Abstract
BackgroundIn 2013, the World Health Organization (WHO) published new guidelines for the management of conditions specifically related to stress, including symptoms of acute stress, bereavement, and post-traumatic stress disorder (PTSD). It is important to evaluate potential challenges for the implementation of these guidelines in low-resource settings, however, there is a dearth of research in this area. The current qualitative study aimed to assess perspectives on the feasibility and acceptability of the new guidelines in four clinics that provide mental health services in post-conflict northern Uganda.MethodsIn-depth interviews were conducted with 19 mental health-care providers and program developers in northern Uganda to address three major research objectives: (1) describe the current standard practices and guidelines used for treating conditions related to stress in Uganda; (2) identify barriers and challenges associated with implementing the new WHO guidelines; and (3) identify and describe potential strategies for overcoming these barriers and challenges. An emergent thematic analysis was used to develop a coding scheme for the transcribed interviews.ResultsPractices for managing conditions related to stress included group psychological interventions, psychoeducation, and medication for clients with severe signs and symptoms. Several themes were identified from the interviews on barriers to guideline implementation. These included (1) a lack of trained and qualified mental health professionals to deliver WHO-recommended psychological interventions; (2) a perception that psychological interventions developed in high-income countries would not be culturally adaptable in Uganda; and (3) reluctance about blanket statements regarding medication for the management of acute stress symptoms and PTSD. Identified strategies for overcoming these barriers included (1) training and capacity building for current mental health staff; (2) a stepped care approach to mental health services; and (3) cultural modification of psychological interventions to improve treatment acceptability by clients.ConclusionsGuidelines were viewed positively by mental health professionals in Uganda, but barriers to implementation were expressed. Recommendations for implementation include (1) strengthening knowledge on effectiveness of existing cultural practices for improving mental health; (2) improving supervision capacity of current mental health staff to address shortage in human resources; and (3) increasing awareness of help-seeking clients on the potential effectiveness of psychological vs. pharmacological interventions.Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-016-0400-z) contains supplementary material, which is available to authorized users.
Highlights
In 2013, the World Health Organization (WHO) published new guidelines for the management of conditions related to stress, including symptoms of acute stress, bereavement, and post-traumatic stress disorder (PTSD)
Research from low- and middle-income countries (LMIC) on guideline implementation is scarce [35]. In this qualitative case study, we examine perspectives on challenges to WHO guideline implementation and potential ways to overcome these in Uganda
Study setting In an effort to address the high prevalence of conditions related to stress and other mental health concerns in northern Uganda, and due to a shortage of mental health services, in 2005, the Ugandan Ministry of Health and the Makerere University Department of Psychiatry entered into a public-private partnership with the Peter C
Summary
In 2013, the World Health Organization (WHO) published new guidelines for the management of conditions related to stress, including symptoms of acute stress, bereavement, and post-traumatic stress disorder (PTSD). Exposure to war and conflict is associated with psychological distress, including acute stress reactions and bereavement, in both child and adult populations [1,2,3,4]. In a meta-analysis of mental health outcomes associated with trauma among populations affected by conflict or displacement, Steel and colleagues calculated an adjusted post-traumatic stress disorder (PTSD) prevalence of 15.4 % across the most rigorous studies [5]. PTSD has been the most commonly studied mental disorder in these contexts, there is broad recognition that a range of mental disorders are of public health importance in conflict-affected settings This range of mental disorders includes both conditions associated with stress, that is, those requiring exposure to major stressors, as well as conditions that may occur without exposure to major stressors (e.g., depression, anxiety disorders, substance use, suicidality) [6]. Studies have suggested that in post-conflict settings, stressors such as stigma and domestic violence are associated with negative psychological consequences [8, 13]
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