A RESEARCH PROJECT SUBMITTED TO THE CENTRE FOR CHILD AND ADOLESCENT MENTAL HEALTH IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN CHILD AND ADOLESCENT MENTAL HEALTH (M.Sc. CAMH) OF THE UNIVERSITY OF IBADAN

Abstract

Background: The global burden of child and adolescent mental disorders is well established to be high, and affecting 1 in every 5 children and adolescents. However, there is paucity of data on the magnitude of child and adolescent mental health problems in Tanzania, particularly at Mirembe Mental Health Hospital (MMHH), which is the only referral tertiary mental health facility in the country, and receives patients from all over Tanzania mainland. There is also little or no information about the pathways utilized by people whose children may require mental health care in Tanzania. Therefore, the purpose of the present study was to determine the magnitude and pattern of neuropsychiatric morbidity among children and young persons at MMHH; pathways used to access CAMHS; factors influencing such choices; and caregivers’ and health workers’ perceptions to CAMHS offered in Tanzania. Methodology: This was a descriptive, cross sectional, hospital based observational study, which was conducted at the CAMH clinic of MMHH, in Dodoma. It comprised of two groups of participants: a) 354 children/young persons aged 6-24 years as well as their caregivers attending the clinic, that were recruited consecutively; and b) 27 MMHH health workers, comprising of the CAMH clinic staff, and the hospital health management team, that were purposefuly sampled. Tools used in data collection were: Researcher designed Socio-demographic Questionnaire, WHO Modified Encounter Form, the Kiddie Schedule for Affective Disorders and Schizophrenia Present and Lifetime version, DSM 5, 2016 (K SADS-PL DSM 5, 2016), the Children Global Assessment Scale (C-GAS), Modified Patients Assessment Care for Chronic Conditions (PACIC) and Modified Assessment of Chronic Illness Care for Mental Illness (ACIC). Data were analyzed using the IBM SPSS software for Windows Version 23. Descriptive statistics such as frequency and proportions and inferential statistics including Chi square and Fisher’s exact tests to test association between categorical variables; and t test to compare means were used. A significance level was set at 5%. Logistic regression analysis model was employed to determine the independent predictors of both choice of care pathways and delay in care seeking. Results: The children and young persons who participated in the study were aged 6 to 24 years, with a mean of 16.72 years (SD: ±5.584) years. Only 57 participants (16.1%) were aged 6-9 years. There were more males thans females 209 (59.0%). Three quarters were residents of Dodoma. The health workers comprised of 14 males and 13 females, with age range of 30 to 60 years, mean 43.19 years (SD ±9.564). They were of different health cadres. Epilepsy was the most prevalent condition (56.5%), followed by Intellectual Disability [ID] (17.5%), schizophrenia (16.4%), psychosis due to general medical condition [GMC] (13.6%) and depression (10.2%) as the top 5, most common conditions. There was also a high comorbidity rate in this study partcipants, with 45% having comorbidities and majority (89.0%) having 2-3 conditions. In addition, the disorders were found to have a specific age and gender distribution. It was shown that depression (p=0.003), bipolar disorders (p=0.012), schizophrenia (p<0.000), psychosis due to GMC (p=0.000), cerebral palsy [CP] (p<0.000), ID (p<0.000), Attention deficit hyperactivity disorder [ADHD] (p<0.000) and Autism spectrum disorder [ASD] (p<0.000) were age related. On the other hand, gender was associated with having schizophrenia (p=0.049), substance induced psychosis (p=0.004), epilepsy (p=0.009), CP (p=0.027), and cannabis use disorder (p=0.006). It was also found that schizophrenia (p=0.001), enuresis (p<0.000), encopresis (p=0.006), epilepsy (p=0.000), CP (p<0.000), ID (p<0.000), ADHD (p<0.000) and ASD (p<0.000) were associated with more functional impairment compared with other conditions. Parents were the main care initiators (89.0%). Forty seven percent used the non-medical care pathways in their first contact of care whereas 15.0% went directly to MMHH. Predictors of choice of a non-medical pathway were: father’s and mother’s education being primary (AOR=0.27, p=0.032) and (AOR=3.25, p=0.032) respectively, belief that the cause of illness was high fever or other (AOR=0.01, p<0.000), caregivers reporting not knowing the cause of the child’s illness (AOR=0.01, p<0.000) and reporting worry/tension about the child’s condition (AOR= 3.55, p=0.022). Mean time for seeking care at MMHH since the onset of symptoms was 66.8 months, with 69.5% reporting having not sought care within a week of onset of symptoms. Factors that were independently associated with delay in care seeking were: being cared for by single parents (AOR=2.71, p=0.018), having normal functioning (AOR=2.59, p=0.010), belief that the cause of illness was high fever or other (AOR=0.50, p=0.031), and having epilepsy (AOR=0.24, p=0.000). Stigma (50.0%), long distance (42.4%), and financial constraints (34.5%) were found to be common barriers to care. With regards to patients’ and caregivers’ perceptions of CAMHS in Tanzania, the overall mean score was 1.83 (median 1.9, interquartile range 1.55) indicating poor support. Health workers’ perceptions about CAMHS offered at MMHH had an overall mean score of 1.9 with median of 1.8 and interquartile range of 0.3, indicating limited to basic support. Conclusion: The primary initiators of care were parents, and the first choice of care pathway for a large proportion of the population continues to be through non-medical services. This study provided evidence that neuropschiatric morbidity is high; and that generally CAMH services in Tanzania are poor, the population is unaware about available services, and are further hampered by financial and distance constraints. Thus, there is a high unmet need and huge treatment gap for children and young persons with neuropsychiatric problems. Concerted efforts aiming to promote public awareness and services utilization are urgently required; as well as effective integration of CAMHS into district and primary care clinics.