BackgroundAlthough maternal common mental disorder (CMD) appears to be a risk factor for infant undernutrition in South Asian countries, the position in sub-Saharan Africa (SSA) is unclearMethodsA population-based cohort of 1065 women, in the third trimester of pregnancy, was identified from the demographic surveillance site (DSS) in Butajira, to investigate the effect of maternal CMD on infant undernutrition in a predominantly rural Ethiopian population. Participants were interviewed at recruitment and at two months post-partum. Maternal CMD was measured using the locally validated Self-Reported Questionnaire (score of ≥ six indicating high levels of CMD). Infant anthropometry was recorded at six and twelve months of age.ResultThe prevalence of CMD was 12% during pregnancy and 5% at the two month postnatal time-point. In bivariate analysis antenatal CMD which had resolved after delivery predicted underweight at twelve months (OR = 1.71; 95% CI: 1.05, 2.50). There were no other statistically significant differences in the prevalence of underweight or stunted infants in mothers with high levels of CMD compared to those with low levels. The associations between CMD and infant nutritional status were not significant after adjusting for pre-specified potential confounders.ConclusionOur negative finding adds to the inconsistent picture emerging from SSA. The association between CMD and infant undernutrition might be modified by study methodology as well as degree of shared parenting among family members, making it difficult to extrapolate across low- and middle-income countries.

BackgroundIt is essential to involve service users in efforts to expand access to mental health care in integrated primary care settings in low- and middle-income countries (LMICs). However, there is little evidence from LMICs to guide this process. The aim of this study was to explore barriers to, and facilitators of, service user/caregiver involvement in rural Ethiopia to inform the development of a scalable approach.MethodsThirty nine semi-structured interviews were carried out with purposively selected mental health service users (n = 13), caregivers (n = 10), heads of primary care facilities (n = 8) and policy makers/planners/service developers (n = 8). The interviews were audio-recorded and transcribed in Amharic, and translated into English. Thematic analysis was applied.ResultsAll groups of participants supported service user and caregiver involvement in mental health system strengthening. Potential benefits were identified as (i) improved appropriateness and quality of services, and (ii) greater protection against mistreatment and promotion of respect for service users. However, hardly any respondents had prior experience of service user involvement. Stigma was considered to be a pervasive barrier, operating within the health system, the local community and individuals. Competing priorities of service users included the need to obtain adequate individual care and to work for survival. Low recognition of the potential contribution of service users seemed linked to limited empowerment and mobilization of service users. Potential health system facilitators included a culture of community oversight of primary care services. All groups of respondents identified a need for awareness-raising and training to equip service users, caregivers, service providers and local community for involvement. Empowerment at the level of individual service users (information about mental health conditions, care and rights) and the group level (for advocacy and representation) were considered essential, alongside improved, accessible mental health care and livelihood interventions.ConclusionAs Ethiopia increases access to mental health care, a fundamental barrier to service user involvement is beginning to be addressed. Our study identified further barriers that need to be tackled, including a supportive political climate, and receptiveness amongst stakeholders. The findings will inform the development of a model of service user involvement, which will be piloted and evaluated.

BackgroundAntenatal depressive symptoms affect around 12.3% of women in in low and middle income countries (LMICs) and data are accumulating about associations with adverse outcomes for mother and child. Studies from rural, low-income country community samples are limited. This paper aims to investigate whether antenatal depressive symptoms predict perinatal complications in a rural Ethiopia setting.MethodsA population-based prospective study was conducted in Sodo district, southern Ethiopia. A total of 1240 women recruited in the second and third trimesters of pregnancy were followed up until 4 to 12 weeks postpartum. Antenatal depressive symptoms were assessed using a locally validated version of the Patient Health Questionnaire (PHQ-9) that at a cut-off score of five or more indicates probable depression. Self-report of perinatal complications, categorised as maternal and neonatal were collected by using structured interviewer administered questionnaires at a median of eight weeks post-partum. Multivariate analysis was conducted to examine the association between antenatal depressive symptoms and self-reported perinatal complications.ResultA total of 28.7% of women had antenatal depressive symptoms (PHQ-9 score ≥ 5). Women with antenatal depressive symptoms had more than twice the odds of self-reported complications in pregnancy (OR=2.44, 95% CI: 1.84, 3.23), labour (OR= 1.84 95% CI: 1.34, 2.53) and the postpartum period (OR=1.70, 95% CI: 1.23, 2.35) compared to women without these symptoms. There was no association between antenatal depressive symptoms and pregnancy loss or neonatal death.ConclusionAntenatal depressive symptoms are associated prospectively with self-reports of perinatal complications. Further research is necessary to further confirm these findings in a rural and poor context using objective measures of complications and investigating whether early detection and treatment of depressive symptoms reduces these complications.

BackgroundPostpartum depression (PPD) affects more than one in ten women and is associated with adverse consequences for mother, child and family. Integrating mental health care into maternal health care platforms is proposed as a means of improving access to effective care and reducing the ‘treatment gap’ in low- and middle-income countries. This study aimed to determine the proportion of women with PPD who sought help form a health facility and the associated factors.MethodsA community based, cross-sectional survey was conducted in southern Ethiopia. A total of 3147 women who were between one and 12 months postpartum were screened for depressive symptoms in their home using a culturally validated version of the Patient Health Questionnaire (PHQ-9). Women scoring five or more (indicating potential depressive disorder) (n = 385) were interviewed regarding help-seeking behavior. Multiple logistic regression was used to identify factors associated independently with help-seeking from health services.ResultsOnly 4.2 % of women (n = 16) with high PPD symptoms had obtained mental health care and only 12.7 % of women (n = 49) had been in contact with any health service since the onset of their symptoms. In the multivariable analysis, urban residence, adjusted odds ratio (aOR): 4.39 (95 % confidence interval (CI) 1.23, 15.68); strong social support, aOR: 2.44 (95 % CI 1.30, 4.56); perceived physical cause, aOR: 6.61 (95 % CI 1.76, 24.80); perceived higher severity aOR: 2.28 (95 % CI 1.41, 5.47); perceived need for treatment aOR: 1.46 (95 % CI 1.57, 18.99); PHQ score, aOR: 1.14 (95 % CI 1.04, 1.25); and disability, aOR: 1.06 (95 % CI 1.01, 1.15) were associated significantly with help-seeking from health services.More than half of the women with high levels of PPD symptoms (n = 231; 60.0  %) attributed their symptoms to a psychosocial cause and 269 (69.9 %) perceived a need for treatment. Equal proportions endorsed biomedical treatment and traditional or religious healing as the appropriate intervention.ConclusionIn the absence of an accessible maternal mental health service the treatment gap was very high. There is a need to create public awareness about PPD, its causes and consequences, and the need for help seeking. However, symptom attributions and help-seeking preferences indicate potential acceptability of interventions located in maternal health care services within primary care.

BackgroundUnderstanding co-morbidity of depression and tuberculosis (TB) has been limited by challenges in measurement of depression due to overlapping symptoms, use of small hospital samples and uncontrolled analysis. This study was conducted to better understand the burden and presentation of depression, and associated factors in people with TB in primary care settings in Ethiopia.MethodsWe conducted a cross-sectional survey among 657 people newly diagnosed with TB. Symptoms of depression were measured using the Patient Health Questionnaire (PHQ-9). TB symptoms and other factors were captured using standardised questionnaires. The factor structure of PHQ-9 was examined. Multivariable analysis was carried out to estimate prevalence ratios.ResultsThe prevalence of probable depression was 54.0%. The PHQ-9 had one factor structure (alpha = 0.81). Little interest or pleasure in doing things (73.0%) was the commonest depressive symptom. Older age (Adjusted Prevalence ratio (APR) = 1.19; 95%CI = 1.06, 1.33), female sex (APR = 1.23; 95%CI = 1.18, 1.27), night sweating (APR = 1.25; 95%CI = 1.16, 1.35), pain (APR = 1.69; 95%CI = 1.24, 2.29), being underweight (APR = 1.10; 95%CI = 1.07, 1.13), duration of illness (APR = 1.35; 95%CI = 1.22, 1.50), level of education (APR = 0.93; 95%CI = 0.90, 0.95), and social support (APR = 0.89; 95%CI = 0.85, 0.93) were independently associated with probable depression.ConclusionsDepression appears highly prevalent in people with TB and PHQ-9 seems to be a useful instrument to detect depression in the context of TB. The frequency of depressive symptoms would suggest that the occurrence of the symptoms in people with TB is in the usual manifestation of the disorder. Prospective studies are needed to understand the longitudinal relationship between TB and depression.

BackgroundLevels of non-adherence to antipsychotic medication in persons with schizophrenia in rural African settings have been shown to be comparable to those found in high-income countries. Improved understanding of the underlying reasons will help to inform intervention strategies relevant to the context.MethodsA qualitative study was conducted among persons with schizophrenia (n = 24), their caregivers (n = 19), research field workers (n = 7) and health workers (n = 1) involved in the ongoing population-based cohort study, ‘The Butajira Study on Course and Outcome of Schizophrenia and Bipolar Disorder’, based in rural Ethiopia. Six focus group discussions and 9 in-depth interviews were conducted to elicit perspectives on non-adherence to antipsychotic medication. Thematic analysis was used to identify prominent perspectives.ResultsPredominant reasons for non-adherence specific to a low-income country setting included inadequate availability of food to counter appetite stimulation and the perceived strength of antipsychotic medications. The vital role of the family or other social support in the absence of a statutory social safety net was emphasised. Expectations of cure, rather than need for continuing care, were reported to contribute to non-adherence in the longer-term.Many of the factors associated with non-adherence in high-income countries were also considered important in Ethiopia, including lack of insight, failure to improve with treatment, medication side effects, substance abuse, stigma and dissatisfaction with the attitude of the care provider.ConclusionThis study identifies additional barriers to medication adherence faced by persons with schizophrenia in Ethiopia compared to those in high-income countries. In this era of scaling up of mental health care, greater attention to provision of social and financial assistance will potentially improve adherence and thereby enable patients to benefit more fully from medication.