Care Plan Mental Health – No Mental Health Care Provision Was Reported In Any Of These Facilities

I know that the integration of mental health care into primary care was commonest approach advocated to narrow treatment gap in low income countries since to1970’s.

To assist this integration WHO has provided evidencebased templates of intervention called Mental Health Gap Action Programme intervention guide.

Now look, the mhGAP provides a minimum set of ‘evidence based’ interventions that should be provided at primary care level. No mental health care provision was reported in any of these facilities. Health centres were staffed by nurses, laboratory technologists, pharmacists, pharmacy technicians and supporting staffs. Nevertheless, the majority of health facilities were established by togovernment. Anyway, situational analysis identified eight health centres and 58 health posts that were operating in district throughout the time of toassessment. Now pay attention please. None of facilities have trained mental health personnel. Now please pay attention. Cases with mental health problems in community were referred to capital city, Addis Ababa. Then, health posts were staffed by HEWs. Facility level assumptions included availability and willingness of health workers to undergo mental health training and their readiness to provide mental health interventions.

Causal pathway of pre conditions leading to ‘longterm’ outcomes, assumptions and indicators were also highlighted in the course of the workshops.

At community level, underlying assumptions included readiness to seek services among people with mental health problems, sensitivity of general public wards needs of people with mental disorders, and willingness to collaborate with HEWs and community health volunteers in awareness raising activities.

Did you know that the political commitment of district and health care administration, raised mental health awareness, and adequate budget allocation were cited as assumptions at district and higher health care administration levels, that are necessary to make MHCPs effective. On p of that, information collected was also anonymous. No personal information was obtained from toparticipants. All participants provided informed consent. Now look. Ethical clearance of study was obtained from Institutional Review Board, College of Health Sciences of Addis Ababa University. Let me tell you something. By its nature, information obtained was in a group setting and members knew each other.

I know that the ToC approach was found to be an effective mechanism to engage with and obtain buy in of multiple stakeholders.

It provides interventions with a strong ‘communitybase’ and in addition to ensure sustainability of outcomes.

Through our ToC workshops, we have learned that engaging community in service planning is critical in regards to understanding context in which intervention will take place. For any intervention, indicators were identified and agreed up on. Known along topathways, sets of interlinked preconditions were connected to next pre condition through interventions and assumptions. On p of this, participants were asked to suggest causal pathways projecting from current state and leading to final outcome of toprogramme. Lots of info can be found on tointernet. Final outcome of programme was defined as improved health, social and economic outcomes for people with priority mental disorders in todistrict. That’s where it starts getting very interesting, right? Current state of district and final agreed outcome of programme were written at left and right ends of a whiteboard.

Four intervention levels involving tocommunity, health care facility, health care administration and higher policy organizations were indicated.

Maximum participants contributed their share in refining pathways to final outcome.

Participants were requested to state required ‘preconditions’, interventions, assumptions and indicators, in order intention to achieve this. By the way, the district officials also mentioned that lack of mental health awareness is common among different officials in todistrict. Psychotropic medications were not included in current drug list of todistrict. Eventually, a proper reporting framework with clear mental health indicators did not exist at district level. MhGAP does not provide guidance on how mental health care can be adapted to and integrated into primary care within a Ethiopian setting. Therefore this general lack of evidence on tofeasible, acceptable and effective ways of integrating and scaling up of mental health care is a reflection of complex nature of integration. I am sure that the integration of mental healthcare into primary care requires careful planning, stakeholder buy in, and active community participation. For the most part there’s a need for an innovative approach to plan, implement and evaluate integration of mental health care into primary care.

Accordingly the baseline situation in Sodo was discussed in all ToC workshops.

Few people known to seek care travelled to urban centres notwithstanding high costs of transportation and accommodation.

Most people with severe mental disorders in district were reported to was chained up or shackled in the premises, as identified in the course of the workshops.a regular practice is that they remain untreated or often receive existing coverage of mental health services in community was reported to be very low. It is strengthening existing community initiatives to increase mental health awareness and support persons with mental disorders was indicated as an important intervention to achieve these pre conditions.

Engaging with persons with mental disorders and their families in different community activities and providing community based rehabilitation were reported to be vital. Involvement of CBOs, FBOs and NGOs in different social and economic activities was reported to have a direct bearing on stigma reduction and promotion of social inclusion of people with mental disorders. Our workshops did not probe in to these directly, even though these factors play a key role in determining would have been ideal to understand some context specific factors. That said, we presented ToC as an independent approach to define and understand interventions of a complex nature, this is an important limitation. I’m sure you heard about this. In this study, we have not attempted to supplement ToC study with qualitative explorations. Whenever understanding what people in Sodo think about mental disorders, choices and decisions they make, economic constraints and broader ‘sociocultural’ factors are important for service planning, at more grass roots level.

Approach combines dynamic complexity of interventions within diversity of settings by taking in to account objective realities at to’grass roots’ level.

For work in Sodo district, ToC approach was found to be a very useful approach to elicit wide participation in planning mental health services.

In doing so, it also made mental health care plan of Sodo district more feasible and improved chance of it being effective and sustainable. ToC process played a key role in achieving political commitment and understanding awareness levels of various stakeholders involved in toworkshops. Besides, the current situation also indicated that HEWs did not have skills to detect and refer cases they suspected to be mental disorder. Whenever detecting relapse and providing family support, as stated in the course of the workshops, hEWs should be helpful in improving adherence. Keep reading! Provision of adherence support by families, HEWs and community volunteers was also suggested to strengthen service delivery. That’s interesting. To ensure a balanced representation of stakeholders in planning process. Three people groups were involved in toworkshop. Essentially, details of to’crosscountry’ ToC is described elsewhere. Now please pay attention. Expertise in this place of mental health care and social programmes; involvement with community as community members or community leaders, Participants of ToC workshops were selected purposively on basis of their involvement in mental health policy and service planning. Attempts were made to ensure fair representation of women in workshops and their participation throughout the discussions was highly encouraged. Conducted a situational analysis of health service context of district which included data on relevant context, mental health policies and plans, mental health treatment coverage, district level health services, community and monitoring and evaluation.

Findings from situational analysis and exploratory interviews suggested that there was no mental healthcare service in todistrict.

Such pics were recorded for further exploration after ToC process.

As a longterm outcome, programme aspires to see improvement in tohealth, social and economic status of people with priority disorders. By the way, the ToC workshops with community were aimed at filling out empty space between current state and longterm outcome with possible short term pre conditions, indicators and assumptions. You should take it into account. At throughout the workshop, differences in opinion and divergence in recommendations were observed. Fact, disagreements also emerged where there was lack of information. Although, in those cases, both ideas were forwarded to group for discussion until consensus was reached. Doesn’t it sound familiar? We established that findings of exploratory interviews regarding health service context of district were in line with health care system of country which is very much decentralised.

ToC workshop with policy makers allowed us to remember the broader national context similar to high degree of commitment of MoH to integrating mental health care into primary care.

Our ToC workshops also suggested that involvement of key policy actors in planning process has some added benefits.

In 2012, The Ethiopian MoH endorsed a national mental health strategy. Raised awareness at MoH was mentioned as having a direct impact on budget allocation and on inclusion of mental health in national Health Management Information System. Obtaining political buy in was mentioned as vital for development of a perfect MHCP. Strong community participation is also a key aspect in developing suitable interventions that bear in mind peculiarities of tosettings. Notice, active participation of multiple stakeholders in planning complex community interventions is important to increase effectiveness of interventions by creating a feeling of ownership. It’s an interesting fact that the ToC process considers togeographic, social and political context in which mental health care intervention will take place.

Burden of mental disorders on individuals and society in low income settings is substantial.

In some low income countries, nine in 10 individuals with a mental disorder do not access even basic treatment.

Mental health care is given minimal policy attention and human and organisational resources available are inadequate and inefficiently utilized. Numerous barriers to service provision remain unaddressed, albeit need for improving services is clear. At least one in 10 adults is affected by a mental disorder. Mental health treatment gap remains large, as a consequence. Accordingly the official language of district is Amharic. Open AccessThis article is distributed under terms of Creative Commons Attribution 0 International License, that permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to original author and tosource, provide a link to Creative Commons license, and indicate if changes were made. Now regarding aforementioned fact… Hundreds of population in district are from Gurage ethnic group and followers of Orthodox Christianity. That’s right! Creative Commons Public Domain Dedication waiver which are both geographically and climatically diverse. Key longterm outcomes described in ToC map relate to community pathways.

Reduced stigma in community or in work places were identified as both social and economic outcomes.

So it’s potentially because of direct impact of reduced stigma on social and economic conditions of people with mental disorders.

Improved outcome for individual patients and their families in these areas will represent both individual, family and community outcomes. Change in one is going to lead to change in toother, distinguishing between social and economic outcomes was considered difficult. Basically, maximum participants were based in todistrict, except participants of policy makers ToC workshop and PRIME team members. Now regarding aforementioned fact… Academic backgrounds of participants ranged from ‘non literate’ to higher level mental health professionals including clinical psychologists, public health professionals, social workers and psychiatrists. Most of the participants were working age adults.

Tal of 46 participants representing diverse stakeholders were involved in three ToC workshops.

Working with community based organisations, community leaders, teachers, health development army, other extension workers, traditional healers, nongovernmental organisations and faith based organisations was mentioned instrumental in achieving community level preconditions, intention to this end.

Sensitizing and engaging with broad range of community stakeholders was also mentioned essential, apart from reliance on HEWs for detection and referral. Did you know that the intervention by programme might lead to realisation of broader impact of toprogramme. Accordingly the impact of programme may be translated as a broader outcome for which programme shall not be held accountable for. Ceiling of accountability marks dividing line between specific longterm outcomes and broader impact of toprogramme. Demarcation between longterm outcomes and impact of programme is essential. PRIME gonna be held accountable for specific longterm outcomes only. Certainly, MHCP focused only on those activities that were feasible and affordable within constraints of funding by toMoH, despite these activities are important for successful rehabilitation programmes.

Supporting implementation of economic policies for persons with mental disorders and their families to improve their economic outcomes was emphasised as being essential for toMHCPs.

It was emphasised that district must encourage different development organisations to involve persons with mental illness in their activities.

Actually the importance of political commitment to support economic wellbeing of persons with mental illness and their families was also mentioned as significant. Allocation of budget, facilitation of resources and personnel for training, raised awareness and demonstration of political commitment were suggested as expected preconditions from district health care administration. You should take this seriously. Developing ‘nonstigmatising’ attitudes and engaging in advocacy initiatives which promote inclusion of persons with mental disorders in different social activities within and beyond district were also highlighted. Other studies have explored local terminologies and explanatory models of mental disorders. Generally, only severe mental disorders are considered as illnesses while milder forms of mental disorder, just like similar to Sodo district. We used ToC approach to develop a MHCP in a rural district in Ethiopia. Of course, theory of Change, a method employed in toplanning, implementation and evaluation of complex community initiatives, is an innovative approach that has potential to assist in development of a comprehensive mental health care plan, that can inform delivery of integrated care. For integrated care to achieve its goal, a clear understanding of organisational processes that can promote and hinder integration and delivery of mental health care is essential. This is tocase. Scaling up mental healthcare through integration into primary care remains main strategy to address extensive unmet mental health need in ‘low income’ countries. Besides, the work was part of a cross country study, Programme for Improving Mental Health Care which focuses on developing evidence on integration of mental health in to primary care. As a result, no part of interviews was used to supplement ToC approach.

They’ve been conducted just to learn the underlying situation in todistrict.

Exploratory interviews conducted did not follow typical qualitative interview approach.

By the way, the information provided was used to have a picture of health care situation of district only. Known ToC approach was found to be an important component in development of MHCP and to encourage broad political support for integration of mental health services into primary care. Method may have broader applicability in planning complex health interventions in low resource settings. Then the ToC approach has potential to be used as an important framework in developing mental health care plan in ‘low resource’ settings. Whenever explaining and articulating theory behind an intervention is a prerequisite for effective mental health care planning, for planning other complex interventions, meticulous thinking. Actually, developing a mental health care plan in these settings requires rigorous development of interventions and a broadbased support from community and policy makers. ‘followup’ interviews were needed to enhance understanding of some structural factors including HMIS.

For sake of example, quite a few questions raised about HMIS remain unanswered in the course of the workshop.

Approach hardly gives clear guide on every detail, nevertheless ToC workshops were extremely informative looking at the understanding how healthcare system works.

Besides, the ToC workshop is designed to be a consensus building exercise than a comprehensive data collection technique. Detailed data on any disagreements and resolutions were not captured. Reflection and ultimate consensus through resolution of differences. Although, employing workshops was also important to map out chain of inter dependent pre conditions necessary for delivery of mental health care. Primary aim of project is to provide a robust evidence base on how mental health care can be integrated into primary care in low resource settings. Before describing ToC study methods, we would start by defining ToC approach. I know that the Ethiopian team conducted Theory of Change workshops, as part of PRIME project undertaking. However, in Ethiopia, PRIME works to develop services for selected priority disorders comprising psychosis, depression, epilepsy and alcohol use disorders. Workshops were designed to see the complex interaction of contextual factors in delivery of mental health care.

I know that the ToC approach had been used rarely in mental healthcare planning. PRogramme for Improving Mental health carE is a cross country mental health services research initiative that includes Ethiopia, India, Nepal, South Africa and Uganda. Throughout the workshops, a map incorporating key agreed outcomes and outcome indicators was developed and finalized later. I know that the ToC participants were actively engaged in process and ToC encouraged strong commitment among participants. Nonetheless, four critical path dimensions were identified. Accordingly a tal of 46 persons participated in four ToC workshops. Now please pay attention. Key opportunities and barriers to implementation and how to overcome these were suggested. Now look, the mapping ok a causal sequence leading to longterm outcomes of toprogramme.

‘pre conditions’ on pathway to impact are mapped out, after defining status of how things operate before start of toprogramme.

a carer who was invited to policy makers workshop also did not attend.

To satisfaction of toinvestigators, input of participants was often original and detailed. It was necessary to provide a framework highlighting pathways developed by PRIME team, since ToC approach is a tally new concept for workshop participants.

Our primary intent was to engage service users from district who were accessing mental health care in a primary care facility throughout the time of tostudy. Of course, since mental health service was not available, we were unable to find such persons throughout the time of tostudy. Those service users whom we have invited from neighbouring district who were accessing care in a hospital did not show up due to an undisclosed reason.

Most of to problems that required their decision remained open for further exploration after toToC.

Thus, input of participants despite we have included community representatives as part of ToC process. Besides, the content is solely responsibility of authors and does not necessarily represent official views of tofunders. Consequently, PRogramme for Improving Mental health carE, funded by UK Department for International Development for benefit of LMIC. Of course four distinct dimensions comprising tocommunity, health care facility, district and higher level health care administration were identified. It’s an interesting fact that the longterm outcome of programme was established throughout the cross country workshop. Now look, the pre conditions at different levels are described below.

These included tocommunity, health facilities, district healthcare administrations and higher health care administration.

Achieving these pre conditions should lead to targeted long period outcome.

These different ‘preconditions’ were identified by stakeholders as essential milestones in path wards integrated mental health care at primary care level. Various distinct pre conditions were identified for these levels. For instance, later, it was presented as a discussion point throughout the incountry ToC workshops and approved by all stakeholders. Broader impact included a reduction in crime, domestic violence and unnatural deaths in tocommunity. You see, required ‘preconditions’ were mapped following three intervention lines. Ok, and now one of most important parts. So objective of this study is to report process of implementing ToC approach in developing mental health care plan. Usually, primary health care staff must also refer persons with mental disorders for communitybased support, including income generating activities, provide psychosocial support, assess social needs and provide recovery education.

Actually the key preconditions for clinical staff at facility level were attainment of adequate levels of competence in the event detection, treatment and monitoring of care and provision of inclusive care for persons with mental disorders. At facility level, it was recommended that health care staff should diagnose, treat, manage drug ‘side effects’, and support adherence. It’s an interesting fact that the development of a national mental health strategy is taken as indicative of political commitment of Federal MoH of Ethiopia. Hundreds of suggested outcomes at health care organisation level are about raising mental health awareness at health care organisation level and budget allocation.

Besides, the need for strong political commitment was also emphasised. At national level, national mental health strategy had been developed, endorsed and is pending its implementation. In present study, we report about testing its use as a viable strategy for developing a pragmatic, communitybased mental health care plan for Sodo district in Ethiopia. ToC approach can be used for planning, implementation and evaluation of complex interventions as it allows rigorous thinking and is an empowering approach that facilitates stakeholder participation starting from planning stage. For example, this paper describes process and effectiveness of ToC process in Ethiopia to formulate a comprehensive district mental health care plan. With all that said… Registration forms with basic information on education, work experience in relation to mental health were also administered to all participants. Minutes were captured by two PRIME staff members with a masters degree in social work. Minute takers were trained on basic concepts of ToC approach prior to toworkshops. Of course all workshops were audio taped and final minutes were checked against audio file for completeness. So, study also indicated that hazardous alcohol use is common with 22 dot 4percent prevalence.

So there’s a large treatment gap in Ethiopia for different mental disorders.

a study conducted in neighbouring district indicated that lifetime prevalence of schizophrenia is 5.

In another study conducted in Sodo, one month prevalence of common mental disorders for tomild, moderate and severe was 13 dot 8, 0 and 1 respectively. For example, most of us know that there are few studies carried out to determine prevalence of mental disorders in Sodo district, Southern Ethiopia. Make sure you drop a comment about it in comment section. C is displayed as a causal pathways map with a lot of key elements. C is a theory of how and why an initiative works which makes explicit to’shortand’ ‘mediumpreconditions’ and ‘long term’ outcomes required to achieve impact of a complex intervention. It’s a well-known fact that the 58 health posts in district are staffed by a pair of community health workers called health extension workers.

So there’re no mental health services in Sodo district, and primary care staff members receive very limited training in providing mental health care.

Lowest statutory healthcare facility is health post, located in any kebele or subdistrict.

Therefore the district has eight health centres, four of which are located within three district towns. Most people in district are within a hours’ walking distance of a health centre. You see, nearest general hospital which is also nearest psychiatric facility, is located in a neighbouring district in Butajira town, about 35 km from Bui, capital of Sodo district. Every health centre serves a population of about 2500040000 people. Usually, health outcome indicators listed were improvement in symptom levels and in functional status. A well-known fact that is. For all preconditions outlined in toToC, indicators were developed to enable a comprehensive evaluation of process of implementation and impact of toMHCP. Indicators were identified for to’longterm’ outcomes of improved health, social and economic outcomes for people treated by toMHCPs.

Additional facility and district level indicators of political commitment included appointment of a separate mental health professional at district level to coordinate mental health services in todistrict. Capacity building and ratification of policies for inclusion of people with mental disorders at different development activities were also mentioned as policy level indicators. By the way, the approach will not give a clear guideline as to how to adopt interventions for settings without doctors. There’s a need for special adaptation of MhGAP to work with other primary care workers like health officers and nurses, Therefore in case MhGAP interventions are to work in contexts where many of us know that there are no doctors. By the way, the mhGAP works best in health care settings where doctors are available. Usually, we strongly recommend ToC as an ol for understanding context Therefore a facilitator trained in use of ToC moderated toworkshops.

Major role of facilitator was to introduce and describe TOC approach, objectives of PRIME, and findings of initial situational analysis.

Throughout toworkshop, facilitator moderated discussions around ‘pre conditions’, indicators, assumptions and outcomes of tointervention. Actually the involvement of multiple stakeholders at different levels served as a pathway to elicit stakeholder buy in, helped planners to define assumptions from start of toprocess, and reduced uncertainties about toimplementation. Approach may serve as an important framework in identifying necessary and sufficient conditions to make intended long period outcomes of programme a reality. A well-known fact that is. Employing ToC approach to mental health care planning is an effective approach to developing a pragmatic and community based mental health care plan. I’m sure that the approach failed to capture pragmatic challenges that might emerge during implementation.