Task-shifting must recognise the professional role of nurses – Author's reply

Abstract

We thank Oladayo Afolabi and colleagues for their comments on our trial.1Gureje O Oladeji BD Montgomery AA et al.Effect of a stepped-care intervention delivered by lay health workers on major depressive disorder among primary care patients in Nigeria (STEPCARE): a cluster-randomised controlled trial.Lancet Glob Health. 2019; 7: e951-e960Summary Full Text Full Text PDF PubMed Scopus (15) Google Scholar Afolabi and colleagues highlight two main points: the use of the term ‘lay health workers’ to describe nurses is incorrect and might be considered disrespectful and derogatory and the ambiguity regarding the definitions used to describe personnel involved in our study might have limited the impact of our findings on policy. We are delighted that the comments provide us with an opportunity to clarify this aspect of our trial. Although our aim was to train a cross-section of frontline health providers (nurses, community health officers, and community health extension workers [CHEWs]), the workers who actually received training and subsequently delivered the intervention were all community health officers and CHEWs. These workers constitute more than 90% of the workforce at the primary health-care level in Nigeria. These individuals are, as per their job description, expected to spend a substantial proportion of their working hours in the community. As Afolabi and colleagues noted, the terms ‘community health workers’ and ‘lay health workers’ have often been used interchangeably. Although these workers do deliver general health care routinely, they are not qualified to provide mental health care, and thus require additional training. It is in this context that we chose to use the term lay health workers in the title of our trial. In most countries in sub-Saharan Africa, lay health workers constitute the bulk of frontline health providers at the primary care level.2Munetsi E Simms V Dzapasi L et al.Trained lay health workers reduce common mental disorder symptoms of adults with suicidal ideation in Zimbabwe: a cohort study.BMC Public Health. 2018; 18: 227Crossref PubMed Scopus (11) Google Scholar Such workers have a variety of designations across the world.3Nkonki L Cliff J Sanders D Lay health worker attrition: important but often ignored.Bull World Health Organ. 2011; 89: 919-923Crossref PubMed Scopus (69) Google Scholar In Nigeria, lay health workers are mainly community health officers and CHEWs. Our study was designed to assess whether these workers, with appropriate training and supervision, could deliver effective care for individuals presenting with depression in primary care settings. We therefore do not agree that our approach is likely to limit the relevance of our findings with regard to policy. The use of other categories of health workers who provide services in primary health care settings in Nigeria, including nurses and physicians, but who do not constitute the main frontline providers, would have produced findings less likely to be of relevance for policy. At present, the Nigerian Government is working on how to implement a programme of task-shifting that is essentially designed around the training of community health officers and CHEWs to deliver frontline services for mental health conditions, with support and supervision provided by nurses, physicians, and mental health specialists, as appropriate and available. We declare no competing interests. Effect of a stepped-care intervention delivered by lay health workers on major depressive disorder among primary care patients in Nigeria (STEPCARE): a cluster-randomised controlled trialFor patients with moderate to severe depression receiving care from non-physician primary health-care workers in Nigeria, a stepped-care, problem-solving intervention combined with enhanced usual care is similarly effective to enhanced usual care alone. Enhancing usual care with mhGAP-IG might provide simple and affordable approach to scaling up depression care in sub-Saharan Africa. Full-Text PDF Open AccessTask-shifting must recognise the professional role of nursesThe Nursing Now campaign and the designation of 2020 as the “Year of the Nurse and Midwife” by WHO highlights the need to acknowledge the competence, increase the influence, and maximise the contribution of nursing to the achievement of universal health coverage. However, poor perceptions and misrepresentation of the professional role of nurses persists. The cluster-randomised controlled trial by Oye Gureje and colleagues (April, 2019)1 published in The Lancet Global Health, which assessed the effectiveness of task-shifting and stepped care in the management of major depressive disorder at the primary health-care level in Nigeria, and the associated commentary by Bolanle Adeyemi Ola and colleagues,2 provide examples of how nurses are misrepresented and the need for the Nursing Now campaign. Full-Text PDF Open Access