Perinatal mental health care in a rural African district, Uganda: A qualitative study of barriers, facilitators and needs

BMC Health Services Research, Volume 16, No. 1, Year 2016

Interpretation

Background: Perinatal mental illness is a common and important public health problem, especially in low and middle-income countries (LMICs). This study aims to explore the barriers and facilitators, as well as perceptions about the feasibility and acceptability of plans to deliver perinatal mental health care in primary care settings in a low income, rural district in Uganda. Methods: Six focus group discussions comprising separate groups of pregnant and postpartum women and village health teams as well as eight key informant interviews were conducted in the local language using a topic guide. Transcribed data were translated into English, analyzed, and coded. Key themes were identified using a thematic analysis approach. Results: Participants perceived that there was an important unmet need for perinatal mental health care in the district. There was evidence of significant gaps in knowledge about mental health problems as well as negative attitudes amongst mothers and health care providers towards sufferers. Poverty and inability to afford transport to services, poor partner support and stigma were thought to add to the difficulties of perinatal women accessing care. There was an awareness of the need for interventions to respond to this neglected public health problem and a willingness of both community- and facility-based health care providers to provide care for mothers with mental health problems if equipped to do so by adequate training. Conclusion: This study highlights the acceptability and relevance of perinatal mental health care in a rural, low-income country community. It also underscores some of the key barriers and potential facilitators to delivery of such care in primary care settings. The results of this study have implications for mental health service planning and development for perinatal populations in Uganda and will be useful in informing the development of integrated maternal mental health care in this rural district and in similar settings in other low and middle income countries. A qualitative study was conducted using focus group discussions and key informant interviews. This was necessitated by the paucity of qualitative enquiry into care, user and providers’ attitudes, experiences and suggestions pertaining to perinatal mental health care in Uganda. In particular, for the Ugandan setting, it was considered critical to understand the rich perspectives of these key stakeholders in order to inform the future development of responsive and relevant services for the PRIME study. The study was carried out in Kamuli district in Eastern Uganda, 140 kilometers from the capital city, Kampala. The district is a densely populated, multi-cultural farming community with a population of nearly 500,000 people. Most people are ethnically Basoga although there are other tribes such as the Bagwere, Baganda and Balamogi. The majority of the population is engaged in subsistence farming. The literacy rate is lower than the national average of 78 % [24]. The health system consists of two district hospitals (one public and another private) and 64 primary health care centers (PHCs) with varying levels of care. The health facilities are graded as health center (HC) I, II, III and IV. The district hospitals serve as the referral points for the lower health centers. The HC IV (Health sub district) and HCIII all have a maternity unit in a building separate from the general health clinics, but within the same compound. The maternity units are staffed with midwives who are the main health care providers for perinatal women. All perinatal women are triaged through the outpatient departments of health facilities to the maternity units. Both antenatal and postnatal services are provided at the maternity units. Male partners are encouraged to attend antenatal and postnatal sessions with the pregnant women. At the community level there is a HC II within each parish which serves a number of villages. This is a general outpatient unit that has no maternity unit and, at times, no midwife. At the lowest level (which is HC I) within each village, volunteers from within the community are nominated by members of the community to form Village Health Teams (VHTs). These VHTs are entrusted with taking care of health matters of the village where they live, and they mobilize people for health programs as well as identify and refer individuals who need care. There is no built structure at this level and there are no qualified health staff. The Kamuli district has only one psychiatric clinical officer (equivalent of a nurse practitioner or nurse prescriber) and a handful of psychiatric nurses. These are all based at the only public hospital and largely work in non-mental health clinics, leaving most of the district with no access to psychiatry personnel. Perinatal women with mental illness are only identified if they are severe enough to be psychotic or suicidal, in which case they are not treated but immediately referred to the regional hospital in the neighboring district of Jinja, sixty kilometers away. Depression and other common mental disorders normally remain undetected and untreated at the primary care level. Study participants consisted of Village Health team members (VHTs), pregnant and postpartum women (within one year of delivery), midwives, general nurses and health managers (Table 1). The district mental health coordinator purposively recruited VHT members from across the district to include those that were most active and likely to have the most knowledge about the health system and community. Twenty VHTs were recruited in two groups of ten. The pregnant and postpartum mothers were recruited from the maternity clinic of the district hospital. Four focus groups were conducted, each with 12 perinatal women. A facilitator presented an overview of the research program and focus group procedures in the hospital’s waiting area, just before the antenatal/postnatal clinic started. Women who were willing to participate were selected by the triage nurse and organized into groups where verbal consent was sought. Eight key informant interviews were conducted with health managers, midwives and general nurses from a wide range of health facilities within the district. Demographic characteristics of participants Focus groups were conducted in the month of May 2013. Each focus group lasted approximately 90 min and was audio taped. Two facilitators (DK or JN) led the groups, one of whom led the discussion while a second person (an assistant) took notes and recorded the proceedings. The facilitators were graduate specialists in mental health who had experience in conducting focus group discussions and key informant interviews. DK had just completed her PhD thesis using qualitative methods and helped to train the assistants in focus group methodology and note taking. Both facilitators worked at the national referral and teaching psychiatric hospital. The assistants were social worker volunteers with a temporary placement at the Kamuli General Hospital. An interview guide was used to guide each focus group discussion and key informant interview (Table 2). The interview guide was developed jointly by the authors (JN, DK, JS, FK. SH and CH). Structured, open-ended questions with guided prompts were developed, based on the existing literature and authors’ experience. The core topics for the focus group interviews were (1) barriers and facilitators to accessing mental health care, (2) knowledge and attitudes towards maternal mental disorders, (3) services available for mothers with mental disorders, (4) identified needs for service for maternal mental disorders, (5) feasibility and acceptability of interventions for maternal mental health care and (6) recommendations. The key informant interviews addressed mainly informants’ perception of the problem of maternal mental disorders in the district; causes; existing capacity to detect and manage maternal mental disorders; feasibility of screening; what mental health interventions can feasibly be integrated into maternal health services; availability of supervision for maternal health services; services currently being offered; mechanisms for referral of mothers with mental disorders; existing needs with regard to maternal mental health care; challenges existing or envisaged. Focus group and key informant interview guide Data were analyzed using the thematic analysis method [25]. Data were transcribed verbatim in the Luganda language and the transcripts were then checked against the audiotapes and scripts. Transcripts were then translated into English and back translated into Luganda by two bilingual authors (JN and DK) to ensure linguistic equivalence. The analyses were performed with the help of qualitative software (Atlas.ti version 6.1) [26]. Both the focus group and key informant data were analyzed together. Two of the authors (JN, EO) independently read through different transcripts each, formulated codes guided by predefined themes in the interview guide as well as by the issues emerging from the data. The two authors met and discussed the codes and emerging themes from the transcripts. A codebook was formulated from the agreed codes and code definitions. One author (EO) then read and coded all of the interview transcripts. After coding, data segments corresponding to major themes were retrieved using Atlas.ti. The retrieved segments of coded data were shared among the authors. Each author read segments allocated to them and wrote memos describing their understanding of what the data said in relation to the study objectives. Finally, data were explored to identify key themes and relationships between themes. This approach was intended to facilitate innovative ways of looking at the data. The study was approved by the School of Medicine Research and Ethics committee (SOMREC), Makerere University College of Health Sciences, and the Uganda National Council of Science and Technology (UNCST). Permission to conduct the formative work of the Program for Improvement of Mental Health care (PRIME) in Uganda, a multi country research consortium, was obtained from District administration. Verbal group consent was obtained at the beginning of each group discussion and written individual consent before each in-depth interview.

AI Digest

Study Justification:

– Perinatal mental illness is a common and important public health problem, especially in low and middle-income countries.
– There is a need to explore the barriers and facilitators to delivering perinatal mental health care in primary care settings in low-income, rural districts.
– Understanding the perceptions and experiences of key stakeholders is crucial for informing the development of responsive and relevant services.

Study Highlights:

– Participants identified an important unmet need for perinatal mental health care in the district.
– Significant gaps in knowledge about mental health problems and negative attitudes towards sufferers were observed.
– Barriers to accessing care included poverty, lack of transportation, poor partner support, and stigma.
– Both community- and facility-based health care providers expressed willingness to provide care if adequately trained.
– The study highlights the acceptability and relevance of perinatal mental health care in a rural, low-income country community.

Study Recommendations:

– Develop interventions to respond to the unmet need for perinatal mental health care.
– Provide adequate training for health care providers to deliver mental health care.
– Address the barriers to accessing care, such as poverty, transportation, and stigma.
– Integrate maternal mental health care into primary care settings.
– Use the study findings to inform mental health service planning and development for perinatal populations in Uganda and similar settings in other low and middle-income countries.

Key Role Players:

– Village Health Teams (VHTs)
– Pregnant and postpartum women
– Midwives
– General nurses
– Health managers

Cost Items for Planning Recommendations:

– Training programs for health care providers
– Transportation services for perinatal women
– Community awareness campaigns
– Development of integrated maternal mental health care services
– Supervision and support for health care providers
– Infrastructure improvements for primary health care centers
– Mental health resources and supplies

Strength of Evidence

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is based on a qualitative study that used focus group discussions and key informant interviews. The study provides detailed information about the barriers and facilitators to perinatal mental health care in a rural district in Uganda. The study also highlights the acceptability and relevance of perinatal mental health care in the community. However, the evidence could be strengthened by including information about the sample size, recruitment process, and data analysis methods. Additionally, the abstract could provide more specific details about the key themes that were identified and the implications of the study findings for mental health service planning and development in Uganda.

Abstract

A qualitative study was conducted using focus group discussions and key informant interviews. This was necessitated by the paucity of qualitative enquiry into care, user and providers’ attitudes, experiences and suggestions pertaining to perinatal mental health care in Uganda. In particular, for the Ugandan setting, it was considered critical to understand the rich perspectives of these key stakeholders in order to inform the future development of responsive and relevant services for the PRIME study. The study was carried out in Kamuli district in Eastern Uganda, 140 kilometers from the capital city, Kampala. The district is a densely populated, multi-cultural farming community with a population of nearly 500,000 people. Most people are ethnically Basoga although there are other tribes such as the Bagwere, Baganda and Balamogi. The majority of the population is engaged in subsistence farming. The literacy rate is lower than the national average of 78 % [24]. The health system consists of two district hospitals (one public and another private) and 64 primary health care centers (PHCs) with varying levels of care. The health facilities are graded as health center (HC) I, II, III and IV. The district hospitals serve as the referral points for the lower health centers. The HC IV (Health sub district) and HCIII all have a maternity unit in a building separate from the general health clinics, but within the same compound. The maternity units are staffed with midwives who are the main health care providers for perinatal women. All perinatal women are triaged through the outpatient departments of health facilities to the maternity units. Both antenatal and postnatal services are provided at the maternity units. Male partners are encouraged to attend antenatal and postnatal sessions with the pregnant women. At the community level there is a HC II within each parish which serves a number of villages. This is a general outpatient unit that has no maternity unit and, at times, no midwife. At the lowest level (which is HC I) within each village, volunteers from within the community are nominated by members of the community to form Village Health Teams (VHTs). These VHTs are entrusted with taking care of health matters of the village where they live, and they mobilize people for health programs as well as identify and refer individuals who need care. There is no built structure at this level and there are no qualified health staff. The Kamuli district has only one psychiatric clinical officer (equivalent of a nurse practitioner or nurse prescriber) and a handful of psychiatric nurses. These are all based at the only public hospital and largely work in non-mental health clinics, leaving most of the district with no access to psychiatry personnel. Perinatal women with mental illness are only identified if they are severe enough to be psychotic or suicidal, in which case they are not treated but immediately referred to the regional hospital in the neighboring district of Jinja, sixty kilometers away. Depression and other common mental disorders normally remain undetected and untreated at the primary care level. Study participants consisted of Village Health team members (VHTs), pregnant and postpartum women (within one year of delivery), midwives, general nurses and health managers (Table 1). The district mental health coordinator purposively recruited VHT members from across the district to include those that were most active and likely to have the most knowledge about the health system and community. Twenty VHTs were recruited in two groups of ten. The pregnant and postpartum mothers were recruited from the maternity clinic of the district hospital. Four focus groups were conducted, each with 12 perinatal women. A facilitator presented an overview of the research program and focus group procedures in the hospital’s waiting area, just before the antenatal/postnatal clinic started. Women who were willing to participate were selected by the triage nurse and organized into groups where verbal consent was sought. Eight key informant interviews were conducted with health managers, midwives and general nurses from a wide range of health facilities within the district. Demographic characteristics of participants Focus groups were conducted in the month of May 2013. Each focus group lasted approximately 90 min and was audio taped. Two facilitators (DK or JN) led the groups, one of whom led the discussion while a second person (an assistant) took notes and recorded the proceedings. The facilitators were graduate specialists in mental health who had experience in conducting focus group discussions and key informant interviews. DK had just completed her PhD thesis using qualitative methods and helped to train the assistants in focus group methodology and note taking. Both facilitators worked at the national referral and teaching psychiatric hospital. The assistants were social worker volunteers with a temporary placement at the Kamuli General Hospital. An interview guide was used to guide each focus group discussion and key informant interview (Table 2). The interview guide was developed jointly by the authors (JN, DK, JS, FK. SH and CH). Structured, open-ended questions with guided prompts were developed, based on the existing literature and authors’ experience. The core topics for the focus group interviews were (1) barriers and facilitators to accessing mental health care, (2) knowledge and attitudes towards maternal mental disorders, (3) services available for mothers with mental disorders, (4) identified needs for service for maternal mental disorders, (5) feasibility and acceptability of interventions for maternal mental health care and (6) recommendations. The key informant interviews addressed mainly informants’ perception of the problem of maternal mental disorders in the district; causes; existing capacity to detect and manage maternal mental disorders; feasibility of screening; what mental health interventions can feasibly be integrated into maternal health services; availability of supervision for maternal health services; services currently being offered; mechanisms for referral of mothers with mental disorders; existing needs with regard to maternal mental health care; challenges existing or envisaged. Focus group and key informant interview guide Data were analyzed using the thematic analysis method [25]. Data were transcribed verbatim in the Luganda language and the transcripts were then checked against the audiotapes and scripts. Transcripts were then translated into English and back translated into Luganda by two bilingual authors (JN and DK) to ensure linguistic equivalence. The analyses were performed with the help of qualitative software (Atlas.ti version 6.1) [26]. Both the focus group and key informant data were analyzed together. Two of the authors (JN, EO) independently read through different transcripts each, formulated codes guided by predefined themes in the interview guide as well as by the issues emerging from the data. The two authors met and discussed the codes and emerging themes from the transcripts. A codebook was formulated from the agreed codes and code definitions. One author (EO) then read and coded all of the interview transcripts. After coding, data segments corresponding to major themes were retrieved using Atlas.ti. The retrieved segments of coded data were shared among the authors. Each author read segments allocated to them and wrote memos describing their understanding of what the data said in relation to the study objectives. Finally, data were explored to identify key themes and relationships between themes. This approach was intended to facilitate innovative ways of looking at the data. The study was approved by the School of Medicine Research and Ethics committee (SOMREC), Makerere University College of Health Sciences, and the Uganda National Council of Science and Technology (UNCST). Permission to conduct the formative work of the Program for Improvement of Mental Health care (PRIME) in Uganda, a multi country research consortium, was obtained from District administration. Verbal group consent was obtained at the beginning of each group discussion and written individual consent before each in-depth interview.

Materials

N/A

Innovations

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

1. Telemedicine: Implementing telemedicine services could allow pregnant and postpartum women in rural areas to access mental health care remotely. This would eliminate the need for long-distance travel and provide convenient access to healthcare professionals.

2. Mobile health (mHealth) applications: Developing mobile applications that provide information and resources on perinatal mental health could help educate and support pregnant and postpartum women. These apps could include self-assessment tools, educational materials, and access to support networks.

3. Community-based interventions: Establishing community-based support groups or programs that focus on perinatal mental health could help reduce stigma and increase awareness. These interventions could provide a safe space for women to share their experiences and receive support from peers and trained facilitators.

4. Training for healthcare providers: Providing comprehensive training for healthcare providers, including midwives and general nurses, on perinatal mental health could improve detection and management of mental health disorders. This would ensure that women receive appropriate care and support at the primary care level.

5. Integration of mental health services into maternal health care: Integrating mental health services into existing maternal health care settings, such as maternity units and primary health care centers, could improve access and reduce the stigma associated with seeking mental health care. This would involve training healthcare providers to identify and manage perinatal mental health disorders.

6. Financial support for transportation: Implementing financial support programs to assist pregnant and postpartum women with transportation costs could help overcome the barrier of inability to afford transport to healthcare services. This would ensure that women can access the care they need without financial constraints.

7. Public awareness campaigns: Launching public awareness campaigns to educate the community about perinatal mental health and reduce stigma could encourage more women to seek help. These campaigns could include media outreach, community events, and partnerships with local organizations.

It is important to note that the implementation of these innovations would require collaboration between various stakeholders, including healthcare providers, policymakers, community leaders, and funding agencies.

AI Innovations Description

The study conducted in Kamuli district, Uganda, aimed to explore the barriers and facilitators to delivering perinatal mental health care in primary care settings. The study found that there was an important unmet need for perinatal mental health care in the district, with significant gaps in knowledge and negative attitudes towards mental health problems among both mothers and healthcare providers. Barriers to accessing care included poverty, lack of transportation, poor partner support, and stigma. However, there was also a willingness among community- and facility-based healthcare providers to provide care if adequately trained.

Based on these findings, the study recommends the development of integrated maternal mental health care in the rural district of Kamuli and similar settings in other low and middle-income countries. This would involve providing adequate training for healthcare providers to address perinatal mental health issues, raising awareness and reducing stigma surrounding mental health problems, and addressing the financial and logistical barriers that prevent women from accessing care. By implementing these recommendations, it is hoped that access to maternal health services and support for perinatal mental health can be improved in these communities.

AI Innovations Methodology

Based on the provided description, here are some potential recommendations to improve access to maternal health:

1. Increase awareness and education: Develop and implement educational campaigns to raise awareness about perinatal mental health issues among pregnant women, postpartum women, and their families. This can include providing information about symptoms, available services, and the importance of seeking help.

2. Strengthen primary care services: Provide training and support to primary healthcare providers, including midwives and general nurses, to identify and manage perinatal mental health issues. This can involve integrating mental health screening and treatment protocols into routine antenatal and postnatal care.

3. Improve transportation access: Address the barrier of transportation by implementing strategies to improve access to healthcare facilities, especially in rural areas. This can include providing transportation subsidies or establishing mobile clinics to reach remote communities.

4. Reduce stigma: Develop community-based interventions to reduce stigma surrounding perinatal mental health issues. This can involve engaging community leaders, religious leaders, and other influential individuals to promote understanding and acceptance.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the indicators: Identify specific indicators that will measure the impact of the recommendations, such as the percentage of pregnant and postpartum women receiving mental health screening, the percentage of women accessing mental health services, or changes in knowledge and attitudes towards perinatal mental health.

2. Collect baseline data: Gather data on the current state of access to maternal health services, including the prevalence of perinatal mental health issues, existing barriers, and the level of awareness and knowledge among healthcare providers and the community.

3. Implement interventions: Implement the recommended interventions, such as awareness campaigns, training programs for healthcare providers, transportation initiatives, and stigma reduction activities.

4. Monitor and evaluate: Continuously monitor the implementation of the interventions and collect data on the identified indicators. This can include conducting surveys, interviews, and focus groups to assess changes in knowledge, attitudes, and access to services.

5. Analyze the data: Analyze the collected data to assess the impact of the interventions on improving access to maternal health. This can involve comparing the baseline data with the post-intervention data to identify any changes or improvements.

6. Adjust and refine: Based on the findings from the data analysis, make any necessary adjustments or refinements to the interventions to further improve access to maternal health.

By following this methodology, it will be possible to simulate the impact of the recommendations on improving access to maternal health and inform the development of integrated maternal mental health care in the rural district of Uganda and similar settings in other low and middle-income countries.

Author

Dima Health

Statistics:

Citations: 29

Identifiers:

DOI: 10.1186/s12913-016-1547-7

Research Areas:

Community Interventions, Disparities, Health System and Policy, Maternal Access, Maternal and Child Health, Mental Health, Quality of Care, Social Determinants, Technology and Innovations, Workforce

Study Countries:

Uganda

Study Design:

Cross Sectional Study, Exploratory Study

Study Approach:

Qualitative

Participants Gender:

Male & Female