Background: Despite the movement in global mental health that advocates for task-sharing, few studies have investigated the experiences of facility-based counsellors (FBCs) who provide a psychosocial intervention for mental illness in primary healthcare. Project MIND, a cluster-randomized controlled trial at 24 primary healthcare facilities in the Western Cape, trained FBCs to deliver a threesession evidence-based intervention for patients with a common mental disorder. Therefore, project MIND presents an opportunity to address a gap in the literature by exploring the experiences and needs of FBCs delivering a psychosocial intervention. Aims & Objectives: The overall aim of this study is to explore the experiences of FBCs working on Project MIND in the dedicated (training and adding a counsellor to the chronic disease team) and designated (training and using existing counsellor from the chronic disease team) intervention arms. Specific objectives included: (1) exploring the barriers and challenges that FBCs experienced while delivering a psychosocial intervention; (2) exploring FBCs' perceptions of regular structured supervision, debriefing and in-service training for improving micro-counselling skills; and (3) eliciting suggestions from the FBCs for future scale up of counselling services in primary healthcare settings. Methods: A qualitative study was conducted among FBCs delivering the project MIND psychosocial intervention (N=18). All interviews were conducted by an independent qualitative interviewer in a private room at the primary healthcare facilities. Interviews were audio-recorded and transcribed verbatim. NVivo 12 was used to store data and facilitate analysis using the Framework Approach. Results: Findings of the study were grouped according to four main themes. The first theme focused on FBCs' perceptions of the benefits of the project MIND training. Several perceived benefits were reported such as having a better understanding about mental illness particularly depression, enhanced counselling skills and transferability of skills to other daily duties in the healthcare facility. Role-playing stood out as a key training component to assess counselling readiness. The second theme focused on barriers and facilitators related to the implementation of the project MIND intervention. Designated FBCs reported competing task demands as a barrier to implementing the MIND intervention compared to designated FBCs. Further, most designated counsellors reported feeling marginalized in the facility due to their lowly status. Other barriers reported which impacted on their motivation to implement the MIND intervention by both dedicated and designated FBCs were low remuneration, a lack of counselling space, and a lack of privacy and confidentiality. Regarding facilitators to implementing the MIND intervention, experiencing first-hand how well patients were able to solve some of their problems using the problem-solving method and taking responsibility for their health motivated FBCs to implement the MIND intervention. In addition, the MIND intervention aided FCBs with solving their own problems which enhanced their belief in the effectiveness of the intervention. The third theme dealt with how FBCs perceive the clinical supervision and debriefing provided by project MIND. Regular structured supervision, debriefing and in-service training delivered by a registered psychological counsellor, a novel approach, was perceived as beneficial to all FBCs as it provided them with a means to reassess and improve their counselling skills. Further, role-playing was reported as an effective method for rehearsing their counselling skills and enhancing quality of intervention delivery. Fidelity feedback through audio-recorded counselling sessions was highlighted as feasible. Considerations around space, location (distance), a lack of privacy, and scheduling were mentioned. The fourth and final theme focused on FBCs' recommendations for improving the project MIND training, supervision and debriefing model, and implementation. FBCs recommended that more time should be allocated for role-playing and skills rehearsal exercises during training to test their counselling skills and readiness. There were some suggestions that the amount of training hours per day should be reduced as it might aid FBCs to remain focused and retain information. Regarding supervision, a few FBCs recommended incorporating occasional peer group supervision and debriefing to benefit from shared experienced. Other recommendations were adding content related to substance use to the intervention and including management in training. Conclusion: Regular structured supervision, debriefing and in-service training provided by a Registered Counsellor are both feasible and beneficial for improving micro-counselling skills and the quality of intervention delivery among FBCs delivering a psychosocial intervention. Considerations for scaling up FBC-led psychosocial interventions should involve addressing barriers such as limited counselling space, remuneration, and marginalization.

Background: Drug use by young people is on the increase globally, regionally and locally, in Zimbabwe. Most of what is known about the risk and protective factors for drug use has been written from studies done in high income countries. Limited studies focused on the low to medium income countries. The available literature for Zimbabwe is a few quantitative studies, done nearly two decades ago. These might not still be relevant today because of the generational changes that have taken place in the society over time. Methods: A qualitative study was conducted in Mufakose, one of the low income high density suburbs of Harare, Zimbabwe. The aim of the study was to find out the reasons why young people in the community were using drugs while others within the same geographical area were not using. A purposive sampling method was used to recruit 40 young people aged between 18 and 24 years who were current drug users, past users and those who had never used drugs at all in their entire lifetime. Individual in-depth interviews and focus group discussions were conducted at two community centres in the community to elicit data from the participants. Data collected from the in-depth interviews and focus group discussions were analysed using NVivo using themes that were derived from literature. Results: Results showed that both risk and protective factors for drug use exist at three levels of human interaction: the micro, meso and macro levels. Micro level risk factors included stressors from the home or living arrangements or workplace, stress due to loss of a loved one, boredom due to unemployment and lack of activities, a lack of commitment to work, sport or school and one's beliefs. Meso level risk factors were exposure to the drug using behaviour by peers and bullying. At family level, exposure to drug use, family conflicts were reported as risk factors. At macro level, drug availability and cost and media influence were cited as risk factors for drug use among the group. For the protective factors leading to non-use, religion was the strongest protective factor at all the three levels. A commitment to work, sport or school was also protective at micro level. Non-exposure to drug using behaviour were protective at the meso level. Conclusion: The current social environment in Zimbabwe together with a breakdown of the country's institutions such as marriage due to death, divorce or migration to other countries. The breakdown has left some children in single parent families vulnerable to a life of drug use. Early initiation into drug use was reported to be through exposure from peers, families and other members of the community as young people in Mufakose are using drugs in-order to escape from the reality of life. Evidence based psychosocial interventions could be used to reduce the impact of drug use among this population.

Includes bibliographical references / Introduction: There is a large treatment gap for people with mental disorders in Africa and other low resourced countries, estimated to be between 70% and 90%. The treatment gap is mainly due to the lack of trained mental health professionals and inadequate mental health service resources in Africa. There has been a growing global movement championed by the World Health Organisation (WHO) to integrate mental health into primary health care as the most effective way of reducing this treatment gap. This study aimed to investigate the impact of WHO Mental Health Gap Action Programme (mhGAP) training and supervision on primary health workers' knowledge, attitudes, confidence and detection rate of major mental disorders in the district of Mulanje, Malawi. Method: The study was a quantitative evaluation using a quasi-experimental method (single cohort pre- and post-measures) and an interrupted time-series design. Forty-three primary healthcare workers from Mulanje, Malawi completed pre- and post- training questionnaires assessing knowledge, attitudes and confidence regarding the assessment and management of major mental disorders. Rates of diagnosis of major mental disorders were obtained from clinic registers for 5 months prior to and 7 months following training. Results: The results showed a significant change on knowledge and confidence scores but not attitudes. The mean knowledge score showed a statistically significantly increase from 11.8 (standard deviation [SD]: 0.33) before training to 15.1 (SD: 0.38) immediately after training; t(42) = 7.79, p <.01. Mean knowledge score was also significantly higher six month post training (13.9, SD: 2.52) than before training; t(42) = 4.57, p < .01. Similarly, the mean confidence score increased significantly from 39.9 (SD): 7.68) before training to 49.6 (SD: 06.14) immediately after training; t(84) = 8.43, p <.01. Mean confidence score was also significantly higher six month post training (46.8, SD: 6.03) than before training; t(84) = 6.60, p <.01. There was no overall significant difference in mean CAMI scores before, immediately after and 6 months after training in all four of the CAMI components. The F-test statistic and P-value for Authoritarianism, Benevolence, Social Restrictiveness and Community Mental Health Ideology were: F2, 126, 0.05 = 2.5; p =.09, F2, 126, 0.05 = 0.1; p =.9, F2, 126, 0.05 = 0.03; p = 1.0 and F2, 126, 0.05 = 0.04; p = 1.0, respectively. In the months January to May 2014 (before training), median number of cases per month was 77 (inter quartile range [IQR]: 65-87) whereas after training (months June to December) median number of cases was 186 (IQR: 175-197) showing a significant increase in median number of cases before and after the training; p =0.001. Conclusion: The results show clear improvements in the knowledge, confidence and detection of severe mental illness in primary care in Mulanje and demonstrate the potential for narrowing the treatment gap by rolling out mhGAP training nationally in Malawi. The findings of this study add to the growing evidence for policy makers of the effectiveness of mental health training and supervision of primary care workers in a resource-constrained country. Further research is needed to evaluate factors that may lead to change in health worker attitudes, to evaluate training and supervision programmes using more robust evaluation designs, such as randomised controlled trials, and to assess the scale up of mhGAP programmes at larger population levels.

Background: Common mental disorders, which account for a major proportion of disease burden globally, can have an onset in childhood and adolescence. The Friendship Bench is a psychosocial intervention aimed at reducing and treating common mental disorders and is provided at 42 City health department clinics in Harare, Zimbabwe. Yet research and anecdotal evidence suggests that adolescents do not remain engaged in this intervention. Reasons for lack of engagement often include demographic, psychosocial, logistical and cultural factors. Understanding the barriers and facilitators to retention amongst adolescents would help to improve retention and mental health outcomes among this vulnerable population. The aim of this study is to explore the barriers and facilitators that adolescents with common mental disorders experience in retention to the Friendship Bench. Methods: A qualitative study was conducted among adolescents who were aged 15-17 years at the time of accessing the Friendship Bench service. Twelve adolescents who visited the Friendship Bench between June 2016 and December 2017 were recruited using purposive sampling. Theoretical saturation was not reached due to recruitment barriers. The adolescents were recruited from five primary care clinics which were selected based on ease of access to the researcher. Semi-structured interviews with open-ended questions were employed to explore the barriers and facilitators adolescents faced in accessing the service, guided by Andersen’s Behavioural Model of Health services use. The interviews were conducted in a space convenient to the participant or at the participant’s local clinic grounds, and they lasted approximately 30 minutes. The adolescents were interviewed by two qualitative researchers and given the option on whether to be interviewed in Shona or English. Data was analysed using thematic analysis with NVivo 12. Results: Barriers to returning to the service included lack of privacy, school or work commitments, poor social support systems, and lack of a nearby clinic, resulting in having to travel far to access clinic services. Some participants who felt better saw no need to continue coming for sessions. Other emerging barriers found included lay health workers’ (LHWs’) attributes and forgetfulness. Important facilitators to retention included knowledge of what depression is, family support, experience with depressive symptoms, a nearby clinic, having other reasons to visit the clinic, and LHW attributes. Discussion: Given the study’s findings, it is recommended that mobile Friendship Benches and phonebased counselling applications be introduced, in addition to recruiting younger LHWs and male LHWs in order to improve retention. Provision should be made to locate Friendship Benches in more private or youth friendly spaces, to raise awareness on mental health issues in schools and communities and to involve parents and caregivers in the intervention development process. Further investigation into barriers and facilitators into psychosocial interventions is required, particularly with LHWs in order to get their perspective. Conclusion: By identifying barriers and facilitators that adolescents experience, this study contributes towards improving access and retention of adolescents to the Friendship Bench, as well as other psychosocial interventions aimed at adolescents in Zimbabwe.

Includes bibliographical references / Introduction: Mental health of Ugandans could be improved through mainstreaming the services into primary care systems. Nurses constitute a high percentage of the workforce in health; therefore they can significantly contribute towards several experiences by patients with mental illness. Stigma towards mental illness and individuals living with mental illness is among the major hindrances to effective mental health service delivery amongst healthcare workers. Therefore it is important for stigma to be explored among general nurses as mental health services are being integrated into the primary health care. The aim of this study was to explore stigma among general nurses towards mental illness and individuals living with mental illness. Methods: This was a cross-sectional quantitative study. Self-administered questionnaires were distributed to nurses working in Amolatar district health facilities that measured knowledge, attitudes and behaviour towards individuals living with mental illness, in addition to their familiarity with a person with mental illness. Descriptive statistics were used to determine the extent to which stigma was reported in this population. Bivariate and multivariate analyses were done using linear and logistic regressions to identify the predictors of the knowledge, attitudes and behaviours of nurses regarding mental illness and individuals living with mental illness. Results: Sixty-three general nurses participated in the study. Most of the participants identified schizophrenia as an SMI, however 79% considered stress to be mental illness and only a quarter of respondents scored above 80% on knowledge about mental illness. Most of the participants believed that psychotherapy was the most effective treatment for mental disorders. The nurses were benevolent (mean 3.06, s.d 0.29) and showed acceptance towards mental health services and individuals living with mental illness in the community (mean 3.56, s.d 0.30) however the nurses tended towards authoritarianism (mean 3.74, s.d 0.34) and social restrictiveness (mean 2.98, s.d 0.27). Level of contact with individuals living with mental illness predicted community mental health ideology and authoritarianism. No demographic variables were associated with level of knowledge using MAKS score and intended behaviour using RIBS tool. Conclusion: This study has provided some of the first data on stigma among primary health care nurses towards people with mental illness in Uganda and has added to knowledge of stigma towards people with mental illness by health care providers in LAMIC. Many of the findings were positive and bode well for the planned integration of mental health in primary health care. The negative findings of this study have shown that there are many areas for improvement which could be tackled by interventions such as public and community education, and in-service training regarding causes and management of mental disorders. Further research could be done to understand more about the negative attitudes found in many LAMIC.

Background: Research predominantly from high income countries suggests that depression and anxiety are highly prevalent among prison inmates. With limited available research from low and middle income countries, this study aimed to estimate the prevalence of possible anxiety and depression among Malawian inmates and identify factors associated with these conditions. Methods: This cross-sectional study was conducted at Thyolo prison situated in the southernmost region in Malawi, from February to March 2018. A total of 378 male prison inmates were interviewed face-to-face using a general questionnaire examining sociodemographic characteristics, prisoners’ previous and current involvement with the prison services, and self-reported mental health problems. Validated screening instruments were used, including the Center for Epidemiologic Studies Depression scale (CES-D) to measure depression; while the Beck Anxiety Inventory (BAI) was used to measure symptoms of anxiety. Multiple logistic regression analyses were conducted to determine the association between anxiety, depression and related variables. Results: The prevalence of possible anxiety disorder and depressive disorder was 62.7% and 72.5% respectively. After adjusting for the effects of the other variables in the model, a multiple logistic regression found that anxiety was significantly associated with no support (AOR 1.65 95% CI: 1.02-2.66) and a previous mental disorder diagnosis prior to imprisonment (AOR 2.07 95% CI: 1.05-4.07); while depression was significantly associated with no support (AOR 5.19 95% CI: 2.66-10.14), and having two or more traumatic events (AOR4.30 95% CI 1.65-11.23). However, being divorced (AOR 0.12, 95% CI: 0.04-0.35) was found to be a protective factor for depression. In addition to this, no support (AOR 2.24 95% CI: 1.36-3.69) and a previous mental disorder diagnosis prior to imprisonment (AOR 2.10 95% CI: 1.05-4.22) were significantly associated with comorbid depression and anxiety. Conclusion: This study provided valuable insights into the prevalence and risk factors associated with possible depression and anxiety among prison inmates in Malawi. Therefore, regular screening of prison inmates for early detection and treatment of mental disorders would be beneficial to improve the quality of life of prison inmates.

Background The assessment of a patient's individual needs offers many benefits and it is essential for planning and implementing services and interventions. Need is a subjective concept and may be defined from several perspectives. Patient, carer and staff interests may differ, influencing their perspectives in defining needs. Traditionally, the staff perspective on needs has taken priority but the steady growth of the 'user movement' and 'recovery philosophy' has led to this being challenged. This study aimed to establish patient, carer and staff perceptions of patient need, the extent to which these perceptions were homo- or heterogeneous, and what factors were associated with local perceived needs. Methods The study was informed by a systematic review of the literature focused on the individual needs of people with severe mental illness assessed from multiple perspectives. Patients, carers and staff on the Valkenberg Hospital assertive community treatment (ACT) service were assessed using the Camberwell Assessment of Need Short Appraisal Schedule to evaluate needs. Patient global functioning and current levels of psychopathological symptoms were assessed using the Global Assessment of Functioning scale and the Positive and Negative Syndrome Scale respectively. Kappa statistics were computed to assess agreement in the participants' perspectives.

Background: Intimate partner violence (IPV) during pregnancy is a common phenomenon across the world. The present study sought to determine the prevalence and predictors of intimate partner violence among pregnant women attending a midwife and obstetrics unit in the Western Cape. Methods: A convenience sample of a hundred and fifty pregnant women (n= 150) attending antenatal appointments at the Mitchell's Plain Midwife and Obstetrics Unit (MOU) were asked to participate in this study. Consenting women participated in an interview where they were asked questions concerning interpersonal violence and other psychosocial constructs, such as history of childhood trauma, exposure to community violence, depressive symptoms and alcohol use. Frequency distributions and descriptive statistics were calculated for categorical and continuous variables. Multivariable logistic models were developed to control for socio-demographics and psychosocial constructs. The first model was based on report of any form of IPV over the previous 12 months, while the remaining three models investigated the disaggregated forms of IPV: physical abuse, sexual abuse and emotional abuse. Results: Overall, the lifetime and 12-month prevalence rate for any IPV was 45% and 32%, respectively. For 12-month IPV, 32% reported general abuse, 29% physical and 20% reported being sexually abused. After adjusting for the effects of the other variables in the model, depressive symptoms, and reporting that this pregnancy was unplanned were significantly associated with the reporting of any IPV in the past 12 months. Looking specifically at 12 months general IPV, women who had depressive symptoms were more likely to experience some form of general IPV (OR= 6.42, CI 2.51-16.41) than women not at risk. Also, women of 'coloured' race were more likely to experience general IPV than Black African respondents (OR= 1.46, 95% CI 0.64-3.34). The model exploring associations for 12-month physical IPV found women who were at risk for depression were more likely to experience physical IPV (OR= 4.42, CI 1.88-10.41) than women not at risk, while the model exploring associations for 12-month sexual IPV found that women who reported experiencing community violence were more likely to report sexual IPV than women who reported no exposure to community violence (OR= 3.85, CI 1.14-13.08). Conclusion: This is the first study, which illustrates high prevalence rates of IPV among pregnant woman at Mitchells Plain MOU. A significant association was found between 12-month IPV and unintended pregnancy. Also, woman who are at risk for depression were found to have an increased chance of experiencing both general and physical IPV. Sexual IPV was associated with high levels of exposure to community violence. Further prospective studies in different centres are needed to address generalisability and the effect of IPV on maternal and child outcomes. Greater recognition of IPV in pregnancy could contribute to improved antenatal care, as well as enhanced policy development for appropriate intervention strategies. Key Words: Intimate partner violence; Interpersonal violence; Domestic violence; Abuse; Pregnancy; Antenatal; Postnatal depression and Community violence

Includes abstract. / Includes bibliographical references. / Electroconvulsive therapy (ECT) involves the administration of an electrical current to the brain in order to produce a tonic-clonic seizure which is deemed therapeutic. It is an effective and safe procedure for the treatment of severe mental illnesses such as major depression, mania and schizophrenia. Currently little is known about the characteristics of ECT practice in South Africa. This study aims to determine current electroconvulsive therapy (ECT) practice and to compare it with reported ECT practice internationally. This is a retrospective, descriptive study, to determine the characteristics of ECT practice in South Africa; data was collected using a self-report questionnaire. The study population consisted of doctors and nurses who practiced ECT in any 12 month period between 2011 and 2012. Both private and state facilities were included in the study. Initially contact was made with hospital mental health facilities to ascertain whether an ECT machine was present on site. Once formal approval was obtained from the appropriate designated bodies, questionnaires were sent to clinical staff involved in ECT at active sites. The 36-item questionnaire covered relevant questions on: utilization rates, equipment, staffing, practice and monitoring parameters, and indications for use. Forty two institutions had an ECT machine on site, of which thirteen institutions reported non-use. Questionnaires were sent to the 29 active ECT sites. Facilities responding to the questionnaire amounted to 83% (n=24), but of these, 21 units responded to the ECT utilization questions. ECT is performed as a modified procedure in six provinces by psychiatrists, registrars, medical officers and general practitioners. In-and outpatient ECT is offered in 79% (n=19) of hospitals. The number of persons treated with ECT/10 000 population per year (ppy) is 0.22 while the number of ECT procedures/10 000 ppy is 1.19. More patients in the private sector receive ECT as a treatment modality than in the public sector (U = 22, p = 0.045). ECT is performed in a minor theatre/operating room in 79% of units, while the rest is performed in a treatment room. All but one unit had a separate recovery room. Informed consent or assent was used in all institutions. Pre-ECT work-up most commonly involved a physical examination (95.5%, n = 21) and basic blood work investigations (87%, n=20). Bilateral, unilateral and bifrontal electrode placements are used, while various dosage- determination and monitoring methods are employed. The vast majority of patients (89.22%, n=869) receiving ECT are between the ages of 18 and 59. The most common indication for ECT is depression (84.77%, n=796). The utilization rate in South Africa is similar to that of countries like Bulgaria, Poland and India, but less than that of some high-income countries. Even though ECT practices in South Africa generally follow international guidelines, standardisation of practice is still recommended.

Background: More than 13% of the global burden of disease is estimated to be due to neuropsychiatric disorders, with over 70% of this burden in low- and middle-income countries. Characterised by severe shortages of human and material resources, formal mental health services alone are inadequate to meet the burden of mental disorders in low- and middle-income countries. New community models and innovative ways of increasing community participation and systematic delegation of specific tasks to other community level professionals have been recommended. Available evidence documents historic clergy involvement in health and wellbeing issues, but they have rarely been viewed as a partner in community mental health care. Aim: This study examines the clergy's conception, recognition of and responses to people with mental illnesses. The purpose of the study is to inform the potential roles and contributions of the clergy to community mental health either as the only contact or as a step in to formal mental health care. Method: Twenty eight in-depth interviews were conducted with clergy from ten church denominations in Harare, Zimbabwe. A framework analysis approach was used for thematic analysis. Nvivo 10 qualitative data software was used to organise the data. Results: Mental illness was conceived as a multifactor phenomenon attributed to both natural (biological and psychosocial) and supernatural (malevolent and benevolent spiritual) causes. Spiritual factors were a dominant theme in both the clergy's views on the causes of, and in their management of mental illness. The clergy were regularly consulted on a variety of emotional and psychological problems. Assistance was readily provided for these problems by all denominations, despite professed capacity gaps in the recognition and management of mental illness, and lack of appropriate training in basic mental health issues. Basic mental health training was recommended by the clergy to enhance clergy capacity for mental health awareness raising, recognition of mental disorders, brief problem focused counseling, and for improving collaborative management for initial and continued informal and formal health care and support. Implications of clergy conceptions, current responses and the perceived role of the church in community mental health are discussed.