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Mental Health Care in Kenya: Investigating strategies for capacity building in primary care settingsElijah MaranguPhD Candidate

Supervisors:Assoc Prof Natisha SandsProf Fethi MansouriDr John RolleyProf David Ndetei

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Global Context•Over 450 million people have a mental illness4

•12% of the global burden of disease5 •Set to increase to 15% by 20205

•Mental health care in low-income countries is described as: – inadequate – inefficient – inequitable6

•The treatment gap is estimated to be 85%6

4WHO. (2001). World health report 2001: mental health: new understanding, new hope: World Health Organization.5WHO. (2009). Improving health systems and services for mental health: WHO.6Saxena, Shekhar, Thornicroft, Graham, Knapp, Martin, & Whiteford, Harvey. (2007). Resources for Mental Health: Scarcity, inequity and inefficiency. The Lancet, 370, 878-889.

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Kenya •Located in East Africa•Population: Nearly 42 million1 •Relatively poor: ranked 148th out of 177 countries (UNDP)2

•Prevalence of psychiatric morbidity: 25%3

•HIV/AIDS prevalence: 7.4%3

1Rakuom, Chris. (2010). Nursing Human Resources in Kenya. Geneva: International Centre for Human Resources in Nursing.2WHO. (2005). Mental Health Atlas 2005 Mental Health Atlas 2005. Geneva; Switzerland: World Health Organization.3Kiima, David, Njenga, Frank, Okonji, Marx, & Kigamwa, Pius. (2004). Kenya Mental Health country profile. International Review of Psychiatry, 16(1-2), 48-53.

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•Mental health workforce – Psychiatrists: 757

–Mental Health Nurses: 5007

– Social workers/Psychologists <207

•Custodial care–Mental Health Hospitals: 38

•Poor regulation8

•Inadequate access in rural and regional areas7

7Ndetei et al. (2007). The challenges of human resources in mental health in Kenya. South African Psychiatry Review, 10, 33-36.8Muga, & Jenkins. (2010). Health care models guiding mental health policy in Kenya 1965 - 1997. International Journal of Mental Health Systems, 4(9).

Kenyan Context

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Global Efforts - mhGAP•mhGAP was developed by WHO in 2001 to work with planners

in low-income countries to improve mental health care9

9 WHO. (2008). Mental Health Global Action Programme (mhGAP): Scaling up care for mental, neurological and substance use disorders: World Health Organisation.

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Research Aims•The overarching goal of this study is to improve community access to

basic mental health care Kenyan primary health care settings•The primary aim of this study is to identify gaps in mental health care,

and to use these findings to inform capacity building efforts in primary care settings in Kenya. The study aims to:

1) Examine current Kenyan mental health policies and existing mental health service structures to determine the extent to which they fulfill mhGAP9 criteria for adequate mental health care

2) Measure the mental health literacy10 levels of the Kenya primary health care workforce

3) Develop a mental health literacy capacity building program for primary health care workers and pilot test it in one district of Kenya

9WHO. (2008). Mental Health Global Action Programme (mhGAP): Scaling up care for mental, neurological and substance use disorders: World Health Organisation. 10Jorm, Anthony. (2000). Mental health literacy: Public knowledge and beliefs about mental disorders. The British Journal of Psychiatry, 177, 396-401.

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Research QuestionThe primary research question guiding this investigation is:

‘Can a mental health literacy program implemented at the primary health care level increase the capacity (knowledge, attitudes, confidence and skills) of Kenyan primary healthcare workers to provide basic mental health care in primary health

care settings?’

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Conceptual Framework•Cosmopolitanism11

–a critical social theory, has been identified as an appropriate conceptual framework to guide this study

•Capabilities Approach –Amatya Sen12 –to guide development of a capacity building intervention

11Delanty, Gerard. (2011). Cultural diversity, democracy and the prospects of cosmopolitanism: a theory of cultural encounters. The British journal of sociology, 62(4), 633-656. 12Strand, Torill. (2010). The making of a new cosmopolitanism. Studies in Philosophy and Education, 29(2), 229-242.

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Cosmopolitanism• a critical social theory• denotes a way of seeing the world as an evolving and a

complex social reality• enables political and social analysis of complex settings like

Kenya13

13Delanty, Gerard. (2012). A cosmopolitan approach to the explanation of social change: social mechanisms, processes, modernity. The Sociological Review, 60(2), 333-354.

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Capabilities Approach–Amatya Sen’s12 theory will be used to – guide development of a capacity building program – economic theory that focuses on what individuals are capable of

doing within their abilities, –used extensively in the design of policies and proposals for social

change12

12Strand, Torill. (2010). The making of a new cosmopolitanism. Studies in Philosophy and Education, 29(2), 229-242.

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Method

• A sequential, multi-phase, mixed-method design

•Conducted over 3 stages

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The PRECEDE-PROCEED ModelThe PRECEDE-PROCEED framework by Green & Kreuter14 to guide the implementation of research.

P – Predisposing P - PolicyR – Reinforcing R - RegulatoryE – Enabling O - OrganisationalC – Constructs C - ConstructsE – Education E - EducationalD – Diagnosis E – EnvironmentalD - Development

14Green, & Kreuter. (2005). Health program planning: an educational and ecological approach: McGraw-Hill New York.

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Stage OneWHO Aims 2.29 In-depth Interviews

Sample:- Analysis of Kenyan health policies, legislation & budgets Setting:- Kenyan Ministry of HealthAnalysis:- Descriptive statistics

Sample- Purposive sampling of 10 key

informants (Clinical Officers Council, National Nurses Association of Kenya

Setting:- National & County governments - Health professional associationsAnalysis:- Halcomb & Davidson15 thematic analysis model

9WHO. (2008). Mental Health Global Action Programme (mhGAP): Scaling up care for mental, neurological and substance use disorders: World Health Organisation. 15Halcomb, Elizabeth J, & Davidson, Patricia M. (2006). Is verbatim transcription of interview data always necessary? Applied Nursing Research, 19(1), 38-42.

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Stage Two• Sample: 1160 Health workers in primary health care settings

including Nurses, Doctors, Clinical Officers• Setting: Primary care settings • Data collection: Anthony Jorm’s Mental Health Literacy

Questionnaire10 (Adapted for Kenya) – self administered• Data analysis:

- Frequencies, Means and Standard Deviations will be calculated- Descriptive statistical analysis of questionnaire data- Chi-square and t-tests to compare between groups- Non-parametric tests (e.g. Mann Whitney U-test) to compare

between groups for non-evenly distributed data

10Jorm, Anthony. (2000). Mental health literacy: Public knowledge and beliefs about mental disorders. The British Journal of Psychiatry, 177, 396-401.

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Stage Three• Sample: Twenty health workers who self-select from district health

centres • Setting: One district in Machakos County• Intervention: A Mental Health Literacy Program designed to build health

workers’ capacity for mental health care• Data collection: Pre and Post test design using the Mental Health Literacy

Questionnaire and a Mental Health Literacy Program• Data analysis:

– Descriptive and statistical analysis of the pre and post test Mental

Health Literacy Questionnaire10

– Qualitative feedback from participants following implementation of

the Mental Health Literacy Program

10Jorm, Anthony. (2000). Mental health literacy: Public knowledge and beliefs about mental disorders. The British Journal of Psychiatry, 177, 396-401.

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Research Outcomes

• Short term outcomes

1) A completed gap analysis of Kenyan Primary Mental Health Care provision

2) A measure of the mental health literacy levels of the Kenyan

primary health care workforce

3) A (pilot-tested) mental health literacy capacity building program

• Longer term outcomes

A key long term goal of this research is building capacity within the Kenyan

primary health care workforce to provide basic mental health care, leading to

improvements in access to mental health care in Kenyan communities.

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Progress To Date•Collaboration with African Mental health Foundation established –

‘In Kind Support’•Human Research Ethics Approval by DUHREC obtained•Kenya HREC application submitted –Kenya Medical Research Institute

•A publication grant $1500 •Two Conference papers– Marangu, E. Sands, N & Karani, A (2012). ‘Mind the Gap’, a discussion on disparity between low and high income countries

in provision of mental health care and implications for capacity in Kenya’s nursing workforce: a discussion paper. 38th ACMHN

Conference 2nd – 5th October, 2012. Darwin, Australia.

– Marangu, E (2012). Mental health nursing in Kenya: Investigating strategies for capacity building in primary health care

settings. Deakin University SoNM, HDR Conference. 29th – 31st October, 2012. Melbourne, Australia

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Challenges•Time required to manage parallel ethics applications•Problems maintaining consistency of research design and

methodology to the satisfaction of two Human Research Ethics Committees in two countries

•Challenges securing funding to fund travel and data collection