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.
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