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

Crick Lund ,T Ntulo,Dixon Chibanda ,Marguerite Schneider ,Simone Honikman ,Jen Ahrens ,Angela Ofori-Atta ,Frances M Cowan ,Sifiso Phakathi ,Larry Wissow ,Charlotte Hanlon ,Ashraf Kagee ,John A Joska ,Melvyn Freeman ,Landon Myer ,Judith K Bass ,Rosie Mayston ,Seggane Musisi ,Martin Prince ,Jonathan K Burns ,Abebaw Fekadu ,Leslie Swartz ,Inge Petersen ,Thandi Davies ,Atalay Alem ,Arvin Bhana ,Teshome Shibre ,Dan J Stein ,Girmay Medhin ,Graham Thornicroft ,Memory Nyatsanza ,Michael Dewey ,Chiwoza Bandawe ,Mark Tomlinson ,Ezra Süsser

doi:10.1017/s2045796015000281

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 nurse-led 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.

Highlights

In sub-Saharan Africa, mental and substance use disorders accounted for 19% of the disability-associated disease burden in 2010, and their relative importance is projected to increase with demographic and epidemiological transitions (Institute of Health Metrics and Evaluation, 2013; Whiteford et al 2013)
Despite the enormous need for mental health care, only 42% of sub-Saharan African countries have an officially adopted mental health policy, and a median of 0.62% of the health budget is spent on mental health in these countries (World Health Organization, 2011)
AFFIRM is a novel mental health programme in sub-Saharan Africa that integrates elements of research, capacity building, international collaboration and policy engagement. Such an approach is necessary to ensure that common problems across the continent are addressed collaboratively, while specific local needs and solutions are identified through rigorous evaluation designs, such as randomised controlled trials (RCTs)

Summary

Introduction

In sub-Saharan Africa, mental and substance use disorders accounted for 19% of the disability-associated disease burden (years lived with a disability, YLD) in 2010, and their relative importance is projected to increase with demographic and epidemiological transitions (Institute of Health Metrics and Evaluation, 2013; Whiteford et al 2013). Despite the enormous need for mental health care, only 42% of sub-Saharan African countries have an officially adopted mental health policy, and a median of 0.62% of the health budget is spent on mental health in these countries (World Health Organization, 2011). It is unlikely that this treatment gap will be met by mental health specialists alone as there is approximately one psychiatrist per 2.5 million people, one psychiatric nurse per 500 000 people and one psychologist per 2 million people in Africa (World Health Organization, 2011)

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