Prevalence and associated factors of common mental disorders in primary care settings in Sofala Province, Mozambique

BJPsych Open, Volume 9, No. 1, Year 2023

Interprétation

Background In Mozambique, the prevalence of common mental illness in primary care is not well established. Aims This study aimed to assess the prevalence of, and associated factors for, common mental illness in patients accessing primary care services in three Ministry of Health clinics in Mozambique. Method Adult patients were recruited from the waiting rooms of prenatal, postpartum and general out-patient consultations. A mental health professional administered a diagnostic interview to examine prevalence of major depressive disorder (MDD), generalised anxiety disorder (GAD), post-traumatic stress disorder (PTSD) and any substance misuse or dependence. Generalised linear mixed models were used to examine the odds of each disorder and sociodemographic associations. Results Of 502 patients interviewed, 74.1% were female (n = 372) and the average age was 27.8 years (s.d. = 7.4). Of all participants, 23.9% (n = 120) met diagnostic criteria for at least one common mental disorder; 8.6% were positive for MDD (n = 43), 13.3% were positive for GAD (n = 67), 4.8% were positive for PTSD (n = 24) and 4.0% were positive for any substance misuse or dependence (n = 20). Patients attending prenatal or postpartum consultations had significantly lower odds of any common mental disorder than patients attending out-patient primary care. Age was negatively associated with MDD, but positively associated with substance misuse or dependence. Conclusions Over 20% of patients attending primary care in Mozambique may have common mental disorders. A specific focus on patients attending general out-patient visits, young people for depression, and older people and men for substance misuse/dependence would provide a targeted response to high-risk demographics. In Mozambique, the National Mental Health Program is managed by the Department of Mental Health at the MoH. The community-based programme sees most patients at out-patient health units, which provide primary healthcare close to communities and places of residence. Programme activities occur at the district and provincial levels, and are reported vertically to the central Ministry. The MoH has prioritised its mental health programme since 1996, and has become a leader in mental healthcare in the Southern African region. Since 1996, the programme has focused on training mid-level mental health professionals, called psychiatric technicians. These providers can diagnose and treat major mental illnesses with a focus on psychopharmacology. In 2014, the Mozambican MoH accomplished their goal of placing at least one psychiatric technician at a primary care health facility within each of the 135 districts nationally.11,12 Challenges remain, however, as the majority of psychiatrists are located in the capital of Maputo, and the distribution of psychiatry technicians is also centred on urban areas, leaving many rural areas without access. Mozambique has an estimated population of 30 million,17 with 15 Mozambican psychiatrists (as of 2016)12 and 84 beds per 100 000 population available for in-patient mental health services via two psychiatric hospitals, as well as beds in general hospitals.14,18,19. Existing psychosocial support services are primarily focused on patients with HIV. This study was carried out in Sofala Province (Fig. 1), located in central Mozambique with a population of approximately 2.3 million according to the most recent census conducted in 2017. The official language is Portuguese, with Cisena and Cindau languages commonly spoken in rural areas. This province has a literacy rate of 56%, an infant mortality rate of 83 per 1000 live births, a life expectancy of 54 years (51 for men and 57 for women) and an HIV prevalence of 14%.20,21 According to statistical data from the Provincial Health Directorate, there are 166 health facilities in Sofala Province, of which 25 (15 percent) have trained mental health personnel. This team includes three psychiatrists, 29 clinical psychologists, 28 psychiatric technicians and one social worker.22 Beira City is the capital of Sofala Province and the second-largest city in Mozambique, with a population of approximately 500 000. Beira City has 13 primary care health facilities, one quaternary-level central hospital and several private health facilities. Dondo is the closest city to Beira (30 km away), and has 16 primary care health facilities serving a population of 180 000.23 In both Dondo and Biera City, general consultations, prenatal consultations and postpartum consultations make up the majority of visits to primary care facilities. This study was conducted in three health facilities: two in Beira City (Macurungo and Chingussura) and one in Dondo (Dondo health facility). We selected these facilities because: they had at least one psychiatric technician and one clinical psychologist; they were health units with a high flow of patients receiving general primary healthcare; they provided comprehensive maternal and child healthcare and they were representative of other urban and peri-urban primary health facilities in Mozambique. Political map of Mozambique, including provincial capital cities. Focal area of Beira City and surrounding Dondo highlighted by the box. The Mini International Neuropsychiatric Interview version 5.0 (MINI 5.0) is a short diagnostic interview developed for the ICD-10 (psychiatric disorders). Mozambique currently uses the ICD-10 classification system for the diagnosis and treatment of mental disorders. It can be administered in approximately 30–45 min by qualified technicians in the area of mental health.24 The MINI 5.0 includes a structured psychiatric interview for all CMDs, severe mental disorders, alcohol/drug misuse and suicidal ideation. Our team used the Brazilian Portuguese version of the MINI 5.0 as a starting point for adaptation to the Mozambican context. A group of local Mozambican mental health professionals (two clinical psychologists and three psychiatric technicians) was first recruited to collaboratively adapt the Brazilian MINI 5.0 to the Mozambican linguistic and cultural context, resulting in the MINI 5.0 MZ. The instrument was then coded in REDCap (version 6 for Windows; Vanderbilt University, Nashville, Tennessee, USA; https://www.project-redcap.org) for use on tablets by a local Mozambican study staff member. Following coding, the same group of mental health staff re-reviewed the MINI 5.0 MZ and focused on understanding, ease of use and logical sequence of questions. All mental health professionals in each health facility participating in the study attended a 2-day training on the correct use of the MINI 5.0 MZ, in which participants practiced administering and being screened with the MINI 5.0 MZ, and notes and revisions were made to improve the instrument. Trainings were led by study staff as well as Mozambican mental health professionals who were experts in administration of the instrument. Participants had one-on-one supervision by experts to ensure proper administration of the tool. Next, the MINI 5.0 MZ pilot was carried out, in which the instrument was tested for 4 days among primary care patients attending out-patient consultations at the Macurungo health centre in the city of Beira, under the supervision of study staff and trained experts. Patients who were administered the MINI 5.0 MZ in piloting were asked what they thought was the underlying meaning of each question, whether the question was obscure or inappropriate or difficult to understand and, if so, how they suggested improving each issue. Following cognitive interviews and the pilot implementation, the mental health professionals reviewed the cognitive interview data and engaged in a collaborative process of improving the MINI 5.0 MZ based on this feedback. Data collection took place from October 2018 to February 2019 at three MoH facilities in Sofala Province. Patients were excluded in cases where they had an acute health condition or disability that impeded their ability to complete the survey. Eligible patients were referred to a trained mental health professional (psychologist or psychiatry and mental health technician), who administered the MINI 5.0 MZ, and sociodemographic data were collected by trained data collectors. The MINI 5.0 MZ assessed the presence of MDD symptoms in the previous 2 weeks, GAD symptoms in the previous 2 weeks, PTSD symptoms in the previous month and alcohol and substance use in the previous 12 months. Administrators of the MINI 5.0 MZ were blinded to the responses of the patient on the sociodemographic information. Tablet-based REDCap software25,26 was used for data collection. Demographic and clinical characteristics were assessed, including age, gender, marital status, education, the reason for visiting the health facility, monthly income and HIV status. We calculated the prevalence of common mental health disorders by using the sociodemographic information administered by data collectors, with the MINI 5.0 MZ administered by psychiatric technicians and psychologists as the gold standard. Summary statistics for mental disorders were analysed by individual disorders, as well as by using the binary variable of ‘any common mental illness’ versus ‘no common mental illness’. CMDs analysed in the present study included major depressive disorder (MDD), generalised anxiety disorder (GAD), post-traumatic stress disorder (PTSD) and any substance misuse or dependence (including alcohol and/or drug use). Regression analyses examined unadjusted and adjusted odds ratios for each CMD diagnostic category. Generalised linear mixed models with a binomial distribution were utilised, including a random intercept by health facility to account for clustering. Adjusted analyses were fully adjusted for patient gender, the reason for health facility visit, marital status, education, HIV status and monthly income simultaneously in the statistical model. Stata software (version 16 for Windows) and an alpha value of 0.05 were used for all statistical analyses. All participants provided informed consent for research procedures. The informed consent process included the following procedure. Individuals interested in participation were directed by a research assistant to a private consultation room to administer the consent form. The form was read to the participant by the research assistant and a copy of the form was provided to the participant. Participants were given the opportunity to ask questions and efforts were made to ensure participants fully understood the research procedures. Participants were given the option to sign their name or provide a fingerprint if they could not sign. The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. All procedures involving human patients were approved by the Mozambican National Committee for Bioethics in Health (CNBS), whose code is IRB00002657, with the approval number 290/CNBS/18. Study procedures were also simultaneously approved by the University of Washington ethics review board.

Résumé de l’IA

Study Justification:

– The prevalence of common mental disorders in primary care settings in Mozambique is not well established.
– Understanding the prevalence and associated factors of common mental disorders is crucial for developing effective mental health interventions in primary care settings.
– This study aims to fill the gap in knowledge by assessing the prevalence and associated factors of common mental disorders in patients accessing primary care services in three Ministry of Health clinics in Mozambique.

Study Highlights:

– A total of 502 adult patients were interviewed, with 74.1% being female and an average age of 27.8 years.
– 23.9% of the participants met diagnostic criteria for at least one common mental disorder.
– The prevalence rates for specific disorders were: 8.6% for major depressive disorder, 13.3% for generalized anxiety disorder, 4.8% for post-traumatic stress disorder, and 4.0% for substance misuse or dependence.
– Patients attending prenatal or postpartum consultations had significantly lower odds of having a common mental disorder compared to patients attending general out-patient primary care.
– Age was negatively associated with major depressive disorder but positively associated with substance misuse or dependence.

Recommendations for Lay Reader and Policy Maker:

– Over 20% of patients attending primary care in Mozambique may have common mental disorders, indicating a need for increased attention to mental health in primary care settings.
– Targeted interventions should focus on patients attending general out-patient visits, young people for depression, and older people and men for substance misuse/dependence.
– Strengthening mental health services in primary care, particularly in rural areas, is crucial to ensure access to care for all individuals.
– Collaboration between the Ministry of Health, mental health professionals, and other stakeholders is essential for implementing and sustaining effective mental health interventions in primary care settings.

Key Role Players Needed to Address Recommendations:

– Ministry of Health: Responsible for overseeing and coordinating the implementation of mental health interventions in primary care settings.
– Mental Health Professionals: Including psychiatrists, clinical psychologists, and psychiatric technicians, who can diagnose and treat common mental disorders in primary care settings.
– Primary Care Health Facilities: Provide the platform for delivering mental health services and should have trained mental health personnel.
– Community Organizations: Play a role in raising awareness, reducing stigma, and providing support for individuals with common mental disorders.
– Non-Governmental Organizations: Can provide resources, training, and technical assistance to support the implementation of mental health interventions in primary care settings.

Cost Items to Include in Planning the Recommendations:

– Training and Capacity Building: Budget for training mental health professionals in the diagnosis and treatment of common mental disorders in primary care settings.
– Infrastructure and Equipment: Allocate funds for establishing and equipping mental health units in primary care health facilities.
– Medications and Supplies: Budget for the procurement and distribution of medications and supplies needed for the treatment of common mental disorders.
– Monitoring and Evaluation: Set aside resources for monitoring and evaluating the implementation and impact of mental health interventions in primary care settings.
– Awareness and Advocacy: Allocate funds for awareness campaigns and advocacy efforts to reduce stigma and promote mental health in the community.
Please note that the above cost items are general categories and the actual cost estimates would depend on the specific context and resources available in Mozambique.

Force de la preuve

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong, but there are some areas for improvement. The study provides a clear description of the methodology, including the sample size and diagnostic criteria used. The prevalence rates of common mental disorders are reported, along with associated factors. However, the abstract could be improved by providing more information on the representativeness of the sample and the generalizability of the findings. Additionally, it would be helpful to include information on the limitations of the study and suggestions for future research.

Abstrait

In Mozambique, the National Mental Health Program is managed by the Department of Mental Health at the MoH. The community-based programme sees most patients at out-patient health units, which provide primary healthcare close to communities and places of residence. Programme activities occur at the district and provincial levels, and are reported vertically to the central Ministry. The MoH has prioritised its mental health programme since 1996, and has become a leader in mental healthcare in the Southern African region. Since 1996, the programme has focused on training mid-level mental health professionals, called psychiatric technicians. These providers can diagnose and treat major mental illnesses with a focus on psychopharmacology. In 2014, the Mozambican MoH accomplished their goal of placing at least one psychiatric technician at a primary care health facility within each of the 135 districts nationally.11,12 Challenges remain, however, as the majority of psychiatrists are located in the capital of Maputo, and the distribution of psychiatry technicians is also centred on urban areas, leaving many rural areas without access. Mozambique has an estimated population of 30 million,17 with 15 Mozambican psychiatrists (as of 2016)12 and 84 beds per 100 000 population available for in-patient mental health services via two psychiatric hospitals, as well as beds in general hospitals.14,18,19. Existing psychosocial support services are primarily focused on patients with HIV. This study was carried out in Sofala Province (Fig. 1), located in central Mozambique with a population of approximately 2.3 million according to the most recent census conducted in 2017. The official language is Portuguese, with Cisena and Cindau languages commonly spoken in rural areas. This province has a literacy rate of 56%, an infant mortality rate of 83 per 1000 live births, a life expectancy of 54 years (51 for men and 57 for women) and an HIV prevalence of 14%.20,21 According to statistical data from the Provincial Health Directorate, there are 166 health facilities in Sofala Province, of which 25 (15 percent) have trained mental health personnel. This team includes three psychiatrists, 29 clinical psychologists, 28 psychiatric technicians and one social worker.22 Beira City is the capital of Sofala Province and the second-largest city in Mozambique, with a population of approximately 500 000. Beira City has 13 primary care health facilities, one quaternary-level central hospital and several private health facilities. Dondo is the closest city to Beira (30 km away), and has 16 primary care health facilities serving a population of 180 000.23 In both Dondo and Biera City, general consultations, prenatal consultations and postpartum consultations make up the majority of visits to primary care facilities. This study was conducted in three health facilities: two in Beira City (Macurungo and Chingussura) and one in Dondo (Dondo health facility). We selected these facilities because: they had at least one psychiatric technician and one clinical psychologist; they were health units with a high flow of patients receiving general primary healthcare; they provided comprehensive maternal and child healthcare and they were representative of other urban and peri-urban primary health facilities in Mozambique. Political map of Mozambique, including provincial capital cities. Focal area of Beira City and surrounding Dondo highlighted by the box. The Mini International Neuropsychiatric Interview version 5.0 (MINI 5.0) is a short diagnostic interview developed for the ICD-10 (psychiatric disorders). Mozambique currently uses the ICD-10 classification system for the diagnosis and treatment of mental disorders. It can be administered in approximately 30–45 min by qualified technicians in the area of mental health.24 The MINI 5.0 includes a structured psychiatric interview for all CMDs, severe mental disorders, alcohol/drug misuse and suicidal ideation. Our team used the Brazilian Portuguese version of the MINI 5.0 as a starting point for adaptation to the Mozambican context. A group of local Mozambican mental health professionals (two clinical psychologists and three psychiatric technicians) was first recruited to collaboratively adapt the Brazilian MINI 5.0 to the Mozambican linguistic and cultural context, resulting in the MINI 5.0 MZ. The instrument was then coded in REDCap (version 6 for Windows; Vanderbilt University, Nashville, Tennessee, USA; https://www.project-redcap.org) for use on tablets by a local Mozambican study staff member. Following coding, the same group of mental health staff re-reviewed the MINI 5.0 MZ and focused on understanding, ease of use and logical sequence of questions. All mental health professionals in each health facility participating in the study attended a 2-day training on the correct use of the MINI 5.0 MZ, in which participants practiced administering and being screened with the MINI 5.0 MZ, and notes and revisions were made to improve the instrument. Trainings were led by study staff as well as Mozambican mental health professionals who were experts in administration of the instrument. Participants had one-on-one supervision by experts to ensure proper administration of the tool. Next, the MINI 5.0 MZ pilot was carried out, in which the instrument was tested for 4 days among primary care patients attending out-patient consultations at the Macurungo health centre in the city of Beira, under the supervision of study staff and trained experts. Patients who were administered the MINI 5.0 MZ in piloting were asked what they thought was the underlying meaning of each question, whether the question was obscure or inappropriate or difficult to understand and, if so, how they suggested improving each issue. Following cognitive interviews and the pilot implementation, the mental health professionals reviewed the cognitive interview data and engaged in a collaborative process of improving the MINI 5.0 MZ based on this feedback. Data collection took place from October 2018 to February 2019 at three MoH facilities in Sofala Province. Patients were excluded in cases where they had an acute health condition or disability that impeded their ability to complete the survey. Eligible patients were referred to a trained mental health professional (psychologist or psychiatry and mental health technician), who administered the MINI 5.0 MZ, and sociodemographic data were collected by trained data collectors. The MINI 5.0 MZ assessed the presence of MDD symptoms in the previous 2 weeks, GAD symptoms in the previous 2 weeks, PTSD symptoms in the previous month and alcohol and substance use in the previous 12 months. Administrators of the MINI 5.0 MZ were blinded to the responses of the patient on the sociodemographic information. Tablet-based REDCap software25,26 was used for data collection. Demographic and clinical characteristics were assessed, including age, gender, marital status, education, the reason for visiting the health facility, monthly income and HIV status. We calculated the prevalence of common mental health disorders by using the sociodemographic information administered by data collectors, with the MINI 5.0 MZ administered by psychiatric technicians and psychologists as the gold standard. Summary statistics for mental disorders were analysed by individual disorders, as well as by using the binary variable of ‘any common mental illness’ versus ‘no common mental illness’. CMDs analysed in the present study included major depressive disorder (MDD), generalised anxiety disorder (GAD), post-traumatic stress disorder (PTSD) and any substance misuse or dependence (including alcohol and/or drug use). Regression analyses examined unadjusted and adjusted odds ratios for each CMD diagnostic category. Generalised linear mixed models with a binomial distribution were utilised, including a random intercept by health facility to account for clustering. Adjusted analyses were fully adjusted for patient gender, the reason for health facility visit, marital status, education, HIV status and monthly income simultaneously in the statistical model. Stata software (version 16 for Windows) and an alpha value of 0.05 were used for all statistical analyses. All participants provided informed consent for research procedures. The informed consent process included the following procedure. Individuals interested in participation were directed by a research assistant to a private consultation room to administer the consent form. The form was read to the participant by the research assistant and a copy of the form was provided to the participant. Participants were given the opportunity to ask questions and efforts were made to ensure participants fully understood the research procedures. Participants were given the option to sign their name or provide a fingerprint if they could not sign. The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. All procedures involving human patients were approved by the Mozambican National Committee for Bioethics in Health (CNBS), whose code is IRB00002657, with the approval number 290/CNBS/18. Study procedures were also simultaneously approved by the University of Washington ethics review board.

Matériaux

N/A

Innovations

Based on the provided information, here are some potential innovations that could improve access to maternal health in Mozambique:

1. Telemedicine: Implementing telemedicine services can help overcome the challenge of limited access to mental health professionals in rural areas. This technology allows pregnant women and new mothers to receive mental health support remotely through video consultations or phone calls.

2. Mobile Health (mHealth) Applications: Developing mobile applications that provide information, resources, and support for maternal mental health can help increase awareness and access to mental health services. These apps can offer self-help tools, educational materials, and even connect women to mental health professionals for virtual consultations.

3. Community Health Workers: Training and deploying community health workers who are specifically trained in maternal mental health can help bridge the gap in access to care. These workers can provide counseling, education, and support to pregnant women and new mothers in their communities.

4. Integration of Mental Health Services: Integrating mental health services into primary care settings, such as prenatal and postpartum clinics, can improve access to care. This approach ensures that mental health screening and support are routinely provided alongside physical health services, reducing stigma and increasing the likelihood of early detection and intervention.

5. Task Shifting: Expanding the roles of non-specialist healthcare providers, such as nurses and midwives, to include mental health screening and basic interventions can help increase access to care. By training these providers in mental health, more women can receive support during their routine visits to healthcare facilities.

6. Mobile Clinics: Establishing mobile clinics that travel to remote and underserved areas can bring maternal health services, including mental health support, directly to the communities that need them. These clinics can provide comprehensive care, including screening, counseling, and referrals for further treatment.

7. Public Awareness Campaigns: Launching public awareness campaigns to reduce stigma and increase awareness about maternal mental health can encourage women to seek help and access available services. These campaigns can use various media channels, including radio, television, and community outreach programs.

It is important to note that the implementation of these innovations should be done in collaboration with local stakeholders, healthcare providers, and policymakers to ensure cultural appropriateness and sustainability.

AI Innovations Description

Based on the provided information, here is a recommendation that can be developed into an innovation to improve access to maternal health:

1. Strengthening Mental Health Services in Primary Care: Given the high prevalence of common mental disorders among patients accessing primary care services in Mozambique, it is crucial to integrate mental health services into existing maternal health programs. This can be achieved by training primary care providers, such as midwives and nurses, to identify and manage common mental disorders during prenatal and postpartum consultations. Additionally, establishing referral pathways to mental health specialists for more severe cases can ensure comprehensive care for pregnant and postpartum women.

2. Telemedicine and Mobile Health Solutions: To address the challenge of limited access to mental health services in rural areas, innovative approaches such as telemedicine and mobile health solutions can be implemented. This would involve using technology to connect patients in remote areas with mental health professionals through virtual consultations. Mobile health applications can also be developed to provide mental health information, self-help tools, and support for pregnant women and new mothers.

3. Community-Based Mental Health Programs: Engaging the community in mental health promotion and prevention can help reduce the stigma associated with mental illness and improve access to care. Community health workers can be trained to provide basic mental health support, conduct awareness campaigns, and facilitate support groups for pregnant women and new mothers. This approach can help reach women who may not seek formal healthcare services due to various barriers.

4. Task-Shifting and Task-Sharing: To address the shortage of mental health professionals in rural areas, task-shifting and task-sharing strategies can be implemented. This involves training and empowering non-specialist healthcare providers, such as nurses and community health workers, to deliver basic mental health services. By expanding the workforce and redistributing tasks, more women can receive timely and appropriate mental health support.

5. Integration of Mental Health into Maternal Health Policies: It is essential to advocate for the integration of mental health into national maternal health policies and guidelines. This can help prioritize mental health within the healthcare system and ensure that adequate resources are allocated for its implementation. Collaboration between the Ministry of Health, mental health stakeholders, and maternal health organizations is crucial to drive policy changes and promote sustainable improvements in access to maternal mental health services.

By implementing these recommendations, Mozambique can improve access to maternal mental health services, reduce the burden of common mental disorders among pregnant women and new mothers, and ultimately contribute to better maternal and child health outcomes.

AI Innovations Methodology

To improve access to maternal health in Mozambique, here are two potential recommendations:

1. Strengthening Community-Based Maternal Health Programs: Implementing community-based programs that focus on maternal health can help improve access to care. These programs can include training community health workers to provide basic prenatal and postpartum care, conducting health education sessions in local communities, and establishing referral systems to ensure that pregnant women have access to appropriate healthcare facilities.

2. Telemedicine and Mobile Health Technologies: Utilizing telemedicine and mobile health technologies can help overcome geographical barriers and improve access to maternal health services. This can involve providing remote consultations and monitoring for pregnant women in rural areas, sending health-related information and reminders via mobile phones, and using telemedicine platforms to connect healthcare providers with pregnant women who are unable to travel to healthcare facilities.

Methodology to simulate the impact of these recommendations on improving access to maternal health:

1. Define the Parameters: Identify the specific indicators that will be used to measure the impact of the recommendations, such as the number of pregnant women accessing prenatal care, the number of women receiving postpartum care, and the reduction in maternal mortality rates.

2. Collect Baseline Data: Gather data on the current state of maternal health access in Mozambique, including the number of healthcare facilities, the availability of trained healthcare providers, and the utilization rates of maternal health services.

3. Develop a Simulation Model: Create a simulation model that incorporates the recommendations and their potential impact on improving access to maternal health. This model should consider factors such as the population size, geographical distribution, and existing healthcare infrastructure.

4. Input Data and Run Simulations: Input the baseline data into the simulation model and run multiple simulations to assess the potential impact of the recommendations. Adjust the parameters of the recommendations, such as the number of community health workers or the coverage of telemedicine services, to explore different scenarios.

5. Analyze Results: Analyze the results of the simulations to determine the potential impact of the recommendations on improving access to maternal health. This can include evaluating changes in the number of pregnant women accessing care, the reduction in maternal mortality rates, and the cost-effectiveness of the interventions.

6. Refine and Validate the Model: Refine the simulation model based on the analysis of the results and validate it using additional data and feedback from experts in the field of maternal health.

7. Policy Recommendations: Based on the findings of the simulations, develop policy recommendations for implementing the identified innovations to improve access to maternal health in Mozambique. These recommendations should consider the feasibility, scalability, and sustainability of the interventions.

Auteurs et co-auteurs

Statistics:

Authors: 6

Identifiers:

DOI: 10.1192/bjo.2022.613

Research Areas:

Community Interventions, Disability, Disparities, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Mental Health, Quality of Care, Social Determinants, Substance Abuse

Study Countries:

Mozambique

Study Design:

Cross Sectional Study, Ethnographic Study, Grounded Theory, Phenomenological Study

Study Approach:

Quantitative

Participants Gender:

Male & Female

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