Generating evidence to narrow the treatment gap for mental disorders in sub-Saharan Africa: rationale, overview and methods of AFFIRM

Abstract

There is limited evidence on the acceptability, feasibility and cost-effectiveness of task-sharing interventions to narrow the treatment gap for mental disorders in sub-Saharan Africa. The purpose of this article is to describe the rationale, aims and methods of the Africa Focus on Intervention Research for Mental health (AFFIRM) collaborative research hub. AFFIRM is investigating strategies for narrowing the treatment gap for mental disorders in sub-Saharan Africa in four areas. First, it is assessing the feasibility, acceptability and cost-effectiveness of task-sharing interventions by conducting randomised controlled trials in Ethiopia and South Africa. The AFFIRM Task-sharing for the Care of Severe mental disorders (TaSCS) trial in Ethiopia aims to determine the acceptability, affordability, effectiveness and sustainability of mental health care for people with severe mental disorder delivered by trained and supervised non-specialist, primary health care workers compared with an existing psychiatric nurseled service. The AFFIRM trial in South Africa aims to determine the cost-effectiveness of a task-sharing counselling intervention for maternal depression, delivered by non-specialist community health workers, and to examine factors influencing the implementation of the intervention and future scale up. Second, AFFIRM is building individual and institutional capacity for intervention research in sub-Saharan Africa by providing fellowship and mentorship programmes for candidates in Ethiopia, Ghana, Malawi, Uganda and Zimbabwe. Each year five Fellowships are awarded (one to each country) to attend the MPhil in Public Mental Health, a joint postgraduate programme at the University of Cape Town and Stellenbosch University. AFFIRM also offers short courses in intervention research, and supports PhD students attached to the trials in Ethiopia and South Africa. Third, AFFIRM is collaborating with other regional National Institute of Mental Health funded hubs in Latin America, sub-Saharan Africa and south Asia, by designing and executing shared research projects related to task-sharing and narrowing the treatment gap. Finally, it is establishing a network of collaboration between researchers, non-governmental organisations and government agencies that facilitates the translation of research knowledge into policy and practice. This article describes the developmental process of this multi-site approach, and provides a narrative of challenges and opportunities that have arisen during the early phases. Crucial to the long-term sustainability of this work is the nurturing and sustaining of partnerships between African mental health researchers, policy makers, practitioners and international collaborators.

A process evaluation exploring the lay counsellor experience of delivering a task shared psycho-social intervention for perinatal depression in Khayelitsha, South Africa

“…Detailed information on the AFFIRM-SA trial and the development of the intervention is available elsewhere [11, 35, 36]. We approached a local Non-Governmental Organisation (NGO) which provided twelve CHWs to participate in the training.…”

Addressing the Unmet Need for Maternal Mental Health Services in Low‐ and Middle‐Income Countries: Integrating Mental Health Into Maternal Health Care

“…The authors demonstrated improved maternal and child health outcomes and established the potential for midwives and community health workers to successfully deliver basic mental health services . Additional evidence will also likely come from the Africa Focus on Intervention Research for Mental Health (AFFIRM) and the Programme for Improving Mental Health Care (PRIME), both multicountry initiatives in low‐ and middle‐income countries with sites in sub‐Saharan Africa that explore the impact of packages of care that integrate mental health services into primary care . Such packages of care are delivered in community settings by community health workers, including midwives, who are trained to identify individuals with mental disorders using locally developed and validated tools and provide manual‐based counseling, under the supervision of mental health specialists .…”

Global Mental Health and systems of diagnostic classification: clinical and cultural perspectives

“…First of all, the implementation of an objective approach requires adequate policies and resources beginning with a genuine integration of the work of primary care providers and mental health professionals through the constitution of multidisciplinary, democratized teams open to the active participation of the patients themselves and their families (31,75,88). All of this entails respect for the human dignity and the cultural background of the individual patient and his/her surroundings, making it possible a comprehensive, realistic and pragmatic clinical management and reasonable outcome-oriented follow up (63,70,89).…”