Training lay- providers to deliver mental health interventions in Sub-Saharan Africa can cut treatment costs says Okoth Paul
Globally, mental health illnesses have a high prevalence, mortality, and morbidity. Adolescents are the worst affected, specifically those living in low and middle-income countries. For example, in sub-Saharan Africa, 1 in 7 adolescents experience mental health disorders. The prevalence differs from country to country, with 1 in 2 adolescents reporting clinically elevated anxiety and depression symptoms in Kenya.
Even though adolescents living in sub-Saharan Africa are disproportionately affected by mental health disorders, the governments have little commitment to improving access to mental health treatment. Kenya, for example, has only about 80 psychiatrists, 30 clinical psychologists, and less than 500 psychiatric nurses, serving 50 million Kenyans. Moreover, the Kenyan government invests just 0.01% of the health budget on mental health.
Why is this the case when WHO states that there is no health without mental health?
The mental health in sub-Saharan Africa is in a mediocre state. Sadly, even the mental health pioneer in Africa, Sierra Leone, is not left out of this puzzle. According to a 2016 report by Sierra Leone’s auditor general, Kissy National Referral Psychiatric Hospital, the only psychiatric hospital in the country is in a state of extinction. It has only one psychiatrist and three psychiatric nurses.
Adolescents in sub-Saharan Africa need practical strategies that address the challenge of accessing mental healthcare, particularly in areas with few trained mental health clinicians.
Mental health care for people living in sub-Saharan Africa is inefficient, inadequate, and inequitable. Due to high treatment costs (single psychotherapy session costs averagely USD 30), most young people in sub-Saharan Africa are left with no choice but to live with untreated mental disorders. The consequences of untreated mental illness include impaired psychological functioning and increased risk of drugs and substance abuse.
Previous studies in LMIC record that mental health interventions implemented by lay providers can be effective, low stigma, low cost, and accessible. Lay providers are individuals without prior formal mental health training. The use of lay providers to implement mental health interventions has become increasingly common because they effectively treat mental health illnesses in low-resource areas such as LMIC.
The effects generated by such strategies are comparable to the treatment offered by qualified psychotherapists. For example, a lay providers-led intervention used in Uganda successfully reduced depressive and anxiety symptoms among orphans living with HIV & AIDS. Moreover, research findings show that such lay provider-led interventions have led to a reduction in anxiety and depression symptoms among those with alcoholism in Goa, India.
Sub-Saharan Africa mainly consists of resource-poor countries that face significant challenges in providing health services to their population. Successful implementation of strategies such as training and supervising lay providers can help manage the shortage of medical personnel in the health sector, especially mental health care, and cut the treatment costs.
The Shamiri Intervention Guide .
Successful implementation of such strategies can be enhanced by adopting the Shamiri Intervention guide to train and supervise lay providers to deliver mental health interventions. The guide advances training and supervision from a randomized controlled trial (RCT) of the Shamiri Intervention (Shamiri is a Swahili word for thrive), a four-session character strength intervention to increase subjective well-being and reduce depressive and anxiety symptoms among Kenyan adolescents.
The Shamiri intervention consists of three modules: a growth-mindset module, lasting two sessions, a gratitude module, enduring one session, and a value affirmations module, lasting one session. The four sessions last 1 hour each and are distributed over four weeks.
In the RCT, Shamiri Institute has delivered a 10-hour training of over two days to 13 lay providers with close assessment of training effectiveness.
In another RCT, Shamiri Intervention involved 420 Kenyan adolescents with clinically elevated anxiety and depression symptoms. Participants met in groups of 8-15, led by lay providers. The intervention reduced depression symptoms for youths with effect sizes exceeding traditional psychotherapy.
It is important to note that various shortcomings face lay providers’ training and supervision. These include lack of extensive training and clinical experience and logistical and monetary challenges of balancing day work and work as a lay provider. Shamiri Intervention has mitigated these risks by developing a thorough training and supervision protocol and a precise compensation and scheduling structure.
The group-based format and use of lay providers enhance the cost-effectiveness and scalability intervention. The group format may increase the number of youths who can benefit from the intervention. Moreover, using trained lay providers may help address the shortage of mental health specialists. In addition, the positive emphasis of the Shamiri Intervention may serve to reduce social stigma around depression and anxiety.
Participants do not explicitly talk about depression and anxiety in the groups, and the intervention is not presented as a means of treating depression and anxiety treatment.
Training and supervising lay providers to deliver mental health interventions is critical in low-income regions such as sub-Saharan Africa. The need for such effective and cost-effective strategies is warranted because while the prevalence of mental health disorders continues to rise, more than 75 percent people do not get needed care. The burden of mental health illnesses is further compounded by shortages of medical personnel, socio-cultural stigma, limited treatment options, and inadequate healthcare financing.
Okoth is a Research Associate at Shamiri Institute. He has also worked with the United Nations Population Fund (UNFPA) and the International Youth Alliance for Family Planning (IYAFP) to create a platform for young people to participate in policy, advocacy and implementation of programs. At 24, he received the Hidden Eco-Hero Award hosted by Samsung Engineering’s Tunza Eco-Generation. Okoth is also a sexual and reproductive health advocate and an op-ed writer. He graduated from Maseno University with a degree in Public Health with IT.