Background
Theoretical framework
Methods
Study design
Study setting
Participant’s recruitment
Participant | Age | Gender | Health cadre | Level of education |
---|---|---|---|---|
P1 | 38 | Female | Nursing officer | Diploma in Nursing and Midwifery |
P2 | 41 | Male | Clinical officer | Degree in Public Health |
P3 | 31 | Female | Enrolled nurse | Certificate in Nursing |
P4 | 32 | Female | Psychiatric nurse | Certificate in Mental Health Nursing |
P5 | 32 | Female | Nursing officer | Diploma in Nursing |
P6 | 45 | Female | Senior Nursing officer | Diploma in Nursing & Health service Management |
P7 | 39 | Female | Midwife | Certificate in Midwifery |
P8 | 49 | Female | Enrolled nurse | Certificate in Nursing |
P9 | 32 | Male | Clinical officer | Diploma in Clinical Medicine |
P10 | 30 | Female | Midwife | Certificate in Midwifery |
P11 | 35 | Female | Enrolled nurse | Certificate in Nursing |
P12 | 49 | Female | Nursing officer | Diploma in Nursing and Midwifery |
P13 | 31 | Female | Psychiatric nurse | Diploma in Mental Health Nursing |
P14 | 38 | Female | Senior Nursing officer | Diploma in Nursing |
P15 | 32 | Female | Midwife | Certificate in Midwifery |
P16 | 32 | Female | Clinical officer | Degree in Public Health |
P17 | 38 | Female | Clinical officer | Diploma in Clinical Medicine |
P18 | 30 | Female | Nursing officer | Diploma in Nursing |
P19 | 47 | Female | Midwife | Certificate in Midwifery |
P20 | 30 | Female | Enrolled nurse | Certificate in Nursing |
Procedure
Data collection and tools
Data management and analysis
Ethical considerations
Results
Capability
Participants seemed more comfortable managing patients with a diagnosis of mental health problems than making a new one. We found that the health centers received patients who had received a diagnosis directly from Mbarara Regional Referral Hospital and were coming for medicine refills; thus preferred to handle such cases.I can make a diagnosis of mental illness, but because they are very many types, I may not be able to differentiate them if the signs are not clear…when we were in school (medical) we read to pass exams and then we come here and we are supposed to diagnose for mental illness; but that was not the focus so we just treat (mental health problems) like any other minor illness (Clinical Officer Health Facility (HF) 2).
In addition, the knowledge about mental health that the participants had was gained during pre-service training; we found that since they started clinical practice, they had not received in-service training in the mental health area.As I told you, for us we do the basics then the rest refer. I think even the structures we have cannot allow us to handle those people from here completely. We don’t have isolation rooms for those people that’s why I say we cannot manage them unless they are treated from the other side and when they calm down, we can continue with their treatment (Nursing Officer HF 1).
There was no senior cadre to seek consultations when not sure mental condition hence referrals of clients who should have otherwise been managed at the lower level. The participants indicated that they preferred management of patients already on treatment.I can say that the knowledge I have on mental illness I got during my training. We do not have in-service training about mental health or the updates; at least if we are updated and we have that knowledge, we can handle (Nursing Officer HF 2).
When asked if they knew about the UCG and how helpful they could be when assessing for mental health problems, we found that the PCPs were aware about the UCG but found it burdensome to consult them unless they were totally in a fix as illustrated below by one participant.I do not think am very comfortable making a diagnosis of mental health problems…there is no colleague to ask if I find something confusing, so I refer to Mbarara Regional Referral Hospital because I know there are specialists there (Clinical Officer HF 1).
To tell the truth it is not my culture to look through those guidelines (UCG) unless I am really cornered with a mother having signs of mental (Midwife HF 6).
Opportunity
The participants who had gained access to the UCG alluded to the fact that they were not practical for use in the local setting and needed to be summarized in a chart form to help them make the correct assessment of patients they suspect could be presenting with signs of mental illness. They noted that the UCG were very detailed and that the content about mental health was hidden and not quickly accessed when required.When you get a client with signs of mental illness, you have to look for the guidelines (UCG), however, this process delays the patient or management of their condition; and it’s a challenge when you also have to look for the dose, calculate, and then think about the side effects of the drug (Midwife HF 3).
The PCPs added that they did not repeatedly deal with clients having mental illness to foster routine usage of the UCG, thus found it bothersome to make reference each time the need arose. The health centers largely receive clients already diagnosed with mental health problems, and only need refills of their medication; there is limited opportunity for the PCPs to make a new diagnosis of mental health problems.Do you see how they have done for HIV care summarizing information on the charts and pinning everywhere…do the same for mental health. I don’t think I can leave a patient in front of me that I am looking for the guidelines (UCG) to read, they need a lot of time to search for information (Clinical Officer HF 6).
Exacerbating the PCPs challenges of integrating mental health services into PHC is that there was neither sensitization about the UCG to the intended users nor provision of sufficient copies to promote self-sensitization.If we were seeing patients with mental illness on a daily basis with the same complaint, we would get used to the guidelines (UCG), but the patients (with mental health related problems) are not common…we mostly receive those with a diagnosis for refills so it is a challenge when we have to go and read the guidelines because we are not used to those patients (Midwife HF 4).
There were no cues at the health centers to remind the PCPs to use UCG when assessing for mental health problems. The PCPs felt that mental health was not as important as other disease where a lot of attention and resources were directed. Some of the health centers had donor funded projects with a set agenda and necessary resources to achieve the aims; this was not known to some participants thus causing them to think that mental healthcare is neglected and therefore not important.We were just told that there are new guidelines to follow…they did not tell us how to use them and also did not give us personal copies. If at lease each one has a copy on their table, then maybe we can read them (Enrolled Nurse HF 1).
The other barrier related to opportunity was that the PCPs who were trained as mental healthcare providers and posted to the various health centers in rural Uganda were not necessarily practicing in their area of training. This caused the PCPs to feel deprived of time to do what they would be happy doing. The mental health integration policy requires all healthcare providers at PHC (lower levels of healthcare) to assess for mental health problems within routine practice. This in a way defeats the purpose of specialized training to practice at lower levels of healthcare where ones mental health should seamlessly be assed at PHC level.Nobody asks us about people with mental problems the way they follow up with other programs like HIV, TB, malaria and immunization…I think if the ministry wants us to comply with mental health, let them support it like the other programs (Nursing Officer HF 4).
The participants decried missed opportunity to provide mental health education to the patients they believed were in the communities and who may neither be aware about their mental illness nor the possibility of having it attended to. The PCPs attributed it to the lack of protected time to practice in the area of training as well as facilitation for mental health outreach activities.I was posted here as a psychiatric nurse, but I don’t work as a psychiatric nurse, I rotate on all wards apart from maternity ward…I don’t have enough time to talk to these patients so that they know more about mental illness (Psychiatric nurse HF 3).
Community outreach programs such as immunization are supported by the Ministry of Health; when asked why they did not utilize that opportunity to integrate mental health education, the participants’ indicated that they would love to do it but because of limited time given and few personnel they are unable to include any other programs.…patients are in the community but they don’t know about mental health concerns. They don’t know that even mentally ill patients can be given treatment and improve to become important. I need to be supported go via the community and talk to the people; but that gap isn’t there to go and talk to the people. Need to go to the churches and to different places and talk to the community (Psychiatric nurse HF 2).
The guidelines (UCG) are helpful because it is not something very hard to follow, you can reach the diagnosis easily… you face it when you do not have the drugs that you would have given the client and you opt for some simple drugs like diazepam instead of the real treatment (Nursing Officer HF 6).
Motivation
Some PCPs had not even seen the UCG at their respective health facilities. This probably was because of either the limited supply of hard copies or lack of knowledge that they were supposed to use the guidelines when assessing patients.I am not confident using the guidelines (UCG) because of the difficult terms in mental health... we were not taken through the guidelines to understand the terms and how to use them (Nursing Officer HF 5).
When asked if screening for mental health problems caused any emotions, the PCPs response was to the affirmative although they indicated that it could not deter them from doing their job as healthcare providers. Emotions were mainly expressed by the female participants who felt distressed especially when dealing with children or unaccompanied persons.…personally, I have not seen those guidelines (UCG) in the room where I work from, I read them once when I was in Mbarara (Mbarara Regional Referral Hospital) like 3 years back (Enrolled Nurse HF 4).
Lack of trained mental health specialists at the health centers is another barrier we identified to the integration of mental health services into PHC. Some PCPs did not feel motivated to uptake the policy option because they did not have mental health specialists for immediate consultation. As remedy to that barrier, they proposed continuous medical education, and refresher courses in mental health to help them perform effectively.…I imagine like if this is my child in that condition, I feel like crying…I feel pity for the family. But again as a health worker of course we should not allow emotions to control us…I go ahead and see this client, I do not sit and cry with them…I try to counsel the patient until they are well (Nursing Officer HF 6).
We found that integration of mental healthcare into routine care has been met with conflicting priorities thus limiting time for effective health education as expressed below.…we do not have a psychiatric nurse to inquire about the difficult terms in mental health that we do not understand; we need CMEs or refresher courses (Midwife HF 4).
Integration of mental health services into PHC is a policy option in Uganda and most of the PCPs are aware that they are supposed to use the UCG when assessing for mental illness. However, there were no regulatory measures at the health facilities to encourage them screen for mental health problems.I don’t health educate mental health on a daily basis because there are other diseases to health educate in like diabetes and hypertension. But after getting those people from the general patients, I put them aside and talk about mental illness because that is my specialty where I talk much (Psychiatric nurse HF 3).
On the facilitative side, the PCPs were cognizant of the fact that if they followed the UCG, there would be improved care of the patients.There is nothing (measures) on ground to make us use the UCG. Maybe other units have but for us here we have not seen anything like that, not even in-service training in mental health. You are even the first person to come here in so many years on this mental health (Clinical Officer HF 6).
In addition, some participants indicated that they would feel contented with the service offered if they followed the UCG.I think it will improve the care of people with the mental illness….we may not miss out on the cause and the management as well as the dosing (Psychiatric nurse HF 3).
When asked what kind of support was needed to enable them comfortably use the UCG when screening for mental health problems, one participant indicated that:...if I know I have done what I am supposed to do confidently and I do it for real, I feel very good because I will have given a good quality of service (Nursing Officer HF 6).
We need to be mentored on the assessment and management of people with mental illness so that it is easier for us when reading the guidelines (UCG) and managing or assessing for mental conditions (Nursing Officer HF 2).