Mendenhall, Emily, Mary J. De Silva, Charlotte Hanlon, Inge Petersen, Rahul Shidhaye, Mark Jordans, Nagendra Luitel, Joshua Ssebunnya, Abebaw Fekadu, Vikram Patel, Mark Tomlinson, Crick Lund. 2014. “Acceptability and feasibility of using non-specialist health workers to deliver mental health care: stakeholder perceptions from the PRIME district sites in Ethiopia, India, Nepal, South Africa, and Uganda.” Social Science and Medicine 118: 33-42.
Three-quarters of the global mental health burden exists in low- and middle-income countries (LMICs), yet the lack of mental health services in resource-poor settings is striking. Task-sharing (also, task-shifting), where mental health care is provided by non-specialists, has been proposed to improve access to mental health care in LMICs. This multi-site qualitative study investigates the acceptability and feasibility of task-sharing mental health care in LMICs by examining perceptions of primary care service providers (physicians, nurses, and community health workers), community members, and service users in one district in each of the five countries participating in the PRogramme for Improving Mental health carE (PRIME): Ethiopia, India, Nepal, South Africa, and Uganda. Thirty-six focus group discussions and 164 in-depth interviews were conducted at the pre-implementation stage between February and October 2012 with the objective of developing district level plans to integrate mental health care into primary care. Perceptions of the acceptability and feasibility of task-sharing were evaluated first at the district level in each country through open-coding and then at the cross-country level through a secondary analysis of emergent themes. We found that task-sharing mental health services is perceived to be acceptable and feasible in these LMICs as long as key conditions are met: 1) increased numbers of human resources and better access to medications; 2) ongoing structured supportive supervision at the community and primary care-levels; and 3) adequate training and compensation for health workers involved in task-sharing. Taking into account the socio-cultural context is fundamental for identifying local personnel who can assist in detection of mental illness and facilitate treatment and care as well as training, supervision, and service delivery. By recognizing the systemic challenges and sociocultural nuances that may influence task-sharing mental health care, locally-situated interventions could be more easily planned to provide appropriate and acceptable mental health care in LMICs.
Mendenhall, Emily, Shane A. Norris, Rahul Shidhaye, Dorairaj Prabhakaran. 2014. “Depression and Type 2 Diabetes in Low and Middle Income Countries: A Systematic Review.” Diabetes Research and Clinical Practice 103: 276–285.
Eighty percent of people with type 2 diabetes reside in low- and middle-income countries (LMICs). Yet much of the research around depression among people with diabetes has been conducted in high-income countries (HICs). In this systematic review we searched Ovid Medline, PubMed, and PsychINFO for studies that assessed depression among people with type 2 diabetes in LMICs. Our focus on quantitative studies provided a prevalence of comorbid depression among those with diabetes. We reviewed 48 studies from 1,091 references. We found that this research has been conducted primarily in middle-income countries, including India (n = 8), Mexico (n = 8), Brazil (n = 5), and China (n = 5). There was variation in prevalence of comorbid depression across studies, but these differences did not reveal regional differences and seemed to result from study sample (e.g., urban vs rural and clinical vs population-based samples). Fifteen depression inventories were administered across the studies. We concluded that despite substantial diabetes burden in LMICs, few studies have reviewed comorbid depression and diabetes. Our review suggests depression among people with diabetes in LMICs may be higher than in HICs. Evidence from these 48 studies underscores the need for comprehensive mental health care that can be integrated into diabetes care within LMIC health systems.
Mendenhall, Emily, and Lesley Jo Weaver. 2014. “Reorienting Women’s Health in Low- and Middle-Income Countries: The case of depression and type 2 diabetes.” Global Health Action 7: 22803 (5 pages).
Women’s health in low- and middle-income countries (LMICs) has historically focused on sexual and reproductive health. However, understanding how women acquire, experience, and treat non-reproductive health conditions, such as non-communicable diseases, has become a fundamental public health concern. Special attention to the social determinants of LMIC women’s health can provide socially and culturally relevant knowledge for implementation of policies and programs for women increasingly confronting these ‘New Challenge Diseases’. This article uses the example of depression and Type 2 diabetes comorbidity to illustrate how attending to the social determinants of mental and physical health beyond the reproductive years contributes to a more holistic agenda for women’s health. For instance, we must address the plurality of experiences that shape women’s health from social determinants of depression, such as gendered subjugation within the home and public sphere, to the structural determinants of obesity and diabetes, such as poor access to healthy foods and health care. Attending to the complexities of health and social well-being beyond the reproductive years helps the women’s global health agenda capture the full spectrum of health concerns, particularly the chronic and non-communicable conditions that emerge as life expectancy increases.
Bearnot, Benjamin, Angela Coria, Brian S. Barnett, Eva H. Clark, Matt G. Gartland, Devan Jaganath, Emily Mendenhall, Lillian Seu, Ayaba G. Worjohoh, Catherine L. Carothers, Sten Vermund, Doug Heimburger. 2014. “Global Health Research in Narrative: A Qualitative Look at the FICRS-F Experience.” Am J Trop Med Hyg. Epub Sep 22. pii: 13-0481.
For American professional and graduate health sciences trainees, a mentored fellowship in a low- or middle-income country (LMIC) can be a transformative experience of personal growth and scientific discovery. We invited 86 American trainees in the Fogarty International Clinical Research Scholars and Fellows Program and Fulbright–Fogarty Fellowship 2011–2012 cohorts to contribute personal essays about formative experiences from their fellowships. Nine trainees contributed essays that were analyzed using an inductive approach. The most frequently addressed themes were the strong continuity of research and infrastructure at Fogarty fellowship sites, the time-limited nature of this international fellowship experience, and the ways in which this fellowship period was important for shaping future career planning. Trainees also addressed interaction with host communities vis-à-vis engagement in project implementation. These qualitative essays have contributed insights on how a 1-year mentored LMIC-based research training experience can influence professional development, complementing conventional evaluations. Full text of the essays is available at http://fogartyscholars.org/.
Ibanez-Gonzalez, Daniel, Emily Mendenhall, and Shane A. Norris. 2014. “A mixed methods exploration of patterns of healthcare utilization of urban women with non-communicable disease in South Africa.” BMC Health Services Research, 14:528.
Lara Muñoz, María del Carmen, Elizabeth A. Jacobs, Marco Antonio Escamilla, and Emily Mendenhall. 2014. “Do women with diabetes experience depression equally in urban centers in Mexico and the United States? A comparative study.” Revista Panamericana de Salud Pública/Pan American Journal of Public Health, 36(4):225-231.
OBJECTIVE: To compare the prevalence and patterns of depressive symptoms among women with type 2 diabetes in Puebla, Mexico, and Chicago, United States. METHODS: Two cross-sectional studies were conducted independently, in Puebla (September 2010-March 2011) and in Chicago (January-July 2010). Depression symptomatology was evaluated in a random sample of 241 women self-reporting type 2 diabetes in Puebla and a convenience sample of 121 women of Mexican descent seeking care for type 2 diabetes in Chicago. Depressive symptomatology was measured by the Center for Epidemiologic Studies Depression Scale administered in either English or Spanish. Women were similarly socioeconomically disadvantaged with low education levels in both locations. RESULTS: The Chicago sample of women reported higher levels of depression than the Puebla sample (38% versus 17%, P < 0.0001). Among those with comorbid depression and diabetes in both sites, minimal variations in symptoms were observed. Depressive symptoms, specifically the subjective element (feeling sad) and symptoms associated with diabetes (fatigue and sleep problems) were heightened in both groups. More frequent reporting of “feeling fearful” was statistically significant in Puebla. CONCLUSIONS: Despite a higher prevalence of depression among Mexican immigrant women with diabetes in the United States compared to Mexico, there was little variation in their depressive symptoms, regardless of residence. However, women in Mexico did report a higher incidence of fear. Screening for depression in patients with diabetes should take into account symptoms of fatigue and sleep and the bi-directional relationship of depression and diabetes.
Seligman, Rebecca, Emily Mendenhall, Maria Valvidonos, Alicia Fernandez, Elizabeth A. Jacobs. 2014. “Self-care and subjectivity among Mexican diabetes patients in the United States.” Medical Anthropology Quarterly, 29(1): 61-79.
Type 2 diabetes is considered a public health crisis, particularly among people of Mexican descent in the United States. Clinical approaches to diabetes management increasingly emphasize self‐care, which places responsibility for illness on individuals and mandates self‐regulation. Using narrative and free‐list data from a two‐phase study of low‐income first‐ and second‐generation Mexican immigrants living with diabetes, we present evidence that self‐care among our participants involves emotion regulation as well as maintenance of and care for family. These findings suggest, in turn, that the ideology of selfhood on which these practices are based does not correspond with the ideology of selfhood cultivated in the U.S. clinical sphere. Divergence between these ideologies may lead to self‐conflict for patients and the experience of moral blame. We argue that our participants use their explanations of diabetes causality and control as a form of self‐making, which both resists such blame and asserts an alternative form of selfhood that may align more closely with the values held by our Mexican‐American participants.