Browsing by Author "Ssebunnya, Joshua"

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Effectiveness and cost-effectiveness of integrating the management of depression into routine HIV care in Uganda (the HIV + D trial): a protocol for a cluster-randomised trial
(Springer Nature: International Journal of Mental Health Systems, 2021-05-12) Kinyanda, Eugene; Kyohangirwe, Leticia; Mpango, Richard S.; Tusiime, Christine; Ssebunnya, Joshua; Katumba, Kenneth; Tenywa, Patrick; Mugisha, James; Taasi, Geoffrey; Sentongo, Hafsa; Akena, Dickens; Laurence, Yoko; Muhwezi, Wilson; Weiss, Helen A.; Neuman, Melissa; Greco, Giulia; Knizek, Birthe; Levin, Jonathan; Kaleebu, Pontiano; Araya, Ricardo; Ssembajjwe, Wilber; Patel, Vikram
An estimated 8-30% of people living with HIV (PLWH) have depressive disorders (DD) in sub- Saharan Africa. Of these, the majority are untreated in most of HIV care services. There is evidence from low- and middle- income countries of the effectiveness of both psychological treatments and antidepressant medication for the treatment of DD among PLWH, but no evidence on how these can be integrated into routine HIV care. This protocol describes a cluster-randomised trial to evaluate the effectiveness and cost-effectiveness of the HIV+D model for the integration of a collaborative stepped care intervention for DD into routine HIV care, which we have developed and piloted in Uganda. Methods: Forty public health care facilities that provide HIV care in Kalungu, Masaka and Wakiso Districts will be randomly selected to participate in the trial. Each facility will recruit 10-30 eligible PLWH with DD and the total sample size will be 1200. The clusters will be randomised 1:1 to receive Enhanced Usual Care alone (EUC, i.e. HIV clinicians trained in Mental Health Gap Action Programme including guidelines on when and where to refer patients for psychiatric care) or EUC plus HIV+D (psychoeducation, Behavioural Activation, antidepressant medication and referral to a supervising mental health worker, delivered in a collaborative care stepwise approach). Eligibility criteria are PLWH attending the clinic, aged >18 years who screen positive on a depression screening questionnaire (Patient Health Questionnaire, PHQ-9≥10). The primary outcome is the mean depressive disorder symptom severity scores (assessed using the PHQ-9) at 3 months post-randomisation, with secondary mental health, disability, HIV and economic outcomes measured at 3 and 12 months. The cost-effectiveness of EUC with HIV+D will be assessed from both the health system and the societal perspectives by collecting health system, patient and productivity costs and mean DD severity scores at 3 months, additional to health and non-health related quality of life measures (EQ-5D-5L and OxCAP-MH). Discussion: The study 􀂦ndings will inform policy makers and practitioners on the cost-effectiveness of a stepped care approach to integrate depression management in routine care for PLWH in low-resource settings.
The experience of mental health service users in health system strengthening: lessons from Uganda
(Springer Nature: International Journal of Mental Health Systems, 2019-09-06) Mugisha, James; Hanlon, Charlotte; Knizek, Birthe Loa; Ssebunnya, Joshua; Vancampfort, Davy; Kinyanda, Eugene; Kigozi, Fred
Mental, neurological and substance use disorders are a public health burden in Uganda. Mental health service user involvement could be an important strategy for advocacy and improving service delivery, particularly as Uganda redoubles its efforts to integrate mental health into primary health care (PHC). However, little is known on the most effective way to involve service users in mental health system strengthening. Methods: This was a qualitative key informant interview study. At national level, 4 interviews were conducted with national level health workers and 3 service user organization representatives. At the district level, 2 interviews were conducted with district level health workers and 5 service user organization representatives. Data were analyzed using content thematic analysis. Findings: Overall, there was low mental service user participation in health system strengthening at both national and district levels. Health system strengthening activities included policy development, implementation of programs and research. Informants mentioned several barriers to service user involvement in mental health system strengthening. These were grouped into three categories: institutional, community and individual level factors. Institutional level barriers included: limited funding to form, train and develop mental health service user groups, institutional stigma and patronage by founder members of user organizations. Community level barriers included: abject poverty and community stigma. Individual level barriers included: low levels of awareness and presence of self-stigma. Informants also recommended some strategies to enhance service user involvement. Conclusion: The Uganda Ministry of Health should develop a strategy to improve service user participation in mental health system strengthening. This requires an appreciation of the importance of service users in improving service delivery. To address the barriers to service user involvement identified in this study requires concerted efforts by the Uganda Ministry of Health and the district health services, specifically with regard to attitudes of health workers, dealing with stigma at all levels, raising awareness about the rights of service users to participate in health systems strengthening activities, building capacity and financial empowerment of service user organizations.
Scaling up integrated primary mental health in six low- and middle-income countries: obstacles, synergies and implications for systems reform
(BJPsych Open Emerald Series., 2019-08-06) Petersen, Inge; Rensburg, André van; Kigozi, Fred; Semrau, Maya; Hanlon, Charlotte; Abdulmalik, Jibril; Kola, Lola; Fekadu, Abebaw; Gureje, Oye; Gurung, Dristy; Jordans, Mark; Mntambo, Ntokozo; Mugisha, James; Muke, Shital; Petrus, Ruwayda; Shidhaye, Rahul; Ssebunnya, Joshua; Tekola, Bethlehem; Upadhaya, Nawaraj; Patel, Vikram; Lund, Crick; Thornicroft, Graham
There is a global drive to improve access to mental healthcare by scaling up integrated mental health into primary healthcare (PHC) systems in low- and middle-income countries (LMICs). Aims To investigate systems-level implications of efforts to scale-up integrated mental healthcare into PHC in districts in six LMICs. Method Semi-structured interviews were conducted with 121 managers and service providers. Transcribed interviews were analysed using framework analysis guided by the Consolidated Framework for Implementation Research and World Health Organization basic building blocks. Results Ensuring that interventions are synergistic with existing health system features and strengthening of the healthcare system building blocks to support integrated chronic care and task-sharing were identified as aiding integration efforts. The latter includes (a) strengthening governance to include technical support for integration efforts as well as multisectoral collaborations; (b) ring-fencing mental health budgets at district level; (c) a critical mass of mental health specialists to support task-sharing; (d) including key mental health indicators in the health information system; (e) psychotropic medication included on free essential drug lists and (f) enabling collaborative and community- oriented PHC-service delivery platforms and continuous quality improvement to aid service delivery challenges in implementation. Conclusions Scaling up integrated mental healthcare in PHC in LMICs is more complex than training general healthcare providers. Leveraging existing health system processes that are synergistic with chronic care services and strengthening healthcare system building blocks to provide a more enabling context for integration are important.
Towards understanding governance issues in integration of mental health into primary health care in Uganda
(Springer Nature: International Journal of Mental Health Systems., 2016-03-24) Mugisha, James; Ssebunnya, Joshua; Kigozi, Fred N.
There is a growing burden of mental illness in low income countries. The situation is further worsened by the high poverty levels in these countries, resulting in difficult choices for their health sectors as regards to responding to the burden of mental health problems. In Uganda, integration of mental health into primary health care (PHC) has been adopted as the most vital strategy for ensuring mental health service delivery to the general population. Objectives: To identify governance related factors that promote/or hinder integration of mental health into PHC in Uganda. Methods: A qualitative research design was adopted at national and district level. A total of 18 Key informant interviews were conducted at both levels. Content thematic analysis was the main method of data analysis. Findings: There were positive gains in working on relevant laws and policies. However, both the mental health law and policy are still in draft form. There is also increased responsiveness/participation of key stakeholders; especially at national level in the planning and budgeting for mental health services. This however seems to be a challenge at both district and community level. In terms of efficiency, human resources, finances, medicines and technologies constitute a major drawback to the integration of mental health into PHC. Ethics, oversight, information and monitoring functions though reported to be in place, become weaker at the district level than at national level due to limited finances, human resources gaps and limited technical capacity. Other governance related issues are also reported in this study. Conclusions: There is some progress especially in the legal and policy arena to support integration of mental health into PHC in Uganda. However, adequate resources are still required to facilitate the effective functioning of all governance pillars that make integration of mental health into PHC feasible in Uganda.