Expanding mental health care in the Kingdom of

Eswatini: Successes, challenges and recommendations

from initial experiences in Lubombo Region

POLICY BRIEF

Leaflet highlighting healthy activities used in psychosocial counselling intervention

Background
In 2017, in collaboration with the Eswatini Ministry of Health, the National Psychiatric Hospital and
other regional stakeholders, COMDIS-HSD developed a brief psychological intervention for people
living with depression to be delivered by nurses in primary care in Eswatini.

Our aim was to improve accessibility of support for depression for all those in need living in
Eswatini. This 1-year initial phase assessed the feasibility and acceptability of this mental health
programme for people living with HIV/TB accessing care in nurse-led primary care in Eswatini.
 Our methods Ministry of Health Mental Health Desk Guide,
providing a comprehensive background on
This programme is not specific to HIV/TB mental health conditions, as well as specific
patients and can be used for anyone with training developed for Eswatini on our
depression. However, we decided to start with psychosocial intervention: a counselling
this group, because: intervention based on the WHO-supported
Behavioural Activation method, called the
‘Healthy Activity Programme’ (HAP). This is
 We know this group have a risk of specifically aimed for non-specialist heathcare
depression/anxiety, due to the condition, the
staff working in primary care.
medication, socioeconomic impacts of the
condition (such as an inability to work or the We asked the participating clinics to screen as
cost of travel to clinics), and social impacts
many of their HIV/TB patients as possible, using
(such as on family life and stigma and
a screening tool called the PHQ-9, which asks 9
discrimination) questions about the patient’s mood and
 We know also that depression/anxiety can wellbeing and is scored out of 27. If the patient
affect treatment adherence, which affects scored greater than 10/27, meaning they have
the individual’s prognosis, increases the risks moderate depression, we advised the nurse
of transmission and interferes with national offer a course of 5-8 counselling sessions. If
goals such as ’90-90-90’ they scored greater than 15, meaning they have
severe depression, we advised the patient also
 Both international and Eswatini national be referred to a doctor.
guidance for these groups advocates for the
inclusion of mental health support for this We trained doctors on our mental health
population. programme. Each clinic was given clinic and
patient-held cards to record information. We
16 nurse counsellors were trained from 8 sites used this monitoring information to evaluate the
across Lubombo. They received training from first 7 months of this programme. We also
the National Psychiatric Hospital on the Eswatini interviewed 21 patients and counsellors.

In under 2 months, 324 HIV/TB patients were screened in 7 sites.

62 patients screened positive for depression

70% of those with depression were female

19% While this is just a rough estimate, if this number were applied to
of these patients people living with HIV (not including TB) in Lubombo only, over
suffered from depression 7,500 people living with HIV could be living with depression1.

1 Population of Lubombo from the 2017 Census (211, 191) x proportion aged >15 years (0.62) x proportion adults HIV
positive from SHIMS2 study (29.4%) x number scoring >10 on PHQ-9 in the pilot (19%)—note that the eligibility for the
study was >18 years and these statistics relate to >15 years, meaning this is likely an underestimation.

2 Expanding mental health care the Kingdom of Eswatini www.comdis-hsd.leeds.ac.uk

 Map of sites that initiated counselling Of the 8 sites that were initially
involved, 7 screened for depression
and 6 sites initiated counselling.
The counselling service was offered
to 60 patients.

The 2 sites that withdrew did so due

to logistical problems, but they are
interested to start this programme
in the next phase.

Malindza Refugee Clinic

Siteki Public Health Unit
Ebenezer Clinic
Good Shepherd Hospital

Tikhuba Clinic

U-Tech Clinic

Number of patients attending

Most patients did not attend the
counselling sessions planned 5 sessions; however, as of the
end of September 2018:
70
 85% participants attended at least
Number of patients attending

60 one counselling session

50
 48% attended 3 sessions and 44%
40 attended 4 sessions (a number
most counsellors felt was sufficient
30 for most patients)
20
 26% had attended at least 5
10 sessions.

0
0 1 2 3 4 5 6 7 8
Patients attended sessions
approximately once/month, coinciding
Number of counselling sessions with collecting their medication refills.

Expanding mental health care the Kingdom of Eswatini www.comdis-hsd.leeds.ac.uk 3

 Outcomes Did patients improve?
The HAP was acceptable to counsellors and Participant mental health was monitored using
patients and, with adjustments, feasible to be the PHQ-9 tool at every session. The average
delivered in primary care and antiretroviral PHQ-9 dropped sharply after each session.
therapy (ART)/TB clinics in Eswatini. Extensive While the reasons behind this are complex, it is
feedback from clinics, counsellors and likely that patients’ mood is improving after
participants was sought to make improvements counselling.
and adjustments to the programme to make this
service more feasible in the Eswatini setting.

PHQ-9 Scores
16

14

12
Average PHQ-9

Threshold for ‘positive’

10

0
0 1 2 3 4 5

Session number

In their own words, patients state that HAP counselling made them feel happier, made them feel like
living, and made them more likely to take their antiretrovirals:

‘I found that my heart feels free ever since I got counselling. I

am so free and happy in my heart. There is no worries.’

‘It has helped because before HAP my lifespan was shortened,

but this getting into HAP my life span has extended. Now I
am able to plan for the future and ensure the legacy of my
children in case I pass away.’

‘It has positively touched me. It was educated and changed my

perception towards the pills, and I feel well.’

4 Expanding mental health care the Kingdom of Eswatini www.comdis-hsd.leeds.ac.uk

7 recommendations for policy and practice

Focus on mental healthcare

There should be continued focus on mental health care in Eswatini,
including improving access to basic management of common mental health
conditions in non-specialist primary care, such as counselling and
medication, given the significant need.

HAP counselling
HAP counselling should be developed as a first-line option for
non-specialist nurse-led primary care for moderate depression.

Sensitisation
All healthcare workers require sensitisation on mental health conditions and
the value and importance of counselling and other treatments.

Routine screening
HAP counselling can be provided through routine screening of a patient
group, for example people living with HIV/TB, and/or when there is clinical
signs or symptoms of depression in any patient attending the health facility.
The first 2 PHQ-9 questions are sufficient in a routine HIV-ART or TB
follow-up. This decision should be made regionally or nationally, based
on capacity and funding.

Good referral systems

Even with HAP counselling, some patients will need referral for further
counselling, psychotherapies or medication. It is essential that good referral
systems exist to the regional referral hospitals, where doctors are trained to
assess, prescribe and have access to anti-depressants. Good links are also
required to the National Psychiatric Hospital, both for advice and referrals.

Mentoring and supervision

Counsellors need regular mentoring and supervision from the Mental
Health Team at their regional referral hospitals.

Monitoring and evaluation

There is a need for ongoing monitoring and evaluation of mental health
care. Data on HAP counselling, referrals and quality of mental health care
should be collected on the Eswatini electronic health record system: Client
Management Information System (CMIS).

Expanding mental health care the Kingdom of Eswatini www.comdis-hsd.leeds.ac.uk 5

 6 challenges to consider for the future

Mental health care need

The extent of need for basic mental health care is not known for
Eswatini. Our crude estimates indicate that there could be many
thousands of individuals in need of this care. This makes service
preparation difficult.

Counselling capacity

Nurses in primary care provide many essential services to the people of

Eswatini and sometimes may lack the capacity to take time for
counselling. It is important that other services are not negatively
affected by this, and that nurses get the necessary support and time.

Incomplete counselling courses

Most patients did not complete a full HAP course (designed to be 5-8
sessions, ideally 2-weekly). This was sometimes due to 3-month
medication refills, with patients unable to attend in the interim due to
time or finances, sometimes because the counsellor was too busy or not
aware the patient was there and sometimes because patients did not
want to continue with the course. Some nurses felt that 3-4 sessions
was enough for their patients to benefit.

Treatment for severe depression

HAP counselling can only give support for moderate depression.
Severe depression, those at risk of suicide and serious mental
illness such as psychosis requires doctor and specialist input and
access to psychiatric medication. Access to quality mental health
care in secondary, tertiary and specialist care requires additional
and sustained focus and development concurrently.

Social barriers
Stigma, discrimination and misunderstandings remain significant
barriers to prevention and care of mental health conditions, both in the
community and in healthcare settings.

Multi-agency support

Our results indicate that traumatic experiences, such as sexual violence,

domestic violence and bereavement are common in patients
experiencing depression. This requires multi-agency focus in terms of
both prevention and care for these individuals.

6 Expanding mental health care the Kingdom of Eswatini www.comdis-hsd.leeds.ac.uk

7 successes of the psychological intervention
Our psychological intervention, delivered on HIV/TB patients in the Lubombo region,
demonstrates that it is feasible to improve accessibility of support for depression in
community clinics through HAP counselling.

Patient benefit
Nurse counsellors report that this service has helped their patients, changed their
understanding of patient behaviour, and enhanced and improved adherence to their
HIV/TB care.

Patient support
Patients report feeling relieved by having someone to talk to and supported and cared
for by their nurse counsellors. They report learning new skills and undertaking healthy
activities to help them with their mood. Patients that had suicidal thoughts prior to
counselling reported feeling better.

Establishing good links

Good links have been built between the Good Shepherd Hospital mental health
department and the community clinics, allowing for ongoing support and mentoring.

Successful referrals
Most patients with severe depression and/or suicidal thoughts have been appropriately
referred to doctors, with most of these patients being prescribed appropriate medication,
indicating functional community-hospital linkages.

Adequate record keeping

Record keeping in community clinics was generally good, allowing for good monitoring
of results.

Using feedback
Extensive feedback has been sought from all study participants, including counsellors,
clinic supervisors, regional matrons and patients. This is to improve the counselling,
training, guidance and advice, and to ensure that this package is contextualised and
appropriate for our Eswatini setting.

Transferable guidance
This package is in line with international guidance on the management of common
mental health conditions in primary care.

Expanding mental health care the Kingdom of Eswatini www.comdis-hsd.leeds.ac.uk 7

Contact
Good Shepherd Hospital Ministry of Health Eswatini
P.O. Box 2 P.O. Box 5
Siteki Mbabane
Eswatini (Swaziland) Eswatini (Swaziland)

Dr Nina Putnis Telephone: +268 2404 5514 / 2404 2431

Telephone: +268 7835 3940 Fax: +268 2404 74 20
Email: [email protected] Email: [email protected]

11/18
This project was
funded with UK aid
from the UK
government