projects, and short courses covering topics such as RCTs and policy making and planning for mental health.
2012 saw the first intake of AFFIRM fellows onto the MPhil in Public Mental Health, run jointly by UCT and Stellenbosch University (SU). 11 students were accepted onto the course in 2012 (pictured in the photo below), and five were sponsored by AFFIRM for one year. The students attended a residential two week course run jointly by the two universities in January 2012 and then returned home to continue their data collection and dissertations. They worked under the guidance of their supervisors based at UCT or SU. The students were very positive about the residential course but felt that the time was too short.
In January 2013 the second residential course was held at UCT and SU, and it was extended to three weeks. Five fellows from the five AFFIRM countries attended the course (pictured below) and all appreciated and enjoyed their time. They are all now in different stages of research and dissertation writing. An increased effort has been made to find more academic and supervisorial support for the students once they are back in their home countries.
In 2014 we accepted eight students to the course; five of whom were funded by AFFIRM and three were self-funded (see photo below). At the beginning of 2014 we also employed an MPhil coordinator to manage and coordinate the course, and assist the students throughout the year. Dr Katherine Sorsdahl has been in the UCT psychiatry department since 2006, and we welcome her to the project.
In addition to the institutional support provided by the CPMH, students are also supported by institutional partners such as Columbia University, King’s College, London and Johns Hopkins University, partners working as part of AFFIRM. In 2015, five more fellows were awarded the scholarship, and three students self funded themselves. Dr Sorsdahl has proved to be of very valuable assistance in supporting the students and improving the delivery of the programme.
The research component comprises two randomised control trials (RCTs), one each in Cape Town, South Africa, and the Butajira district, Ethiopia.
THE SOUTH AFRICAN TRIAL IN KHAYELITSHA, CAPE TOWN – URBAN AREA
Principal Investigator: Crick Lund
High rates of antenatal and postnatal depression have been reported in Khayelitsha, and maternal depression has been shown to negatively impact the mother and her baby’s health. Our group is testing the efficacy of a counselling intervention for maternal depression in Khayelitsha in the form of a randomized controlled trial (RCT). What is special about this trial is that community health workers (CHWs) will be trained to deliver the intervention, as part of a task sharing strategy in primary health care.
With support from senior management in the Western Cape Government Department of Health, we are working with colleagues in the Michael Mapongwana Midwife Obstetric Unit and Site B Midwife Obstetric Unit.
The first phase of this five year study involved formative research to establish the feasibility and acceptability of the intervention. Pregnant women and mothers of young babies were interviewed to discover issues that would affect the research and counselling intervention. Women were also interviewed about their perceptions and descriptions of depression, and its various causes and symptoms.
Also included in the formative phase was the development of a ‘Functional Assessment Instrument’, which aims to assess in what way depression specifically affects pregnant women and mothers of young infants in Khayelitsha. This is guided by collaborators from Johns Hopkins University.
Official recruitment for the trial began in October 2013. This phase involves enrolling approximately 420 women into the RCT. As part of the RCT, the women will be randomly allocated to either receive the counselling intervention (6-8 sessions of a structured evidence-based programme delivered either in the clinic or at home by the CHWs), or receive enhanced usual care, which will comprise a monthly structured phone call from a CHW unassociated with the counselling CHWs.
Due to a slower than anticipated recruitment rate at Michael Mapongwana MOU, in January 2014 we included a second location for recruitment – Site B Community Centre MOU. The characteristics of the clinics and the women attending them are very similar, and recruitment increased, with the employment of two more field workers too. Recruitment was completed in October 2014, and the field workers are now concentrating on the follow up assessments, which occur at 1 month before birth, 3 months and 12 months after birth.
The third phase will involve conducting qualitative interviews with some of the participants and the counsellors in order to ascertain the successes and challenges of the intervention.
One of the major questions we seek to answer through the research is whether community health workers can effectively deliver counselling interventions, as this may inform their role in delivering mental health services. This vision is part of the national primary health care revitalization programme, where ward agents or CHWs are expected to play a major preventive and promotive role.
THE ETHIOPIAN TRIAL IN BUTAJIRA, GURAGE ZONE – RURAL AREA
Principal Investigator: Charlotte Hanlon
The Ethiopian trial focuses on task sharing care of stabilised persons with severe mental disorders with primary health care workers (PHWs). The participants are already diagnosed with severe mental disorders and have been receiving care from psychiatric nurses at Butajira hospital. These participants will be randomised into intervention and comparison groups, with the intervention group being those whose mental health management or care plan is transferred to the primary health care level and managed by primary health care workers. The comparison group will continue receiving hospital based mental health care. The aim is to determine whether the transfer to the primary health care level is as effective and not inferior to the management by psychiatric nurses.
The formative phase explored a range of issues to be addressed in the main trial, such as how potential participants understand randomisation, and how well the intervention will be accepted given the history of receiving the hospital based services. The complexity of these issues has required the formative phase to be expanded to include discussions with relevant stakeholders on issues such as randomisation.
As with the South African trial, the Ethiopia team is also developing and adapting outcome measures for the main RCT. This will create an indigenous scale to measure functional impairment and recovery in persons with severe mental disorders in the Butajira District. In addition, a measure of patient satisfaction with services is being adapted for the Ethiopian context. These culturally appropriate measures will be used primarily as secondary outcome measures, but will also provide important insights into the functional status or people with mental disorders. They will be an important contribution from the AFFIRM project, with potential application in both clinical and research settings.