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Little is known about the household economic costs associated with mental, neurological and substance use (MNS) disorders in low- and middle-income countries.
To assess the association between MNS disorders and household education, consumption, production, assets and financial coping strategies in Ethiopia, India, Nepal, Nigeria, South Africa and Uganda.
We conducted an exploratory cross-sectional household survey in one district in each country, comparing the economic circumstances of households with an MNS disorder (alcohol-use disorder, depression, epilepsy or psychosis) (n = 2339) and control households (n = 1982).
Despite some heterogeneity between MNS disorder groups and countries, households with a member with an MNS disorder had generally lower levels of adult education; lower housing standards, total household income, effective income and non-health consumption; less asset-based wealth; higher healthcare expenditure; and greater use of deleterious financial coping strategies.
Households living with a member who has an MNS disorder constitute an economically vulnerable group who are susceptible to chronic poverty and intergenerational poverty transmission.
Declaration of interest
D.C. is a staff member of the World Health Organization. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy or views of the World Health Organization.
Although financing represents a critical component of health system strengthening and also a defining concern of efforts to move towards universal health coverage, many countries lack the tools and capacity to plan effectively for service scale-up. As part of a multi-country collaborative study (the Emerald project), we set out to develop, test and apply a fully integrated health systems resource planning and health impact tool for mental, neurological and substance use (MNS) disorders.
A new module of the existing UN strategic planning OneHealth Tool was developed, which identifies health system resources required to scale-up a range of specified interventions for MNS disorders and also projects expected health gains at the population level. We conducted local capacity-building in its use, as well as stakeholder consultations, then tested and calibrated all model parameters, and applied the tool to three priority mental and neurological disorders (psychosis, depression and epilepsy) in six low- and middle-income countries.
Resource needs for scaling-up mental health services to reach desired coverage goals are substantial compared with the current allocation of resources in the six represented countries but are not large in absolute terms. In four of the Emerald study countries (Ethiopia, India, Nepal and Uganda), the cost of delivering key interventions for psychosis, depression and epilepsy at existing treatment coverage is estimated at US$ 0.06–0.33 per capita of total population per year (in Nigeria and South Africa it is US$ 1.36–1.92). By comparison, the projected cost per capita at target levels of coverage approaches US$ 5 per capita in Nigeria and South Africa, and ranges from US$ 0.14–1.27 in the other four countries. Implementation of such a package of care at target levels of coverage is expected to yield between 291 and 947 healthy life years per one million populations, which represents a substantial health gain for the currently neglected and underserved sub-populations suffering from psychosis, depression and epilepsy.
This newly developed and validated module of OneHealth tool can be used, especially within the context of integrated health planning at the national level, to generate contextualised estimates of the resource needs, costs and health impacts of scaled-up mental health service delivery.
The prevalence of depression in rural Ugandan communities is high and yet detection and treatment of depression in the primary care setting is suboptimal. Short valid depression screening measures may improve detection of depression. We describe the validation of the Luganda translated nine- and two-item Patient Health Questionnaires (PHQ-9 and PHQ-2) as screening tools for depression in two rural primary care facilities in Eastern Uganda.
A total of 1407 adult respondents were screened consecutively using the nine-item Luganda PHQ. Of these 212 were randomly selected to respond to the Mini International Neuropsychiatric Interview diagnostic questionnaire. Descriptive statistics for respondents’ demographic characteristics and PHQ scores were generated. The sensitivity, specificity and positive predictive values (PPVs), and area under the ROC curve were determined for both the PHQ-9 and PHQ-2.
The optimum trade-off between sensitivity and PPV was at a cut-off of ≧5. The weighted area under the receiver Operating Characteristic curve was 0.74 (95% CI 0.60–0.89) and 0.68 (95% CI 0.54–0.82) for PHQ-9 and PHQ-2, respectively.
The Luganda translation of the PHQ-9 was found to be modestly useful in detecting depression. The PHQ-9 performed only slightly better than the PHQ-2 in this rural Ugandan Primary care setting. Future research could improve on diagnostic accuracy by considering the idioms of distress among Luganda speakers, and revising the PHQ-9 accordingly. The usefulness of the PHQ-2 in this rural population should be viewed with caution.
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