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Background Postpartum 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. Methods A 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. Results Only 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. Conclusion In 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.

The World Health Organization (WHO) recently put forth a Global Strategy on Digital Health 2020–2025 with several countries having already achieved key milestones. We aimed to understand whether and how digital health technologies (DHTs) are absorbed in Africa, tracking Ethiopia as a key node. We conducted a systematic review, searching PubMed-MEDLINE, Embase, ScienceDirect, African Journals Online, Cochrane Central Registry of Controlled Trials, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform databases from inception to 02 February 2021 for studies of any design that investigated the potential of DHTs in clinical or public health practices in Ethiopia. This review was registered with PROSPERO ( CRD42021240645 ) and it was designed to inform our ongoing DHT-enabled randomized controlled trial (RCT) (ClinicalTrials.gov ID: NCT04216420 ). We found 27,493 potentially relevant citations, among which 52 studies met the inclusion criteria, comprising a total of 596,128 patients, healthy individuals, and healthcare professionals. The studies involved six DHTs: mHealth (29 studies, 574,649 participants); electronic health records (13 studies, 4534 participants); telemedicine (4 studies, 465 participants); cloud-based application (2 studies, 2382 participants); information communication technology (3 studies, 681 participants), and artificial intelligence (1 study, 13,417 participants). The studies targeted six health conditions: maternal and child health (15), infectious diseases (14), non-communicable diseases (3), dermatitis (1), surgery (4), and general health conditions (15). The outcomes of interest were feasibility, usability, willingness or readiness, effectiveness, quality improvement, and knowledge or attitude toward DHTs. Five studies involved RCTs. The analysis showed that although DHTs are a relatively recent phenomenon in Ethiopia, their potential harnessing clinical and public health practices are highly visible. Their adoption and implementation in full capacity require more training, access to better devices such as smartphones, and infrastructure. DHTs hold much promise tackling major clinical and public health backlogs and strengthening the healthcare ecosystem in Ethiopia. More RCTs are needed on emerging DHTs including artificial intelligence, big data, cloud, cybersecurity, telemedicine, and wearable devices to provide robust evidence of their potential use in such settings and to materialize the WHO’s Global Strategy on Digital Health.

ObjectiveThe impact of severe mental illnesses (SMIs) is not limited to the person with the illness but extends to their family members and the community where the patient comes from. In this review, we systematically analyse the available evidence of impacts of SMI on family members, including parents, grandparents, siblings, spouses and children.Data sourcesPubMed, PsycINFO, Embase and Global Index Medicus were searched from the inception of each database up to 9 November 2019. We also did manual searches of grey literature.Eligibility criteriaWe included studies that assessed the impacts of SMI on any family member. We excluded studies in admitted clinics and acute wards to rule out the acute effect of hospitalisation.Data extractionTwo reviewers extracted data independently using the Cochrane handbook guideline for systematic reviews and agreed on the final inclusion of identified studies.Risk of biasThe quality of the included studies was assessed using effective public health practice project quality assessment tool for quantitative studies.The review protocol was registered in the PROSPERO database.ResultsWe screened a total of 12 107 duplicate free articles and included 39 articles in the review. The multidimensional impact of SMI included physical health problems (sleeplessness, headache and extreme tiredness.), psychological difficulties (depression and other psychological problems) and socioeconomic drift (less likely to marry and higher divorce rate and greater food insecurity). Impacts on children included higher mortality, poor school performance and nutritional problems. However, the quality of one in five studies was considered weak.ConclusionsOur review indicated a high level of multidimensional impact across multiple generations. The serious nature of the impact calls for interventions to address the multidimensional and multigenerational impact of SMI, particularly in low/middle-income countries. Given the relatively high number of studies rated methodologically weak, more robust studies are indicated.PROSPERO registration numberCRD42018064123.

Background Wellbeing of healthcare workers is important for the effective functioning of health systems. The aim of this study was to explore the conceptualisations of wellbeing, stress and burnout among healthcare workers in primary healthcare settings in rural Ethiopia in order to inform the development of contextually appropriate interventions. Methods A qualitative study was conducted in a rural zone of southern Ethiopia. A total of 52 frontline primary healthcare workers participated in in-depth interviews ( n  = 18) or Focus Group Discussions (FGDs) (4 groups, total n  = 34). There were 35 facility based healthcare professionals and 17 community-based health workers. Data were analysed using thematic analysis. Results Most participants conceptualised wellbeing as absence of stress rather than as a positive state. Many threats to wellbeing were identified. For facility-based workers, the main stressors were inadequate supplies leading to fears of acquiring infection and concerns about performance evaluation. For community health workers, the main stressor was role ambiguity. Workload and economic self-sufficiency were a concern for both groups. Burnout and its symptoms were recognised and reported by most as a problem of other healthcare workers. Derogatory and stigmatising terms, such as “chronics”, were used to refer to those who had served for many years and who appeared to have become drained of all compassion. Most participants viewed burnout as inevitable if they continued to work in their current workplace without career progression. Structural and environmental aspects of work emerged as potential targets to improve wellbeing, combined with tackling stigmatising attitudes towards mental health problems. An unmet need for intervention for healthcare workers who develop burnout or emotional difficulties was identified. Conclusion Ethiopian primary healthcare workers commonly face job-related stress and experience features of burnout, which may contribute to the high turnover of staff and dissatisfaction of both patients and providers. Recent initiatives to integrate mental healthcare into primary care provide an opportunity to promote the wellbeing of healthcare workers and intervene to address burnout and emotional problems by creating a better understanding of mental health.

Background Understanding the perspectives of caregivers of children with developmental disorders living in low-income countries is important to inform intervention programmes. The purpose of this study was to examine the stigma experiences, explanatory models, unmet needs, preferred interventions and coping mechanisms of caregivers of children with developmental disorders in Ethiopia. Methods Participants comprised caregivers ( n  = 102) of children with developmental disorders attending two child mental health clinics in Addis Ababa. The majority (66.7 %; n  = 68) had a diagnosis of intellectual disability (ID); 34 children (33.3 %) had autism spectrum disorder (ASD) as their primary diagnosis. All caregivers were administered a structured questionnaire via a face-to-face interview, which included an adaptation of the Family Interview Schedule, closed questions about socio-demographic characteristics, explanatory models of illness, type of interventions used or desired and coping strategies, and an open ended question regarding the family’s unmet needs. Results Most caregivers reported experience of stigma: 43.1 % worried about being treated differently, 45.1 % felt ashamed about their child’s condition and 26.7 % made an effort to keep their child’s condition secret. Stigma did not depend on the type of developmental disorder, the child’s age or gender, or on the age or level of education of the caregiver (all p  > 0.05). Reported stigma was significantly higher in caregivers who had sought traditional help ( p  < 0.01), provided supernatural explanations for their child’s condition ( p  = .02) and in caregivers of Orthodox Christian faith ( p  = .03). Caregivers gave a mixture of biomedical explanations (e.g. head injury (30.4 %) or birth complications (25.5 %)) and supernatural explanations (e.g. spirit possession (40.2 %) or sinful act (27.5 %)) for their child’s condition. The biggest reported unmet need was educational provision for their child (74.5 %), followed by treatment by a health professional (47.1 %), financial support (30.4 %) and expert help to support their child’s development (27.5 %). Most caregivers reported that talking to health professionals (86.3 %) and family (85.3 %) helped them to cope. Many caregivers also used support from friends (76.5 %) and prayer (57.8 %) as coping mechanisms. Conclusions This study highlights the stigma experienced by families caring for a child with a developmental disorder. Designing interventions appropriate for low-income settings that improve awareness about developmental disorders, decrease stigma, improve access to appropriate education and strengthen caregivers’ support are needed.

Background Most women with postpartum depression (PPD) in low- and middle-income countries remain undiagnosed and untreated, despite evidence for adverse effects on the woman and her child. The aim of this study was to identify the coping strategies used by women with PPD symptoms in rural Ethiopia to inform the development of socio-culturally appropriate interventions. Methods A population-based, cross-sectional study was conducted in a predominantly rural district in southern Ethiopia. All women with live infants between one and 12 months post-partum ( n  = 3147) were screened for depression symptoms using the validated Patient Health Questionnaire, 9 item version (PHQ-9). Those scoring five or more, ‘high PPD symptoms’, ( n  = 385) were included in this study. The Brief Coping with Problems Experienced (COPE-28) scale was used to assess coping strategies. Construct validity of the brief COPE was evaluated using confirmatory factor analysis. Results Confirmatory factor analysis of the brief COPE scale supported the previously hypothesized three dimensions of coping (problem-focused, emotion-focused, and dysfunctional). Emotion-focused coping was the most commonly employed coping strategy by women with PPD symptoms. Urban residence was associated positively with all three dimensions of coping. Women who had attended formal education and who attributed their symptoms to a physical cause were more likely to use both problem-focused and emotion-focused coping strategies. Women with better subjective wealth and those who perceived that their husband drank too much alcohol were more likely to use emotion-focused coping. Dysfunctional coping strategies were reported by women who had a poor relationship with their husbands. Conclusions As in high-income countries, women with PPD symptoms were most likely to use emotion-focused and dysfunctional coping strategies. Poverty and the low level of awareness of depression as an illness may additionally impede problem-solving attempts to cope. Prospective studies are needed to understand the prognostic significance of coping styles in this setting and to inform psychosocial intervention development.

Background Although alcohol use disorders contribute a high proportion of population disease burden, the treatment gap is large, especially in low- and middle-income countries. To narrow this gap, contextually relevant evidence is needed to inform service development in low- and middle-income country settings. The aim of this study was to assess the magnitude of the treatment gap for alcohol use disorder, help-seeking behavior, stigma and barriers to care among people with alcohol use disorder in rural Ethiopia. Methods A cross-sectional, house-to-house survey was conducted in Sodo district, south Ethiopia. A sample of 1500 adults was selected using simple random sampling from a census of households and screened for alcohol use disorder using the alcohol use disorders identification tool (AUDIT). Help-seeking, barriers to care and internalized stigma were investigated among people with moderately severe alcohol use disorder (AUDIT score ≥ 16). Poisson regression with robust variance was used to examine factors associated with alcohol use disorder. Results The prevalence of alcohol use disorder (AUDIT ≥8) in the past 12 months was 13.9% (25.8% in men and 2.4% in women, p -value < 0.001). People with alcohol use disorder had increased disability (adjusted prevalence ratio (aPR) 1.03, 95% confidence interval (CI) 1.01, 1.03) and higher depressive symptom scores (aPR 1.02, 95% CI 1.01, 1.04). The treatment gap was very wide, about 87.0% (only 13% sought help) of participants with an AUDIT score ≥ 16 had never sought help for their alcohol problems and 70.0% reported high internalized stigma. Major barriers to seeking help were wanted to handle the problem on their own, believing that it would get better by itself and being unsure about where to go. Conclusions Although alcohol use disorders are common problems in Ethiopian community, the unmet need for treatment is substantial. An integrated care approach has the potential to address this need, but stigma and low awareness may be major barriers to help-seeking. Interventions to reduce stigma and enhance community awareness are recommended.

Background Several studies have been conducted on the effect of interventions on the detection of depression in primary healthcare (PHC). Systematic reviews have also been done on the effectiveness of separate interventions. However, systematic reviews are not done on the comparative effectiveness of several interventions. This study, therefore, aimed at synthesizing the global evidence on the effectiveness of interventions to improve the detection of depression in PHC. Methods We searched PubMed, Embase, PsycINFO, Web of Science, Cochrane Database of Systematic Reviews, Global Index Medicus, African Index Medicus, and African Journals Online, from the inception of the databases to until the 4th week of April 2020. We also searched references of the included articles. We included randomized trials, cluster randomized trials, or quasi-experimental studies, which evaluated the effectiveness of an intervention to improve detection of depression in the PHC setting. Two of the review authors independently extracted data from the included studies. The methodological quality of the included studies was assessed using the Assessment Tool for Quantitative Studies developed by the Effective Public Health Practice Project. The protocol for the review was registered on PROSPERO (CRD42020166291). Results Of 23,305 records identified, we included 58 articles in the review. Diverse types of interventions were evaluated to improve clinician diagnosis of depression in the PHC setting. Interventions related to implementation of guidelines, screening with feedback, educational interventions which incorporated active learning and clinical practice, and disclosure of screening results were found to be mostly effective. Interventions which combined education, screening, and feedback were particularly more effective. Most of the included studies were weak or moderate in their methodological quality. Conclusions Our review indicates that implementation of a single type of intervention does not improve the detection of depression in PHC. Combining aspects of each type of intervention which are more effective may be useful. Education and training interventions which include more simulation and role playing are found to be effective over time. Most of the studies conducted in the area are from high-income countries and are weak in their methodological quality. There is need to conduct more number of studies in low-income settings.

Background Treatment-resistant depression (TRD) is a serious and relatively common clinical condition. Lack of consensus on defining and staging TRD remains one of the main barriers to understanding TRD and approaches to intervention. The Maudsley Staging Method (MSM) is the first multidimensional model developed to define and stage treatment-resistance in “unipolar depression”. The model is being used increasingly in treatment and epidemiological studies of TRD and has the potential to support consensus. Yet, standardised methods for rating the MSM have not been described adequately. The aim of this report is to present standardised approaches for rating or completing the MSM. Method Based on the initial development of the MSM and a narrative review of the literature, the developers of the MSM provide explicit guidance on how the three dimensions of the MSM--treatment failure, severity of depressive episode and duration of depressive episode-- may be rated. Result The core dimension of the MSM, treatment failure, may be assessed using the Maudsley Treatment Inventory (MTI), a new method developed for the purposes of completing the MSM. The MTI consists of a relatively comprehensive list of medications with options for rating doses and provisions treatment for multiple episodes. The second dimension, severity of symptoms, may be assessed using simple instruments such as the Clinical Global Impression, the Psychiatric Status Rating or checklist from a standard diagnostic checklist. The standardisation also provides a simple rating scale for scoring the third dimension, duration of depressive episode. Conclusion The approaches provided should have clinical and research utility in staging TRD. However, in proposing this model, we are fully cognisant that until the pathophysiology of depression is better understood, staging methods can only be tentative approximations. Future developments should attempt to incorporate other biological/ pathophysiological dimensions for staging.