UK Essay Writing Service - We accept all subjects. Just send us your instructions. Only £10 per page. www.mywritingassistant.com
Hong Kong Essay Writing Service - We accept all subjects. Just send us your instructions. Only HK$117 per page. www.mywritingassistant.com
Singapore Essay Writing Service - We accept all subjects. Just send us your instruction. Only SG$19.32 per page. www.mywritingassistant.com.
MENTAL HEALTH RESEARCH CENTER KENYA
2011
MENTAL HEALTH RESEARCH CENTER OF KENYA
Priorities for research into mental illness in the developing world are not the same as those in the West, writes Katherine Nightingale.There are 450 million people around the world living with a mental disorder.
MHRC KENYA
NAIROBI KENYA
Concept Paper for Initiating a
Mental Health Research Center in Kenya
FORWARD
MENTAL HEALTH RESEARCH CENTER
It is widely acknowledged that high quality research enhances strategic planning and service delivery. It is of equal importance to the policy maker, the practitioner and the user of the service. The challenge for the Mental Health Commission, in collaboration with all our stakeholders, is to promote research in the Irish mental health services which will be accessible and relevant to those working in the mental health services, involves users, addresses the complexities and changing needs in mental health and encourages innovation and critical appraisal. The Action Plan, outlined in this paper, will facilitate the development of a comprehensive body of research information and knowledge in relation to the mental health services in Kenya and, and promote strategic alliances between academic centre’s and institutions, and the mental health services.
This Concept paper has been prepared by
Dr. Nelly Kitazi Okatch. M.B.Ch.B., M.Med(Psych.)Assisted By Mr. Richard Kamonya BA( Hons)Public Adm. ,MA International Relations.
For Any Enquiries Please Contact:
Dr. Kitazi On nkitazi@yahoo.com Or Richard on jrkamonya@gmail.com
MENTAL HEALTH RESEARCH CENTER
The Proposed Mental Health Research Center will be an independent, statutory body under the auspices of KEMRI established by an Act of Parliament under the provisions of the Mental Health Act.
The principle functions of the Mental Health Research Center, will be specified in the Act, as it will promote, encourage and foster the establishment and maintenance of high standards and good practices in the delivery of mental health services and to take all reasonable steps to protect the interests of persons detained in approved centre’s. The Mental Health Research Center will also be empowered to undertake such activities as it deems appropriate to foster and promote these standards and practices. Its strategic plan will be based on the following six strategic priorities, one of which is “to promote and enhance knowledge and research on mental health services and treatment interventions”. One of the targets for achieving this strategic priority is to publish at least the research strategy for the Mental Health Research Center.
1.0 INTRODUCTION
1.1 WHY DO WE NEED A MENTAL HEALTH RESEARCH CENTER AND STRATEGY IN KENYA ?
Mental health is a key health issue. It has been stated that “there is no health without mental health” (Lavikainen et al., 2001). One quarter of the population can expect to be affected by a mental health problem at some time in their lives. Mental illnesses impose a significant burden on the health and well being of communities worldwide.
Five of the world's ten leading causes of disability are related to mental illness. The share of global disease burden associated with mental illnesses is predicted to grow further in the coming decades, increasing by almost 50%, from 10.5% of the total burden to almost 15% in 2020 (WHO, 2004).
Approximately 20% of all people will experience some form of mental illness in their lifetime. One of the challenges for mental health research is to ensure that the resources devoted to it reflect the prevalence, burden and cost of mental ill health in Kenya.
In spite of this significant burden of mental ill health, there is a scarcity or lack of high quality mental health research in Kenya that has an impact on mental health policy or service delivery. There is little published research in Kenya on how best to deliver high quality mental health services. What are the components that work and how can they be replicated? The capacity to carry out high quality research is certainly present, as evidenced for example, by the international collaborative studies being carried out by other institutions in developed countries e.g. The Health Research Board and the Virginia Commonwealth University (Straub et al., 2002), but their focus on genetic epidemiology is very specialist- and clinically-based.
“…evidence of effectiveness must inform the policy and decision-making process across the health system. An evidence- based approach will ensure clearer accountability and support improved outcomes generally.” (p. 86).
The promotion of an evidence-based approach to the provision of mental health services is one of the functions of the Mental Health Research Center. However, there is a lack of quality mental health research in Kenya that can direct service development in a strategic manner. Some of the reasons for this are explored here and the areas in which research has a critical function are outlined.
1.2 WHAT IS RESEARCH?
For the rationale of developing a research strategy it is useful to define what is meant by research. The Irish Health Research Board (HRB) Consultation Document Making Knowledge Work for Health (2000), gives a useful definition of research in this context:
“Research is an activity with the following characteristics:
1. It is intended to provide new knowledge and/or understanding
2. The results are generalisable. The methodology is designed so that the results will be of value to those facing similar problems or can be reproduced in similar circumstances
3. The findings are put in the public domain for critical examination and access by those who could benefit from them.” (p.14, HRB, 2000).
There are other activities that overlap with research to some extent, or share some features of this definition, such as routine data collection and clinical audit. These may contribute to the research process but do not fall completely within the definition described above.
1.3 RESEARCH GOVERNANCE
The fundamental principles and core values of the proposed Mental Health Research Center will apply to all aspects of the work of the Center, including research. Some may have a specific relevance to research and are expanded on here with a view to their relevance to mental health research:
* Achieving together - a partnership approach is essential to producing the highest quality research with greatest relevance to service users and providers. A typical mental health research study might involve; a multidisciplinary team, service users and carers, mental health service management/funders, a third-level institution, a research funding body and more;
* Empowerment and advocacy - the Commission is committed to facilitating the realization of the full potential of those availing of mental health services and promoting their best interests. This includes involving users and carers in all aspects of research, not just as subjects, but in designing planning, and carrying out studies;
* Quality - in research depends on those responsible for the research having the relevant skills and experience to deliver dependable research;
* Dignity and respect - all participants in a research study should be treated with dignity and respect at all times;
* Confidentiality - is an essential value of any research.
There are values which are specific to the conduct of high quality research which collectively come under the heading of research governance. We are familiar with clinical governance, which aims to continually improve the overall standards of clinical care. Research governance describes a process aimed at the continuous improvement of standards in research, and in the context of this strategy, of mental health research. A proper governance process is essential to ensure that the public and all those involved in mental health research have confidence in, and can benefit from research. Research governance has become even more important in light of the EU Directive on Good Clinical Practice in Clinical Trials (2001/20/EC). This directive aims to:
* protect the rights, safety and well- being of trial participants, consistent with the principles set out in the Declaration of Helsinki
* simplify and harmonise the administrative provisions governing clinical trials by establishing a transparent procedure that will harmonise conditions for co-ordinating trials in the EU by competent authorities, and to ensure the credibility of results.
1.4 OBJECTIVES OF THE MENTAL HEALTH RESEARCH CENTER
* To undertake sustainable, highest quality, basic neuroscience, clinical and public health research
* To promote understanding of and investment in research through advocacy
* To educate clinicians and researchers
* To provide expert commentary on the scientific basis of mental illness including psychotic illness (schizophrenia and depression) and neurodegenerative diseases (e.g. dementia and Alzheimer’s disease).
2.0 SITUATIONAL ANALYSIS OF THE STATE OF KENYAS MENTAL HEALTH
2.1.1 Mental Health In Kenya: A Prognosis
The Kenyan budget allocates less than 10 per cent of financial resources to the health sector despite the government’s stated commitment to the Abuja Declaration promising at least 15 per cent of its budget allocations to the health sector.
Out of this meagre allocation, the Ministry of Health allocates less than 0.01 per cent of their expenditure to mental health services countrywide.
The division of mental health at Afya House is woefully understaffed and practically unfunded, and the majority of mental health programmes in this country are funded by non-governmental organisations.
Occurrences in this country since the last days of the colonial administration have left no doubt about the need for a comprehensive mental health policy that adequately addresses the various challenges we face as a nation.
From the Mau Mau concentration camps to the periodic eruptions of collective insanity after elections, evidence abounds on the role of mental ill-health in our national troubles.
The Mental Health Act of 1989 established the Kenya Board of Mental Health as well as District Mental Health Councils to be financed by funds ‘‘voted for the purpose by Parliament’’.
It is unclear whether any of these bodies are operational after over 20 years since the Act was passed by Parliament. What is crystal clear is that there is still no vote for mental health in the budget for the Ministry of Health.
2.1.2 A lack of resources
Reasons for sparse research output is a shortage of mental-health workers, which stem from
1. A lack of funds.
2. Other health areas are simply more attractive, less stigmatising; there are more career options
3. More resources are given to them and the moment something has more resources — particularly in poor countries — people will be attracted to it, because survival is important to health workers as well.
4. Specialist outpatient and inpatient services
Evaluation of the status of mental health services in the country by the Ministry of Health in collaboration with this project reconfirmed that the country's health care system operates under extremely resource-restricted conditions, in terms of infrastructure, manpower and finances. Mental health specialist care is largely delivered at district level by psychiatric nurses running outpatient clinics, by psychiatric nurses at provincial levels running inpatient units and outpatient clinics, and by the national referral hospitals at Mathari, University of Nairobi, Gilgil hospital and Moi University.
5. Hospital capacities
The total number of hospital beds for a population of over 38 million is 1114 (750 beds but around 500-600 occupancy at Mathari; 40 beds at Moi University teaching and referral hospital at Eldoret; 100 beds at Gil Gill (established for long stay patients from Mathari but now takes acute cases as well); 6 provincial units of 22 beds each at Nakuru (Rift Valley), Kisumu (Nyanza), Nyeri (Central), Embu (Eastern), Port Reitz (Coast) Kakamega (Western); and 5 district units (Machakos 22, Isiolo 10, Kerugoya 20, Muranga, 20, Meru 12, Siaya, 8,) which works out at less than 1 bed per 34,000 population. In practice, in most provinces there are only 22 beds per 4 M i.e. 1 bed per 200,000 population. With the prevalence of probable psychosis running at over 1%, it would be helpful for every district hospital to have a 20 bed inpatient unit for brief admissions to assess and stabilise complex cases. This would still leave more than 99% of people with psychosis to be managed in the community by the health centre and dispensary levels.
6. Staff capacity and training
Kenya has its own self sustaining training programme for psychiatrists at the University of Nairobi, producing around 6 new psychiatrists per year, and the numbers have expanded from 16 psychiatrists in the public service in 2001, to 46 in 2009. In addition, there are 24 psychiatrists working in private practice In Kenya and another 20 outside the country. A further five trained in Kenya have already died. The psychiatrists in the public service are deployed to the national hospital Mathari (4 plus 1 on long term sick leave), the MOH HQ (3 plus 1 on secondment to the WHO country office plus 1 provincial director of medical services in Nairobi), the University of Nairobi (10), Kenyatta Hospital (6), Kenyatta University (2), Armed forces hospital (1), Moi University (6), Provincial hospitals (6 -Garissa has none), plus 5 placed in the district hospitals of Machakos (1), Thika (1), Muranga (1), Meru (1), and Kisii (1).
Thus it can be noted that the bulk of psychiatrists are in Nairobi, and that the effective psychiatrist population ratio outside Nairobi is 1 psychiatrist per province of 3-5 million people. North Eastern Province, an exceptionally difficult location adjoining Somalia, has no psychiatrist or psychiatric nurse. At the current rate of rolling out university graduates it will take about 100 years to turn out enough psychiatrists to have at least one in every district, taking into account retirement, and cutting out further brain drain. To illustrate this the University of Nairobi initiated in the year 2000 which had 37 students(Clinical psychologists) and psychiatric social workers from 2005 (currently 1 student). It initiated a new post graduate diploma in substance abuse with only 2 students.
There are 418 trained psychiatric nurses in Kenya of whom only 250 are currently deployed in psychiatry (the other 250 are deployed in general medical, surgical and obstetric services or in HIV centres), 70 are in Mathari National Hospital, leaving 180 in the districts and provinces, resulting in only less than 1 psychiatric nurse per new district or 2-3 psychiatric nurses per old district.
Sad as it may be, many psychiatric nurses have retired, died, left the country fo greener pastures or work in NGOs, especially linked to HIV activities, and new applicants for mental health nurse training are dwindling. Worse still is that 2009 churned out only one new psychiatric nurse for Kenya. There is 1 medical social worker in each province but none at district level, and there are social workers in prisons, probation services, the children's dept and the ministry of Social services.
There are a handful of psychologists in university or private practice in Nairobi. Thus the specialist service for nearly all regions and districts is largely delivered by extremely overstretched mental health nurses, who have had no access to Continuing Professional Development throughout their careers until that afforded by phase 2 of this programme of work, funded by Nuffield. This lack of human resource and the continued limited funding of mental health services both severely curtail access to specialist care, and this situation will rapidly get worse unless urgent action is taken to train more psychiatric nurses. The Ministry of Health is planning to offer 10 bursaries for training mental health nurses next year, but if the numbers are to expand rather than simply replace losses, that figure will need to double.
The production of other specialist cadres would also benefit from support.
1. Kenya is not alone. Low-income countries have an average of only five psychiatrists and one-and-a-half psychiatric nurses per million people. Chad, Eritrea and Liberia have just one psychiatrist each.
2. Half of the developing countries studied in a report by the Global Forum for Health Research and the WHO had fewer than five mental health researchers. A similar proportion of universities had the equivalent of US$10,000 per year to spend on mental health research, and many active researchers spend only 25 per cent of their time on research.
2.1.3 Depending on the donor
Dependence on international funding is another factor controlling the level of research. Few funding bodies specifically support mental health in developing countries — there is no 'global fund' for mental health.
The behemoth of global health funding, The Bill and Melinda Gates Foundation, gives no money directly to mental health research, and others, such as the UK Department for International Development, do not keep track of money allocated to mental health.
It is possible that mental health research is not as attractive to donors as, say, infectious disease, because there isn't as much potential for 'success'.
[Infectious diseases] are things that you can cure — and if you can do research that demonstrates that you can control disease, then you make a huge impact with chronic diseases, such as mental health, it is much harder to demonstrate an impact, and this usually requires a sustained intervention rather than a simple short one, he adds.
The agendas of Western funding bodies such as the Gates Foundation are often very different from agendas in developing countries. In poor countries, they have to be donor-driven.
The argument here is that the people who are making health policy for developing countries are implying that the health needs of these countries are different to those of their own families… heart disease, depression etcetera.in this case what happens is that once countries develop and become free of donor money, mental health is prioritised — a situation that has been experienced in India.
Another argument that can be raised is that agencies do not make their funding decisions from ivory towers. They do not dream up their own priorities without any regard for what the morbidity burden or priorities might be in developing countries.
Funding agencies often "get out and about", talking to researchers and policymakers in countries.
One of the problems is that research that delivers treatment, is "difficult to do well" and often not particularly exciting or appealing to some funding bodies who want to be seen as at the cutting edge.
The Wellcome Trust spent five per cent of its total mental health research budget on global mental health between 1994 and 2004 — about US$55 million.
2.1.4 Getting it out there
But even when research is being carried out in developing countries, researchers often find it tricky to publish in peer-reviewed journals and are therefore unable to use their publications as scientific 'currency' to build up their reputation.
When researchers try to get published, they are occasionally limited access to quality and up-to-date information, lack of training in trial design and protocol, and, all compound issues already thrown up by a lack of material and financial resources.
Mental health researchers are not alone in this regard; those in all fields in developing countries suffer from the same problems. But the publishing community seems to be coming to mental health researchers' aid.
In 2004, 42 editors of journals that publish mental health research signed a statement, along with the WHO, saying they aimed to reduce the gap between developed and low- and middle-income countries in published research by helping authors overcome impediments to publication (see 'Journals to bolster mental health research').
It is perhaps too early to say whether this [2004 statement] has had an effect. But journals should be wary not to publish work that is sub-standard simply because of its source. When [editors] are reviewing research from a developing country, there needs to be a sensitive review group, that is a critical thing, but that cannot be in lieu of a minimum acceptable quality of research.
2.1.5 Finding a way forward
But how to get research done?
The anticipation is that the Government of Kenya and some of the biggest donors will adopt mental health and look at capacity building, not necessarily mental health research capacity building, but integrate mental health into existing research programmes.
3.0 THE IMPORTANCE OF HAVING A MENTAL HEALTH RESEARCH CENTER
A. Service planning
The first step in providing equitable mental health services is a population- based needs assessment. Services cannot be planned without some knowledge of how many people in the population need what service. The type of questions faced by service planners includes; how many adolescents in our catchment area are likely to develop a psychosis? How long they are likely to need specialist services and what type of services they will need? How many people in our catchment area have depression that needs treatment in a specialist mental health facility? What are the particular needs of these individuals and how best can our services meet these needs? These are questions that must be answered if services are to be planned that will be responsive, effective and equitable. These are questions that can be answered through accessing available information and specific research. Some have already been answered and many more remain to be answered.
B. Effective services
Most research is conducted at the level of the individual; answering questions such as how effective a specific intervention is for a specific problem. This type of research is essential in providing evidence-based care, so that interventions that have been shown to be effective are available for service users. How we should structure our services around the individuals and their different needs is not so well understood, as the management and organisation of mental health services is an often neglected aspect of research. What model of service delivery is most effective and efficient? What interventions should be provided in what settings? Service level research is needed to answer such questions. Service providers must be familiar with current best practice in their area and be able to access and understand data and methodologies to implement best practice.
C. Driving mental health service development
Rigorous, well-conducted research has the potential to lead to more responsive, efficient and effective mental health services. However, mental health service- based research has so far had little effect on shaping policy or driving service developments (Fitton, 2002). One of the key reasons for this is the lack of dissemination of research findings. A good deal of mental health research is carried out in Kenya, but it tends to remain very local and therefore others don’t find out about potentially useful service innovations or interventions. There are also gaps in our knowledge in terms of what works best in the organisation and delivery of mental health services. Larger scale, more sophisticated studies may be required to identify the mechanisms whereby interventions are effective, and part of this process is ensuring that the relevant staff are appropriately trained in delivering these interventions (Thornicroft et al. 2002). High quality mental health research, designed with a view to dissemination is required to drive further mental health service developments.
D. Driving staff development
The opportunity to carry out research is a requirement of the contracts of some health care staff, and is strongly supported by the professional organisations of all disciplines as essential for continuing professional development (CPD). It is also an important factor in creating a dynamic working environment and thus helps in retaining staff.
E. Mental health information
There is no national mental health information system. Mental health services around the country vary greatly in the information they collect, how it is collected and the IT infrastructure available to do this. A few services have well developed, comprehensive, computer-based information systems which capture the activity and to some extent the outcome of mental health services on an individual patient basis. The vast majority of services however, still work from paper-based systems. Limited service-based information is available (for example a total count of attendances at a service) but information which needs to recorded on an individual patient-basis (such as diagnosis, to report diagnostic profile of attenders) is not routinely available. We thus need a Health Research Board [HRB] which will endevour to provide useful national information on inpatient activity at he the same time there is the need to have a National Psychiatric Inpatient Reporting System [NPIRS], but this is only one part of mental health services required. Limited information on community-based services is not available from reports generated from grassroots levels. All mental health information in Kenya is limited by the lack of a unique identifier for service users. Thus having an NPIRS tool can tell us the total inpatient admissions for a year, as is the case now we may not know how individuals were admitted. There is also a clear lack of investment in mental health information, compared to the Hospital Inpatient Enquiry (HIPE) [see data in appendix].There is no such infrastructure for mental health information.
Good quality information is a pre- requisite to mental health research and much of the time and effort in mental health research in Kenya is taken up with collecting the type of information that should be readily available from a computer-based information systems.
3.1 Research infrastructure
Research infrastructure for mental health is greatly underdeveloped in Kenya. There is no identified fund for mental health research and no national strategy for mental health research. The lack of an identifiable mental health research infrastructure makes it very difficult for interested individuals in mental health services to carry out research, as they must firstly devote time to procuring funding for essential items such as computers before they can carry out even basic research. Unfortunately, researchers can find themselves in the vicious cycle of being unable to secure funding in a grants process because of the lack of a track record in research and the lack of an established infrastructure.
Research is a way of generating funding for support staff who can then facilitate a wider research function, thereby drawing in more research funding. It is often a matter of creating a ‘critical mass’ of research infrastructure to enable individuals to produce useful, high quality research, which in turn, enables them to apply for grants and further enhance their research capability.
3.2 Summary
The central answer to the question of why we need a Mental Health Research Center and Strategy is because of the shortage of mental health research in Kenya and the lack of impact of most of the mental health research that has been carried out.
* What works in Kenyan mental health services and why does it work?
* What do we need to ensure more high quality, effective mental health research is carried out?
A Mental Health Research Center will give an overall direction and guidance to mental health research in Kenya and will help prioritise issues and identify areas for action to produce real results. The crucial aim of establishing a Mental Health Research Center is to promote a mental health research community that is dynamic, productive and innovative, producing high quality research that is receptive to service needs, involves users, helps create services that are evidence-based, and which impacts positively on how mental health services in Kenya are planned, implemented and evaluated. In this case the strategy involved here encompasses all mental health services, all disciplines involved in providing mental health services, service users and carers, voluntary organisations and other organisations involved in mental health and related research.
The crucial aim of this Mental Health Research Center is to promote a mental health research community that is dynamic, productive and innovative, producing high quality research that is receptive to service
Following an examination of the context for mental health research nationally and internationally, a series of actions will be outlined in order to achieve this aim.
needs, involves users, helps create services that are evidence-based, and which impacts positively on how mental health services in Ireland are planned, implemented and evaluated.
3.3 The (Kenyan) national context
There is no national policy devoted to Mental Health Research. Making Knowledge Work for Health - A Strategy for Health Research (Department of Health and Children, 2001) is the national strategy for health research. Health research is important because:
1. research is a key factor in promoting health, combating disease, reducing disability and improving quality of care
2. Research is vital if health services are to become more efficient and effective. The importance of research in encouraging health professionals to undertake their training and seek employment in Kenyan health services is of vital importance. The need for the establishment of a research and development function within health services has to be acknowledged, and to achieve this concept paper recommend that:
A. A research and development officer be appointed to the Ministry of Health
B. Research and development officers be appointed in health boards and in specialist health agencies
C. Health boards and specialist agencies should prepare institutional research strategies that reflect health service priorities
D. A Forum for Health and Social Care Research be set up to advice on agreed research agendas and address the main objectives of the health services.
Unfortunately, there is non of these in our current Mental Health administrative systems and the research function is still seriously underdeveloped. This leaves a critical vacuum at the Department of Health and Health Board level, with no direction on research and no means or funding to develop this function., or the proposed County Health Boards.
It could be argued that they have an even greater resonance for mental health research as the capacity for this type of research is so underdeveloped in Kenya, compared to other areas of health research which are more technologically based. This is reflected in the provision of research grants for health research by donors.
3.4 Health Strategy
We propose a high-performing research and academic community” and recommend that academic research centers be created as an authoritative source of policy and practice advice.
3.5 Status Mental Health Research In Kenya
Mental health research and other research relevant to mental health is currently carried on in individual mental health services by interested professionals in all disciplines, by voluntary organisations such as, in universities and other academic institutions, and in other organisations. Research that is carried out by individuals is often poorly funded, or not funded at all, is ad hoc and very local.
Larger scale, well-funded research tends to focus on clinical issues. For example, of the four studies funded by the HRB in recent years which focus on schizophrenia, three are concerned with genetics and one is a service innovation on carer education.
3.6 Conclusions
In the overall health service, research and information have traditionally had a low profile. Health service providers have tended to focus on delivering services on a reactive basis. A strategic approach to planning and developing health services has been adopted relatively recently. In this type of culture, research and information are greatly undervalued; an “add-on” activity, to be indulged in when an individual or service has the time and some funding.
These observations are equally true for mental health services. It could be argued that the functions of information and research are even more poorly developed in mental health than in general health services.
4.0 THE INTERNATIONAL CONTEXT
4.1.1 EUROPEAN UNION (EU)
Under the health information and knowledge strand of the Public Health Programme of the EU, a Mental Health Working Party was established in 2003. The aim of the Working Party is to contribute to the improvement of information and knowledge and to the promotion of positive mental health and well-being and prevention of mental ill-health. Among the tasks of this Working Party are:
* to contribute to the compilation and development of a sustainable health monitoring system in the field of mental health, to the collection, sharing and diffusion of mental health data
* to advise on the preparation of a European strategy in mental health
* to evaluate, benchmark and diffuse national “good and best practices”
* to examine the possibilities of common evidence-based actions.
As this working party has only recently been established it has had a limited impact to date.
4.1.2 ENGLAND AND WALES
A recent development in England and Wales is the establishment of the National Institute of Mental Health in England (NIMHE), the aim of which is to work with others to improve services and support for people who experience mental distress. One of the standing programmes for the NIMHE is the Mental Health Research Network (MHRN), the principle aims of which are:
* to organise and deliver large-scale research projects to inform policy and practice as it develops, and to help services implement change
* to broaden the scope and capacity of research, including full involvement of service users and carers in commissioning and delivering research
* to help identify the research needs of mental health (particularly in health and social care), working with frontline staff, service users and carers
* to develop research capacity through a range of initiatives at a local, regional and national level.
The MHRN supports high quality research that will remain useful over time, connects research to practice and will ultimately improve the quality of treatment and care for people using mental health services.
There are seven key priority areas for research in England and Wales, one of which is mental health. The Policy Research Programme commissions research to support a wide range of policy activity in health and social care and the Research Capacity Development Programme provides personal awards and funds academic infrastructure to support research capacity development within the NHS. In England and Wales, the Department of Health spent approximately £540 million (2002-2003) through these research programmes on health research in general (not just mental health research).
4.1.3 THE WORLD HEALTH ORGANISATION [WHO]
The World Health Organisation Report (2001) Mental Health: New Understanding, New Hope, is a seminal report which marked the beginning of a renewed interest in mental health internationally. This report specifies ten recommendations for action which are key values or principles which WHO believes should be adapted by each country according to its needs, and implemented to improve mental health services. One of these ten recommendations is to support more research. The different areas of mental health research discussed in the WHO report are:
A. Epidemiological research - epidemiological data are essential for setting priorities within mental health and for designing and evaluating public mental health interventions. While the National Psychiatric Inpatient Reporting System managed by a Health Research Board will provide data on one part of mental health services, there is a paucity of information on the prevalence and the burden of major mental and behavioural disorders in Kenya;
B. Treatment, prevention and promotion outcome research - effective interventions must be developed and disseminated. WHO believes there is a ‘knowledge gap’ concerning the efficacy and effectiveness of pharmacological, psychological and psychosocial interventions. A distinction is made between efficacy research, which refers to “the examination of an intervention’s effects under highly controlled experimental conditions”, and effectiveness research, which “examines the effects of interventions in those settings or conditions in which the intervention will ultimately be delivered.” Where there is an established knowledge base for an intervention, as there is for the efficacy of a number of psychotropic drugs for example, there needs to be a shift in research emphasis towards the conduct of effectiveness research. There is also an “urgent need” for implementation research into those factors likely to enhance the uptake and utilisation of effective interventions in the community. This describes what is termed “service- based research” in this strategy and will be the focus of Priority Four of the Mental Health Research Center;
C. Policy and service research - among the priorities for WHO under this heading is an examination of training requirements for mental health professionals, given the critical importance of human resources for administering treatments and delivering services. More research is needed on informal care and the interface with primary care. WHO also believes more research is required to understand better the effects of policy decisions on access, equity and treatment outcomes;
D. Economic research - given the great potential economic evaluations have to provide information to support choice of interventions and rational planning, it is important that there is local information on the costs of mental illness and local economic evaluations of treatment, prevention and promotion programmes. There is a paucity of up-to-date local data on costs in Kenyan Mental Health Services, or on the costs of mental illness in Ireland.
4.1.4 UNITED STATES
The importance of mental health research is also recognised in the report of the New Freedom Commission on Mental Health (2003) in the United States. This Commission was created in 2002 and was charged with studying the problems and gaps in the mental health system and making concrete recommendations for immediate improvements that the Federal government, State governments, local agencies, as well as public and private health care providers could implement.
The Commission identified six goals as: the foundation for transforming mental health care in America. It was stressed that these goals are “intertwined” and that no single step can achieve the restructuring that is needed to transform the system.
One of these six goals (Goal 5) states that: “Excellent mental health care is delivered and research is accelerated”. The recommendations under this goal are:
* Recommendation 5.1: Accelerate research to promote recovery and resilience, and ultimately to cure and prevent mental illnesses.
* Recommendation 5.2: Advance evidence-based practices using dissemination and demonstration projects and create a public-private partnership to guide their implementation.
* Recommendation 5.3: Improve and expand the workforce providing evidence-based mental health services and supports.
* Recommendation 5.4: Develop the knowledge base in four understudied areas: mental health disparities, long- term effects of medications, trauma and acute care.
The National Institute for Mental Health in the US (which is the national body for mental health research) has a budget of approximately $1.3 billion (2003) to support in-house research and research in universities and hospitals.
5.0 MENTAL HEALTH RESEARCH INFRASTRUCTURE
The requirements to undertake Mental Health Research include the following:
1. The availability of individuals with expertise in conducting research, including expert advice on research design, IT/computer hardware and software, expert statistical advice, other experts in the relevant area
2. Sufficient computer facilities and appropriate software
3. Library resources and internet access
4. Individuals who can assist in data input and offer research assistance in terms of interviewing subjects and collating information
5. access to peer review systems and ethics committees
6. Research funding.
The central requirement for Mental Health Research is usually for people rather than physical infrastructure, that is, interviewers and experts who can design and carry out a research study. However, many research grants are directed towards the provision of the type of sophisticated testing equipment and laboratory supplies that are required for clinical/bio-medical research.
5.8 FUNDING FOR MENTAL HEALTH RESEARCH
The provision of any infrastructure requires financial resources. There is No Budget for Mental Health Research in the Ministry of Health [Kenya] as is the case in the UK for example. This is probably due to the lack of an explicit Research and Development Function as discussed earlier.
One of the main sources of funding for any research in Kenya is through research grants from a number of funding bodies and most mental health research is done at University level through cost sharing or through sponsorships. The Kenya Medical Research Institute through CDC, USAID and other funding agencies is one of the main providers of funds for health research in Kenya. Health boards provide ‘one-off ’ type funding for small-scale, local research projects, and voluntary organisations fund research in a similar way. One of the objectives of having at the proposed Mental Health Research Center is to support high-quality, inter-disciplinary and inter-institutional research.
When mental health is competing with many other specialties’, it tends not to do well. For example, it has been shown that in Australia, mental illness contributes 19% to the total disease burden (ahead of cardiovascular disease and cancer) but receives less than 9% of national medical research funding (Jorm et al., 2002). One possible solution to this is to have ring- fenced funds for mental health research.
One of the key funders in mental health research is the pharmaceutical industry. The main area of funding is for drug trials. While this funding is undoubtedly useful for carrying out research, the implications of this source of funding must be considered. The influence exerted by drug companies is significant and varied, focusing on individual psychiatrists, medical education, health service initiatives, the organisation of research and the dissemination of research findings. The implications of this influence are far-reaching. It has been argued that the influence of drug companies has “helped to create and reinforce a narrow, biological approach to the explanation and treatment of mental disorders and had led to the exclusion of alternative explanatory paradigms. In addition, alternative treatment approaches are neglected…and…the adverse effects of drugs are neglected.” (p. 1 Moncrieff, 2003).
Bodenheimer (2000) has reported that the pharmaceutical industry now underwrites 70% of research into drug treatments, and he has concluded that “trials conducted in the commercial (research) sector are heavily tipped towards industry interests.” There are also concerns around the presentation of findings from drug trials, given the fact that drug companies now control most of the process of most clinical trials from design and implementation through to data analysis, publication and dissemination (Bodenheimer, 2000; Healy and Cattell, 2003).
Codes of ethics for most professions cover sponsorship of clinical trials. There are guidelines to this effect which state that doctors should not permit their relationship with commercial firms to influence their attitude towards the design or the results of trials. A partnership approach to research means that we must be aware of ethical guidelines and balance the good arising from the research that can be carried out, with the implications of accepting funding from a vested interest or an agency with a commercial agenda.
In institutions where one of the main functions is research, such as academic institutions and teaching hospitals, there is already an infrastructure in place that does not require separate funding, for example, library resources, computing resources and the availability of expert advice. In these situations, individuals interested in research are in a supportive environment which facilitates the preparation of proposals to access funding for their research. Individuals in a different situation, for example, those working in services with no links to a teaching hospital or academic institution, have little expert support in preparing a research proposal, and also have to look for assistance in setting up the very basic infrastructure (such as a computer) which is readily available in other institutions. Thus it is more difficult for such individuals to access funding and to create the infrastructure which would enable them to access funding.
In summary, there are many barriers to conducting Mental Health Research in Kenya. At the policy level, it is just mentioned but not given any priority thus actually leaving a vacuum in terms of direction, priority setting and funding for health research. Sadly there is no National Mental Health Research Strategy. There is little established research capacity for carrying out mental health research. With a lack of support for mental health research at national and local health levels, mental health research is left up to interested and committed individuals fitting research into already over-stretched schedules.
However, there are opportunities to be seized in mental health research. The establishment a mental Health Research Center and the provisions of a proposed mental Health Act, should be able to facilitate an environment in which research will be of central importance in mental health services. It is also hoped that by initiating a Mental Health Research Strategy this will help build capacity for mental health research and create a culture in which mental health research and information is seen as a central, underpinning function in the provision of high quality mental health services.
5.9 ACTION PLAN FOR THE MENTAL HEALTH RESEARCH CENTER
Some of the structural barriers to mental health research have been discussed in this strategy; chief among them being the lack of infrastructure for mental health research. The importance of research governance and the provision for mental health research nationally and internationally have been outlined. If mental health research in Kenya is to progress it is clear that the following areas need to be addressed:
a) capacity for mental health research
b) systems for recording and disseminating knowledge on best practice in the mental health services
c) creating links in mental health research
d) The research agenda and priorities.
1. Building capacity for mental health research
The lack of mental health research infrastructure was discussed above. Some basic requirements for mental health research include the availability of:
* Individuals with expertise in conducting research, including expert advice on designing and planning research, IT/computer hardware and software, expert statistical advice, other experts in the relevant area
* Sufficient computer facilities and appropriate software
* library resources and internet access
* Individuals who are competent in fieldwork, can assist in data input and offer other research assistance
* Access to peer review systems and ethics committees
* Research funding.
It is proposed that the proposed Mental Health Research Center initiate the following practical steps to set up infrastructure for mental health research:
* Produce guidance on ethics committees and peer review processes for mental health research
* Encourage the establishment of regional ethics committees for mental health research
* produce guidance on Data Protection
* Acts and the Freedom of Information Act
* Create awareness among individuals involved in mental health research of facilities that are already available in health services, such as library services, IT facilities and expertise
* Produce a directory of sources of research funds.
As funding is probably the greatest single impediment to conducting service-based mental health research, it is proposed that the Mental Health Research Center establish a number of research fellowships to enable interested, suitably skilled individuals to conduct research on identified, priority areas.
It may be worthwhile to conduct a brief study among those working in mental health services to establish what they see as the greatest barriers to conducting mental health research. This would enable the Research Center to prioritise the above actions and identify other areas that aneed to be addressed.
2. Recording and disseminating mental health research
One of the barriers to the conduct of high quality mental health research in Kenya is the isolation of many of those involved in this research. This is not just geographical isolation, but also isolation in terms of lack of infrastructure, such as being the sole individual trying to design and conduct a study, or not being able to access advice or expertise on different aspects of research. There can also difficulties in establishing what research has already or is currently being done in Ireland, particularly if it is in the “grey literature” (i.e. not widely published).
It is proposed that the Mental Health Center establish a Kenya Mental Health Research Association and Database (KMHRA & D) to put researchers in touch with each other and to create a system that will record the mental health research carried out in Kenya.
3. Partnership in mental health research
Mental Health Research Strategy
There are strong indications that a process for a partnership approach to supporting research for health is in existence. Partnerships will also be one of the core values of the proposed Mental Health Research Center. A partnership approach to mental health research is one which would involve service providers, researchers, service users and carers, academic institutions, voluntary bodies and the healthcare industry.
Involving users in health services is key since it envisages a people-centered health system that “helps individuals to participate in decision-making to improve their health.” Involving service users in research is another step in that process. This means involvement not just as subjects, but in designing and carrying out research studies. In their paper on Creating the infrastructure for mental health research, Thornicroft et al. (2002) list user participation as one of the important gaps in research coverage. They recommend that there should be a review to establish “meaningful and sustainable ways in which users can directly participate in research.”
While some research relevant to mental health is carried out in third level institutions and other research bodies, there are few, if any, formal links between academic researchers and mental health service providers. To promote these links, and the concept of partnership in mental health research, it is proposed that:
Mental Health Research Centre be set up in at KEMRI to carry out multidisciplinary, service- based mental health research. This centre could also pioneer models for involving service users in research which could then be adopted by other researchers.
The healthcare and pharmaceutical industry also have a role in mental health research. In order to clarify this role in light of the potential conflict of interest for researchers funded by drug companies, it is proposed that guidelines be drawn up for the involvement of pharmaceutical companies in mental health research.
4. Setting the mental health research agenda
The Mental Health Center will cover all mental health services and will have the mandate to promote, encourage and foster the establishment and maintenance of high standards and good practices in the delivery of mental health services. In the course of its work, issues which require further examination or clarification will be identified by the Center. Progress can be made on these issues by identifying them as priorities for further research.
It is proposed that a Mental Health Research Committee be established by the Mental Health Research Center as a mechanism by which to set the mental health research agenda. This committee could liaise with stakeholders regarding their research priorities, and could draw on Kenyan and international research to inform this priority setting. In order to reflect the range of interests in mental health care, this committee should be multidisciplinary, and include service users. Individuals with a well established and varied research experience should be included.
Some of the possible research topics that could be considered include but not limited to the following;[see Document for administration of research center]
1. Identifying in a more systematic manner the components of successful community-based mental health services so that they can be replicated elsewhere
2. Establishing reliable cost data for Kenyan Mental Health Services. These data could be used in service evaluations and could also help the Mental Health Center advocate for infrastructure and funding
3. The use of a variety of methodologies in mental health research, in particular the greater use of qualitative methods. Randomized controlled trials, while recognised as the gold standard for answering questions on the efficacy of interventions, are not the best method for assessing effectiveness that is the usefulness of an intervention under everyday conditions. Methodologies using mixed methods, such as case studies, are very useful for answering more complex questions concerning the organisation and structure of services, which will be an important issue in the Kenyan Mental Health services.
REFERENCES
Bodenheimer, T. (2000) Uneasy alliance - clinical investigators and the pharmaceutical industry. New England Journal of Medicine, 342, 1539-1544.
Department of Health and Children (2001) Quality and Fairness - A Health System for You. Health Strategy. Stationery Office, Dublin.
Department of Health and Children (2001) Primary Care a New Direction. Health Strategy. Stationery Office, Dublin.
Department of Health and Children (2001) Making Knowledge Work for Health. A Strategy for Health Research. Stationery Office, Dublin.
Department of Health and Children (2004) Health Information: A National Strategy. Stationery Office, Dublin.
Department of Health (2004) Final Report. Research for Patient Benefit Working Party. www.dh.gov.uk/PolicyAndGuidance/Research And Development//Research and Development AZ/Priorities for Research
Department of Health (2002) Research Governance Framework for Health and Social Care. www.dh.gov.uk/PolicyAndGuidance/ Research and Development European Parliament (2001) Directive 2001/20/EC Good Practice in Clinical Trials. Official Journal of the European Communities.
Fitton (2002) Establishing the Mental Health Research Network. The National Institute for Mental Health in England, Manchester.
Health Research Board (2000) Making Knowledge Work for Health. Consultation Document. Health Research Board, Dublin.
Healy, D. & Cattell, D. (2003) The interface between authorship, industry and science in the domain of therapeutics. British Journal of Psychiatry, 183, 22-27.
Jorm, A.F., Griffiths, K., Christensen, H and Medway, J. (2002) Research priorities in mental health Part I: An evaluation of the current research effort against the criteria of disease burden and health system costs. Australian and New Zealand Journal of Psychiatry, 36, 322-326.
Lavikainen, J., Lahtinen, E and Lehtinen, V. (2001) Public Health Approach on Mental Health in Europe. National Research and Development Centre for Welfare and Health, STAKES, Finland.
Medical Council (2004) A guide to ethical conduct and behaviour. Sixth edition. Medical Council, Dublin.
Mental Health Commission (2003) Strategic Plan 2004-2005. Mental Health Commission, Dublin.
Moncrieff, J. (2003) Is psychiatry for sale? Maudsley Discussion Paper. Institute of Psychiatry, London.
Northern Ireland Association for Mental Health & Sainsbury Centre for Mental Health (2004) Counting the Cost: The economic and social costs of mental illness in Northern Ireland. Northern Ireland Association for Mental Health Sheikh, A.A. (2002) Genetic Research and Human Biological Samples. Health Research Board, Dublin.
Straub, R.E. Jiang, Y., McClean, C. J., et al. (2002) Genetic variation in the 6p22.3 gene DTNBP1, the human ortholog of the mouse dysbindin gene, is associated with schizophrenia. American Journal of
Human Genetics, 71(2): 337-48.
The President’s New Freedom Commission on Mental Health (2003) Achieving the Promise: Transforming Mental Health Care in America.
Final Report. www.mentalhealthcommission.gov
Thornicroft, G., Bindman, J., Goldberg, D., Gournay, K and Huxley, P. (2002) Creating the infrastructure for mental health research. Psychiatric Bulletin, 26, 403-406.
Tyrer, P. (2002) Commentary: research into health services needs a new approach. Psychiatric Bulletin, 26, 406-407.
World Health Organisation (2001) Mental Health - New Understanding, New Hope. World Health Organisation, Geneva.
World Medical Association (1964) Declaration of Helsinki. Ethical Principles for Medical Research Involving Human Subjects. www.wma.net
2011
MENTAL HEALTH RESEARCH CENTER OF KENYA
Priorities for research into mental illness in the developing world are not the same as those in the West, writes Katherine Nightingale.There are 450 million people around the world living with a mental disorder.
MHRC KENYA
NAIROBI KENYA
Concept Paper for Initiating a
Mental Health Research Center in Kenya
FORWARD
MENTAL HEALTH RESEARCH CENTER
It is widely acknowledged that high quality research enhances strategic planning and service delivery. It is of equal importance to the policy maker, the practitioner and the user of the service. The challenge for the Mental Health Commission, in collaboration with all our stakeholders, is to promote research in the Irish mental health services which will be accessible and relevant to those working in the mental health services, involves users, addresses the complexities and changing needs in mental health and encourages innovation and critical appraisal. The Action Plan, outlined in this paper, will facilitate the development of a comprehensive body of research information and knowledge in relation to the mental health services in Kenya and, and promote strategic alliances between academic centre’s and institutions, and the mental health services.
This Concept paper has been prepared by
Dr. Nelly Kitazi Okatch. M.B.Ch.B., M.Med(Psych.)Assisted By Mr. Richard Kamonya BA( Hons)Public Adm. ,MA International Relations.
For Any Enquiries Please Contact:
Dr. Kitazi On nkitazi@yahoo.com Or Richard on jrkamonya@gmail.com
MENTAL HEALTH RESEARCH CENTER
The Proposed Mental Health Research Center will be an independent, statutory body under the auspices of KEMRI established by an Act of Parliament under the provisions of the Mental Health Act.
The principle functions of the Mental Health Research Center, will be specified in the Act, as it will promote, encourage and foster the establishment and maintenance of high standards and good practices in the delivery of mental health services and to take all reasonable steps to protect the interests of persons detained in approved centre’s. The Mental Health Research Center will also be empowered to undertake such activities as it deems appropriate to foster and promote these standards and practices. Its strategic plan will be based on the following six strategic priorities, one of which is “to promote and enhance knowledge and research on mental health services and treatment interventions”. One of the targets for achieving this strategic priority is to publish at least the research strategy for the Mental Health Research Center.
1.0 INTRODUCTION
1.1 WHY DO WE NEED A MENTAL HEALTH RESEARCH CENTER AND STRATEGY IN KENYA ?
Mental health is a key health issue. It has been stated that “there is no health without mental health” (Lavikainen et al., 2001). One quarter of the population can expect to be affected by a mental health problem at some time in their lives. Mental illnesses impose a significant burden on the health and well being of communities worldwide.
Five of the world's ten leading causes of disability are related to mental illness. The share of global disease burden associated with mental illnesses is predicted to grow further in the coming decades, increasing by almost 50%, from 10.5% of the total burden to almost 15% in 2020 (WHO, 2004).
Approximately 20% of all people will experience some form of mental illness in their lifetime. One of the challenges for mental health research is to ensure that the resources devoted to it reflect the prevalence, burden and cost of mental ill health in Kenya.
In spite of this significant burden of mental ill health, there is a scarcity or lack of high quality mental health research in Kenya that has an impact on mental health policy or service delivery. There is little published research in Kenya on how best to deliver high quality mental health services. What are the components that work and how can they be replicated? The capacity to carry out high quality research is certainly present, as evidenced for example, by the international collaborative studies being carried out by other institutions in developed countries e.g. The Health Research Board and the Virginia Commonwealth University (Straub et al., 2002), but their focus on genetic epidemiology is very specialist- and clinically-based.
“…evidence of effectiveness must inform the policy and decision-making process across the health system. An evidence- based approach will ensure clearer accountability and support improved outcomes generally.” (p. 86).
The promotion of an evidence-based approach to the provision of mental health services is one of the functions of the Mental Health Research Center. However, there is a lack of quality mental health research in Kenya that can direct service development in a strategic manner. Some of the reasons for this are explored here and the areas in which research has a critical function are outlined.
1.2 WHAT IS RESEARCH?
For the rationale of developing a research strategy it is useful to define what is meant by research. The Irish Health Research Board (HRB) Consultation Document Making Knowledge Work for Health (2000), gives a useful definition of research in this context:
“Research is an activity with the following characteristics:
1. It is intended to provide new knowledge and/or understanding
2. The results are generalisable. The methodology is designed so that the results will be of value to those facing similar problems or can be reproduced in similar circumstances
3. The findings are put in the public domain for critical examination and access by those who could benefit from them.” (p.14, HRB, 2000).
There are other activities that overlap with research to some extent, or share some features of this definition, such as routine data collection and clinical audit. These may contribute to the research process but do not fall completely within the definition described above.
1.3 RESEARCH GOVERNANCE
The fundamental principles and core values of the proposed Mental Health Research Center will apply to all aspects of the work of the Center, including research. Some may have a specific relevance to research and are expanded on here with a view to their relevance to mental health research:
* Achieving together - a partnership approach is essential to producing the highest quality research with greatest relevance to service users and providers. A typical mental health research study might involve; a multidisciplinary team, service users and carers, mental health service management/funders, a third-level institution, a research funding body and more;
* Empowerment and advocacy - the Commission is committed to facilitating the realization of the full potential of those availing of mental health services and promoting their best interests. This includes involving users and carers in all aspects of research, not just as subjects, but in designing planning, and carrying out studies;
* Quality - in research depends on those responsible for the research having the relevant skills and experience to deliver dependable research;
* Dignity and respect - all participants in a research study should be treated with dignity and respect at all times;
* Confidentiality - is an essential value of any research.
There are values which are specific to the conduct of high quality research which collectively come under the heading of research governance. We are familiar with clinical governance, which aims to continually improve the overall standards of clinical care. Research governance describes a process aimed at the continuous improvement of standards in research, and in the context of this strategy, of mental health research. A proper governance process is essential to ensure that the public and all those involved in mental health research have confidence in, and can benefit from research. Research governance has become even more important in light of the EU Directive on Good Clinical Practice in Clinical Trials (2001/20/EC). This directive aims to:
* protect the rights, safety and well- being of trial participants, consistent with the principles set out in the Declaration of Helsinki
* simplify and harmonise the administrative provisions governing clinical trials by establishing a transparent procedure that will harmonise conditions for co-ordinating trials in the EU by competent authorities, and to ensure the credibility of results.
1.4 OBJECTIVES OF THE MENTAL HEALTH RESEARCH CENTER
* To undertake sustainable, highest quality, basic neuroscience, clinical and public health research
* To promote understanding of and investment in research through advocacy
* To educate clinicians and researchers
* To provide expert commentary on the scientific basis of mental illness including psychotic illness (schizophrenia and depression) and neurodegenerative diseases (e.g. dementia and Alzheimer’s disease).
2.0 SITUATIONAL ANALYSIS OF THE STATE OF KENYAS MENTAL HEALTH
2.1.1 Mental Health In Kenya: A Prognosis
The Kenyan budget allocates less than 10 per cent of financial resources to the health sector despite the government’s stated commitment to the Abuja Declaration promising at least 15 per cent of its budget allocations to the health sector.
Out of this meagre allocation, the Ministry of Health allocates less than 0.01 per cent of their expenditure to mental health services countrywide.
The division of mental health at Afya House is woefully understaffed and practically unfunded, and the majority of mental health programmes in this country are funded by non-governmental organisations.
Occurrences in this country since the last days of the colonial administration have left no doubt about the need for a comprehensive mental health policy that adequately addresses the various challenges we face as a nation.
From the Mau Mau concentration camps to the periodic eruptions of collective insanity after elections, evidence abounds on the role of mental ill-health in our national troubles.
The Mental Health Act of 1989 established the Kenya Board of Mental Health as well as District Mental Health Councils to be financed by funds ‘‘voted for the purpose by Parliament’’.
It is unclear whether any of these bodies are operational after over 20 years since the Act was passed by Parliament. What is crystal clear is that there is still no vote for mental health in the budget for the Ministry of Health.
2.1.2 A lack of resources
Reasons for sparse research output is a shortage of mental-health workers, which stem from
1. A lack of funds.
2. Other health areas are simply more attractive, less stigmatising; there are more career options
3. More resources are given to them and the moment something has more resources — particularly in poor countries — people will be attracted to it, because survival is important to health workers as well.
4. Specialist outpatient and inpatient services
Evaluation of the status of mental health services in the country by the Ministry of Health in collaboration with this project reconfirmed that the country's health care system operates under extremely resource-restricted conditions, in terms of infrastructure, manpower and finances. Mental health specialist care is largely delivered at district level by psychiatric nurses running outpatient clinics, by psychiatric nurses at provincial levels running inpatient units and outpatient clinics, and by the national referral hospitals at Mathari, University of Nairobi, Gilgil hospital and Moi University.
5. Hospital capacities
The total number of hospital beds for a population of over 38 million is 1114 (750 beds but around 500-600 occupancy at Mathari; 40 beds at Moi University teaching and referral hospital at Eldoret; 100 beds at Gil Gill (established for long stay patients from Mathari but now takes acute cases as well); 6 provincial units of 22 beds each at Nakuru (Rift Valley), Kisumu (Nyanza), Nyeri (Central), Embu (Eastern), Port Reitz (Coast) Kakamega (Western); and 5 district units (Machakos 22, Isiolo 10, Kerugoya 20, Muranga, 20, Meru 12, Siaya, 8,) which works out at less than 1 bed per 34,000 population. In practice, in most provinces there are only 22 beds per 4 M i.e. 1 bed per 200,000 population. With the prevalence of probable psychosis running at over 1%, it would be helpful for every district hospital to have a 20 bed inpatient unit for brief admissions to assess and stabilise complex cases. This would still leave more than 99% of people with psychosis to be managed in the community by the health centre and dispensary levels.
6. Staff capacity and training
Kenya has its own self sustaining training programme for psychiatrists at the University of Nairobi, producing around 6 new psychiatrists per year, and the numbers have expanded from 16 psychiatrists in the public service in 2001, to 46 in 2009. In addition, there are 24 psychiatrists working in private practice In Kenya and another 20 outside the country. A further five trained in Kenya have already died. The psychiatrists in the public service are deployed to the national hospital Mathari (4 plus 1 on long term sick leave), the MOH HQ (3 plus 1 on secondment to the WHO country office plus 1 provincial director of medical services in Nairobi), the University of Nairobi (10), Kenyatta Hospital (6), Kenyatta University (2), Armed forces hospital (1), Moi University (6), Provincial hospitals (6 -Garissa has none), plus 5 placed in the district hospitals of Machakos (1), Thika (1), Muranga (1), Meru (1), and Kisii (1).
Thus it can be noted that the bulk of psychiatrists are in Nairobi, and that the effective psychiatrist population ratio outside Nairobi is 1 psychiatrist per province of 3-5 million people. North Eastern Province, an exceptionally difficult location adjoining Somalia, has no psychiatrist or psychiatric nurse. At the current rate of rolling out university graduates it will take about 100 years to turn out enough psychiatrists to have at least one in every district, taking into account retirement, and cutting out further brain drain. To illustrate this the University of Nairobi initiated in the year 2000 which had 37 students(Clinical psychologists) and psychiatric social workers from 2005 (currently 1 student). It initiated a new post graduate diploma in substance abuse with only 2 students.
There are 418 trained psychiatric nurses in Kenya of whom only 250 are currently deployed in psychiatry (the other 250 are deployed in general medical, surgical and obstetric services or in HIV centres), 70 are in Mathari National Hospital, leaving 180 in the districts and provinces, resulting in only less than 1 psychiatric nurse per new district or 2-3 psychiatric nurses per old district.
Sad as it may be, many psychiatric nurses have retired, died, left the country fo greener pastures or work in NGOs, especially linked to HIV activities, and new applicants for mental health nurse training are dwindling. Worse still is that 2009 churned out only one new psychiatric nurse for Kenya. There is 1 medical social worker in each province but none at district level, and there are social workers in prisons, probation services, the children's dept and the ministry of Social services.
There are a handful of psychologists in university or private practice in Nairobi. Thus the specialist service for nearly all regions and districts is largely delivered by extremely overstretched mental health nurses, who have had no access to Continuing Professional Development throughout their careers until that afforded by phase 2 of this programme of work, funded by Nuffield. This lack of human resource and the continued limited funding of mental health services both severely curtail access to specialist care, and this situation will rapidly get worse unless urgent action is taken to train more psychiatric nurses. The Ministry of Health is planning to offer 10 bursaries for training mental health nurses next year, but if the numbers are to expand rather than simply replace losses, that figure will need to double.
The production of other specialist cadres would also benefit from support.
1. Kenya is not alone. Low-income countries have an average of only five psychiatrists and one-and-a-half psychiatric nurses per million people. Chad, Eritrea and Liberia have just one psychiatrist each.
2. Half of the developing countries studied in a report by the Global Forum for Health Research and the WHO had fewer than five mental health researchers. A similar proportion of universities had the equivalent of US$10,000 per year to spend on mental health research, and many active researchers spend only 25 per cent of their time on research.
2.1.3 Depending on the donor
Dependence on international funding is another factor controlling the level of research. Few funding bodies specifically support mental health in developing countries — there is no 'global fund' for mental health.
The behemoth of global health funding, The Bill and Melinda Gates Foundation, gives no money directly to mental health research, and others, such as the UK Department for International Development, do not keep track of money allocated to mental health.
It is possible that mental health research is not as attractive to donors as, say, infectious disease, because there isn't as much potential for 'success'.
[Infectious diseases] are things that you can cure — and if you can do research that demonstrates that you can control disease, then you make a huge impact with chronic diseases, such as mental health, it is much harder to demonstrate an impact, and this usually requires a sustained intervention rather than a simple short one, he adds.
The agendas of Western funding bodies such as the Gates Foundation are often very different from agendas in developing countries. In poor countries, they have to be donor-driven.
The argument here is that the people who are making health policy for developing countries are implying that the health needs of these countries are different to those of their own families… heart disease, depression etcetera.in this case what happens is that once countries develop and become free of donor money, mental health is prioritised — a situation that has been experienced in India.
Another argument that can be raised is that agencies do not make their funding decisions from ivory towers. They do not dream up their own priorities without any regard for what the morbidity burden or priorities might be in developing countries.
Funding agencies often "get out and about", talking to researchers and policymakers in countries.
One of the problems is that research that delivers treatment, is "difficult to do well" and often not particularly exciting or appealing to some funding bodies who want to be seen as at the cutting edge.
The Wellcome Trust spent five per cent of its total mental health research budget on global mental health between 1994 and 2004 — about US$55 million.
2.1.4 Getting it out there
But even when research is being carried out in developing countries, researchers often find it tricky to publish in peer-reviewed journals and are therefore unable to use their publications as scientific 'currency' to build up their reputation.
When researchers try to get published, they are occasionally limited access to quality and up-to-date information, lack of training in trial design and protocol, and, all compound issues already thrown up by a lack of material and financial resources.
Mental health researchers are not alone in this regard; those in all fields in developing countries suffer from the same problems. But the publishing community seems to be coming to mental health researchers' aid.
In 2004, 42 editors of journals that publish mental health research signed a statement, along with the WHO, saying they aimed to reduce the gap between developed and low- and middle-income countries in published research by helping authors overcome impediments to publication (see 'Journals to bolster mental health research').
It is perhaps too early to say whether this [2004 statement] has had an effect. But journals should be wary not to publish work that is sub-standard simply because of its source. When [editors] are reviewing research from a developing country, there needs to be a sensitive review group, that is a critical thing, but that cannot be in lieu of a minimum acceptable quality of research.
2.1.5 Finding a way forward
But how to get research done?
The anticipation is that the Government of Kenya and some of the biggest donors will adopt mental health and look at capacity building, not necessarily mental health research capacity building, but integrate mental health into existing research programmes.
3.0 THE IMPORTANCE OF HAVING A MENTAL HEALTH RESEARCH CENTER
A. Service planning
The first step in providing equitable mental health services is a population- based needs assessment. Services cannot be planned without some knowledge of how many people in the population need what service. The type of questions faced by service planners includes; how many adolescents in our catchment area are likely to develop a psychosis? How long they are likely to need specialist services and what type of services they will need? How many people in our catchment area have depression that needs treatment in a specialist mental health facility? What are the particular needs of these individuals and how best can our services meet these needs? These are questions that must be answered if services are to be planned that will be responsive, effective and equitable. These are questions that can be answered through accessing available information and specific research. Some have already been answered and many more remain to be answered.
B. Effective services
Most research is conducted at the level of the individual; answering questions such as how effective a specific intervention is for a specific problem. This type of research is essential in providing evidence-based care, so that interventions that have been shown to be effective are available for service users. How we should structure our services around the individuals and their different needs is not so well understood, as the management and organisation of mental health services is an often neglected aspect of research. What model of service delivery is most effective and efficient? What interventions should be provided in what settings? Service level research is needed to answer such questions. Service providers must be familiar with current best practice in their area and be able to access and understand data and methodologies to implement best practice.
C. Driving mental health service development
Rigorous, well-conducted research has the potential to lead to more responsive, efficient and effective mental health services. However, mental health service- based research has so far had little effect on shaping policy or driving service developments (Fitton, 2002). One of the key reasons for this is the lack of dissemination of research findings. A good deal of mental health research is carried out in Kenya, but it tends to remain very local and therefore others don’t find out about potentially useful service innovations or interventions. There are also gaps in our knowledge in terms of what works best in the organisation and delivery of mental health services. Larger scale, more sophisticated studies may be required to identify the mechanisms whereby interventions are effective, and part of this process is ensuring that the relevant staff are appropriately trained in delivering these interventions (Thornicroft et al. 2002). High quality mental health research, designed with a view to dissemination is required to drive further mental health service developments.
D. Driving staff development
The opportunity to carry out research is a requirement of the contracts of some health care staff, and is strongly supported by the professional organisations of all disciplines as essential for continuing professional development (CPD). It is also an important factor in creating a dynamic working environment and thus helps in retaining staff.
E. Mental health information
There is no national mental health information system. Mental health services around the country vary greatly in the information they collect, how it is collected and the IT infrastructure available to do this. A few services have well developed, comprehensive, computer-based information systems which capture the activity and to some extent the outcome of mental health services on an individual patient basis. The vast majority of services however, still work from paper-based systems. Limited service-based information is available (for example a total count of attendances at a service) but information which needs to recorded on an individual patient-basis (such as diagnosis, to report diagnostic profile of attenders) is not routinely available. We thus need a Health Research Board [HRB] which will endevour to provide useful national information on inpatient activity at he the same time there is the need to have a National Psychiatric Inpatient Reporting System [NPIRS], but this is only one part of mental health services required. Limited information on community-based services is not available from reports generated from grassroots levels. All mental health information in Kenya is limited by the lack of a unique identifier for service users. Thus having an NPIRS tool can tell us the total inpatient admissions for a year, as is the case now we may not know how individuals were admitted. There is also a clear lack of investment in mental health information, compared to the Hospital Inpatient Enquiry (HIPE) [see data in appendix].There is no such infrastructure for mental health information.
Good quality information is a pre- requisite to mental health research and much of the time and effort in mental health research in Kenya is taken up with collecting the type of information that should be readily available from a computer-based information systems.
3.1 Research infrastructure
Research infrastructure for mental health is greatly underdeveloped in Kenya. There is no identified fund for mental health research and no national strategy for mental health research. The lack of an identifiable mental health research infrastructure makes it very difficult for interested individuals in mental health services to carry out research, as they must firstly devote time to procuring funding for essential items such as computers before they can carry out even basic research. Unfortunately, researchers can find themselves in the vicious cycle of being unable to secure funding in a grants process because of the lack of a track record in research and the lack of an established infrastructure.
Research is a way of generating funding for support staff who can then facilitate a wider research function, thereby drawing in more research funding. It is often a matter of creating a ‘critical mass’ of research infrastructure to enable individuals to produce useful, high quality research, which in turn, enables them to apply for grants and further enhance their research capability.
3.2 Summary
The central answer to the question of why we need a Mental Health Research Center and Strategy is because of the shortage of mental health research in Kenya and the lack of impact of most of the mental health research that has been carried out.
* What works in Kenyan mental health services and why does it work?
* What do we need to ensure more high quality, effective mental health research is carried out?
A Mental Health Research Center will give an overall direction and guidance to mental health research in Kenya and will help prioritise issues and identify areas for action to produce real results. The crucial aim of establishing a Mental Health Research Center is to promote a mental health research community that is dynamic, productive and innovative, producing high quality research that is receptive to service needs, involves users, helps create services that are evidence-based, and which impacts positively on how mental health services in Kenya are planned, implemented and evaluated. In this case the strategy involved here encompasses all mental health services, all disciplines involved in providing mental health services, service users and carers, voluntary organisations and other organisations involved in mental health and related research.
The crucial aim of this Mental Health Research Center is to promote a mental health research community that is dynamic, productive and innovative, producing high quality research that is receptive to service
Following an examination of the context for mental health research nationally and internationally, a series of actions will be outlined in order to achieve this aim.
needs, involves users, helps create services that are evidence-based, and which impacts positively on how mental health services in Ireland are planned, implemented and evaluated.
3.3 The (Kenyan) national context
There is no national policy devoted to Mental Health Research. Making Knowledge Work for Health - A Strategy for Health Research (Department of Health and Children, 2001) is the national strategy for health research. Health research is important because:
1. research is a key factor in promoting health, combating disease, reducing disability and improving quality of care
2. Research is vital if health services are to become more efficient and effective. The importance of research in encouraging health professionals to undertake their training and seek employment in Kenyan health services is of vital importance. The need for the establishment of a research and development function within health services has to be acknowledged, and to achieve this concept paper recommend that:
A. A research and development officer be appointed to the Ministry of Health
B. Research and development officers be appointed in health boards and in specialist health agencies
C. Health boards and specialist agencies should prepare institutional research strategies that reflect health service priorities
D. A Forum for Health and Social Care Research be set up to advice on agreed research agendas and address the main objectives of the health services.
Unfortunately, there is non of these in our current Mental Health administrative systems and the research function is still seriously underdeveloped. This leaves a critical vacuum at the Department of Health and Health Board level, with no direction on research and no means or funding to develop this function., or the proposed County Health Boards.
It could be argued that they have an even greater resonance for mental health research as the capacity for this type of research is so underdeveloped in Kenya, compared to other areas of health research which are more technologically based. This is reflected in the provision of research grants for health research by donors.
3.4 Health Strategy
We propose a high-performing research and academic community” and recommend that academic research centers be created as an authoritative source of policy and practice advice.
3.5 Status Mental Health Research In Kenya
Mental health research and other research relevant to mental health is currently carried on in individual mental health services by interested professionals in all disciplines, by voluntary organisations such as, in universities and other academic institutions, and in other organisations. Research that is carried out by individuals is often poorly funded, or not funded at all, is ad hoc and very local.
Larger scale, well-funded research tends to focus on clinical issues. For example, of the four studies funded by the HRB in recent years which focus on schizophrenia, three are concerned with genetics and one is a service innovation on carer education.
3.6 Conclusions
In the overall health service, research and information have traditionally had a low profile. Health service providers have tended to focus on delivering services on a reactive basis. A strategic approach to planning and developing health services has been adopted relatively recently. In this type of culture, research and information are greatly undervalued; an “add-on” activity, to be indulged in when an individual or service has the time and some funding.
These observations are equally true for mental health services. It could be argued that the functions of information and research are even more poorly developed in mental health than in general health services.
4.0 THE INTERNATIONAL CONTEXT
4.1.1 EUROPEAN UNION (EU)
Under the health information and knowledge strand of the Public Health Programme of the EU, a Mental Health Working Party was established in 2003. The aim of the Working Party is to contribute to the improvement of information and knowledge and to the promotion of positive mental health and well-being and prevention of mental ill-health. Among the tasks of this Working Party are:
* to contribute to the compilation and development of a sustainable health monitoring system in the field of mental health, to the collection, sharing and diffusion of mental health data
* to advise on the preparation of a European strategy in mental health
* to evaluate, benchmark and diffuse national “good and best practices”
* to examine the possibilities of common evidence-based actions.
As this working party has only recently been established it has had a limited impact to date.
4.1.2 ENGLAND AND WALES
A recent development in England and Wales is the establishment of the National Institute of Mental Health in England (NIMHE), the aim of which is to work with others to improve services and support for people who experience mental distress. One of the standing programmes for the NIMHE is the Mental Health Research Network (MHRN), the principle aims of which are:
* to organise and deliver large-scale research projects to inform policy and practice as it develops, and to help services implement change
* to broaden the scope and capacity of research, including full involvement of service users and carers in commissioning and delivering research
* to help identify the research needs of mental health (particularly in health and social care), working with frontline staff, service users and carers
* to develop research capacity through a range of initiatives at a local, regional and national level.
The MHRN supports high quality research that will remain useful over time, connects research to practice and will ultimately improve the quality of treatment and care for people using mental health services.
There are seven key priority areas for research in England and Wales, one of which is mental health. The Policy Research Programme commissions research to support a wide range of policy activity in health and social care and the Research Capacity Development Programme provides personal awards and funds academic infrastructure to support research capacity development within the NHS. In England and Wales, the Department of Health spent approximately £540 million (2002-2003) through these research programmes on health research in general (not just mental health research).
4.1.3 THE WORLD HEALTH ORGANISATION [WHO]
The World Health Organisation Report (2001) Mental Health: New Understanding, New Hope, is a seminal report which marked the beginning of a renewed interest in mental health internationally. This report specifies ten recommendations for action which are key values or principles which WHO believes should be adapted by each country according to its needs, and implemented to improve mental health services. One of these ten recommendations is to support more research. The different areas of mental health research discussed in the WHO report are:
A. Epidemiological research - epidemiological data are essential for setting priorities within mental health and for designing and evaluating public mental health interventions. While the National Psychiatric Inpatient Reporting System managed by a Health Research Board will provide data on one part of mental health services, there is a paucity of information on the prevalence and the burden of major mental and behavioural disorders in Kenya;
B. Treatment, prevention and promotion outcome research - effective interventions must be developed and disseminated. WHO believes there is a ‘knowledge gap’ concerning the efficacy and effectiveness of pharmacological, psychological and psychosocial interventions. A distinction is made between efficacy research, which refers to “the examination of an intervention’s effects under highly controlled experimental conditions”, and effectiveness research, which “examines the effects of interventions in those settings or conditions in which the intervention will ultimately be delivered.” Where there is an established knowledge base for an intervention, as there is for the efficacy of a number of psychotropic drugs for example, there needs to be a shift in research emphasis towards the conduct of effectiveness research. There is also an “urgent need” for implementation research into those factors likely to enhance the uptake and utilisation of effective interventions in the community. This describes what is termed “service- based research” in this strategy and will be the focus of Priority Four of the Mental Health Research Center;
C. Policy and service research - among the priorities for WHO under this heading is an examination of training requirements for mental health professionals, given the critical importance of human resources for administering treatments and delivering services. More research is needed on informal care and the interface with primary care. WHO also believes more research is required to understand better the effects of policy decisions on access, equity and treatment outcomes;
D. Economic research - given the great potential economic evaluations have to provide information to support choice of interventions and rational planning, it is important that there is local information on the costs of mental illness and local economic evaluations of treatment, prevention and promotion programmes. There is a paucity of up-to-date local data on costs in Kenyan Mental Health Services, or on the costs of mental illness in Ireland.
4.1.4 UNITED STATES
The importance of mental health research is also recognised in the report of the New Freedom Commission on Mental Health (2003) in the United States. This Commission was created in 2002 and was charged with studying the problems and gaps in the mental health system and making concrete recommendations for immediate improvements that the Federal government, State governments, local agencies, as well as public and private health care providers could implement.
The Commission identified six goals as: the foundation for transforming mental health care in America. It was stressed that these goals are “intertwined” and that no single step can achieve the restructuring that is needed to transform the system.
One of these six goals (Goal 5) states that: “Excellent mental health care is delivered and research is accelerated”. The recommendations under this goal are:
* Recommendation 5.1: Accelerate research to promote recovery and resilience, and ultimately to cure and prevent mental illnesses.
* Recommendation 5.2: Advance evidence-based practices using dissemination and demonstration projects and create a public-private partnership to guide their implementation.
* Recommendation 5.3: Improve and expand the workforce providing evidence-based mental health services and supports.
* Recommendation 5.4: Develop the knowledge base in four understudied areas: mental health disparities, long- term effects of medications, trauma and acute care.
The National Institute for Mental Health in the US (which is the national body for mental health research) has a budget of approximately $1.3 billion (2003) to support in-house research and research in universities and hospitals.
5.0 MENTAL HEALTH RESEARCH INFRASTRUCTURE
The requirements to undertake Mental Health Research include the following:
1. The availability of individuals with expertise in conducting research, including expert advice on research design, IT/computer hardware and software, expert statistical advice, other experts in the relevant area
2. Sufficient computer facilities and appropriate software
3. Library resources and internet access
4. Individuals who can assist in data input and offer research assistance in terms of interviewing subjects and collating information
5. access to peer review systems and ethics committees
6. Research funding.
The central requirement for Mental Health Research is usually for people rather than physical infrastructure, that is, interviewers and experts who can design and carry out a research study. However, many research grants are directed towards the provision of the type of sophisticated testing equipment and laboratory supplies that are required for clinical/bio-medical research.
5.8 FUNDING FOR MENTAL HEALTH RESEARCH
The provision of any infrastructure requires financial resources. There is No Budget for Mental Health Research in the Ministry of Health [Kenya] as is the case in the UK for example. This is probably due to the lack of an explicit Research and Development Function as discussed earlier.
One of the main sources of funding for any research in Kenya is through research grants from a number of funding bodies and most mental health research is done at University level through cost sharing or through sponsorships. The Kenya Medical Research Institute through CDC, USAID and other funding agencies is one of the main providers of funds for health research in Kenya. Health boards provide ‘one-off ’ type funding for small-scale, local research projects, and voluntary organisations fund research in a similar way. One of the objectives of having at the proposed Mental Health Research Center is to support high-quality, inter-disciplinary and inter-institutional research.
When mental health is competing with many other specialties’, it tends not to do well. For example, it has been shown that in Australia, mental illness contributes 19% to the total disease burden (ahead of cardiovascular disease and cancer) but receives less than 9% of national medical research funding (Jorm et al., 2002). One possible solution to this is to have ring- fenced funds for mental health research.
One of the key funders in mental health research is the pharmaceutical industry. The main area of funding is for drug trials. While this funding is undoubtedly useful for carrying out research, the implications of this source of funding must be considered. The influence exerted by drug companies is significant and varied, focusing on individual psychiatrists, medical education, health service initiatives, the organisation of research and the dissemination of research findings. The implications of this influence are far-reaching. It has been argued that the influence of drug companies has “helped to create and reinforce a narrow, biological approach to the explanation and treatment of mental disorders and had led to the exclusion of alternative explanatory paradigms. In addition, alternative treatment approaches are neglected…and…the adverse effects of drugs are neglected.” (p. 1 Moncrieff, 2003).
Bodenheimer (2000) has reported that the pharmaceutical industry now underwrites 70% of research into drug treatments, and he has concluded that “trials conducted in the commercial (research) sector are heavily tipped towards industry interests.” There are also concerns around the presentation of findings from drug trials, given the fact that drug companies now control most of the process of most clinical trials from design and implementation through to data analysis, publication and dissemination (Bodenheimer, 2000; Healy and Cattell, 2003).
Codes of ethics for most professions cover sponsorship of clinical trials. There are guidelines to this effect which state that doctors should not permit their relationship with commercial firms to influence their attitude towards the design or the results of trials. A partnership approach to research means that we must be aware of ethical guidelines and balance the good arising from the research that can be carried out, with the implications of accepting funding from a vested interest or an agency with a commercial agenda.
In institutions where one of the main functions is research, such as academic institutions and teaching hospitals, there is already an infrastructure in place that does not require separate funding, for example, library resources, computing resources and the availability of expert advice. In these situations, individuals interested in research are in a supportive environment which facilitates the preparation of proposals to access funding for their research. Individuals in a different situation, for example, those working in services with no links to a teaching hospital or academic institution, have little expert support in preparing a research proposal, and also have to look for assistance in setting up the very basic infrastructure (such as a computer) which is readily available in other institutions. Thus it is more difficult for such individuals to access funding and to create the infrastructure which would enable them to access funding.
In summary, there are many barriers to conducting Mental Health Research in Kenya. At the policy level, it is just mentioned but not given any priority thus actually leaving a vacuum in terms of direction, priority setting and funding for health research. Sadly there is no National Mental Health Research Strategy. There is little established research capacity for carrying out mental health research. With a lack of support for mental health research at national and local health levels, mental health research is left up to interested and committed individuals fitting research into already over-stretched schedules.
However, there are opportunities to be seized in mental health research. The establishment a mental Health Research Center and the provisions of a proposed mental Health Act, should be able to facilitate an environment in which research will be of central importance in mental health services. It is also hoped that by initiating a Mental Health Research Strategy this will help build capacity for mental health research and create a culture in which mental health research and information is seen as a central, underpinning function in the provision of high quality mental health services.
5.9 ACTION PLAN FOR THE MENTAL HEALTH RESEARCH CENTER
Some of the structural barriers to mental health research have been discussed in this strategy; chief among them being the lack of infrastructure for mental health research. The importance of research governance and the provision for mental health research nationally and internationally have been outlined. If mental health research in Kenya is to progress it is clear that the following areas need to be addressed:
a) capacity for mental health research
b) systems for recording and disseminating knowledge on best practice in the mental health services
c) creating links in mental health research
d) The research agenda and priorities.
1. Building capacity for mental health research
The lack of mental health research infrastructure was discussed above. Some basic requirements for mental health research include the availability of:
* Individuals with expertise in conducting research, including expert advice on designing and planning research, IT/computer hardware and software, expert statistical advice, other experts in the relevant area
* Sufficient computer facilities and appropriate software
* library resources and internet access
* Individuals who are competent in fieldwork, can assist in data input and offer other research assistance
* Access to peer review systems and ethics committees
* Research funding.
It is proposed that the proposed Mental Health Research Center initiate the following practical steps to set up infrastructure for mental health research:
* Produce guidance on ethics committees and peer review processes for mental health research
* Encourage the establishment of regional ethics committees for mental health research
* produce guidance on Data Protection
* Acts and the Freedom of Information Act
* Create awareness among individuals involved in mental health research of facilities that are already available in health services, such as library services, IT facilities and expertise
* Produce a directory of sources of research funds.
As funding is probably the greatest single impediment to conducting service-based mental health research, it is proposed that the Mental Health Research Center establish a number of research fellowships to enable interested, suitably skilled individuals to conduct research on identified, priority areas.
It may be worthwhile to conduct a brief study among those working in mental health services to establish what they see as the greatest barriers to conducting mental health research. This would enable the Research Center to prioritise the above actions and identify other areas that aneed to be addressed.
2. Recording and disseminating mental health research
One of the barriers to the conduct of high quality mental health research in Kenya is the isolation of many of those involved in this research. This is not just geographical isolation, but also isolation in terms of lack of infrastructure, such as being the sole individual trying to design and conduct a study, or not being able to access advice or expertise on different aspects of research. There can also difficulties in establishing what research has already or is currently being done in Ireland, particularly if it is in the “grey literature” (i.e. not widely published).
It is proposed that the Mental Health Center establish a Kenya Mental Health Research Association and Database (KMHRA & D) to put researchers in touch with each other and to create a system that will record the mental health research carried out in Kenya.
3. Partnership in mental health research
Mental Health Research Strategy
There are strong indications that a process for a partnership approach to supporting research for health is in existence. Partnerships will also be one of the core values of the proposed Mental Health Research Center. A partnership approach to mental health research is one which would involve service providers, researchers, service users and carers, academic institutions, voluntary bodies and the healthcare industry.
Involving users in health services is key since it envisages a people-centered health system that “helps individuals to participate in decision-making to improve their health.” Involving service users in research is another step in that process. This means involvement not just as subjects, but in designing and carrying out research studies. In their paper on Creating the infrastructure for mental health research, Thornicroft et al. (2002) list user participation as one of the important gaps in research coverage. They recommend that there should be a review to establish “meaningful and sustainable ways in which users can directly participate in research.”
While some research relevant to mental health is carried out in third level institutions and other research bodies, there are few, if any, formal links between academic researchers and mental health service providers. To promote these links, and the concept of partnership in mental health research, it is proposed that:
Mental Health Research Centre be set up in at KEMRI to carry out multidisciplinary, service- based mental health research. This centre could also pioneer models for involving service users in research which could then be adopted by other researchers.
The healthcare and pharmaceutical industry also have a role in mental health research. In order to clarify this role in light of the potential conflict of interest for researchers funded by drug companies, it is proposed that guidelines be drawn up for the involvement of pharmaceutical companies in mental health research.
4. Setting the mental health research agenda
The Mental Health Center will cover all mental health services and will have the mandate to promote, encourage and foster the establishment and maintenance of high standards and good practices in the delivery of mental health services. In the course of its work, issues which require further examination or clarification will be identified by the Center. Progress can be made on these issues by identifying them as priorities for further research.
It is proposed that a Mental Health Research Committee be established by the Mental Health Research Center as a mechanism by which to set the mental health research agenda. This committee could liaise with stakeholders regarding their research priorities, and could draw on Kenyan and international research to inform this priority setting. In order to reflect the range of interests in mental health care, this committee should be multidisciplinary, and include service users. Individuals with a well established and varied research experience should be included.
Some of the possible research topics that could be considered include but not limited to the following;[see Document for administration of research center]
1. Identifying in a more systematic manner the components of successful community-based mental health services so that they can be replicated elsewhere
2. Establishing reliable cost data for Kenyan Mental Health Services. These data could be used in service evaluations and could also help the Mental Health Center advocate for infrastructure and funding
3. The use of a variety of methodologies in mental health research, in particular the greater use of qualitative methods. Randomized controlled trials, while recognised as the gold standard for answering questions on the efficacy of interventions, are not the best method for assessing effectiveness that is the usefulness of an intervention under everyday conditions. Methodologies using mixed methods, such as case studies, are very useful for answering more complex questions concerning the organisation and structure of services, which will be an important issue in the Kenyan Mental Health services.
REFERENCES
Bodenheimer, T. (2000) Uneasy alliance - clinical investigators and the pharmaceutical industry. New England Journal of Medicine, 342, 1539-1544.
Department of Health and Children (2001) Quality and Fairness - A Health System for You. Health Strategy. Stationery Office, Dublin.
Department of Health and Children (2001) Primary Care a New Direction. Health Strategy. Stationery Office, Dublin.
Department of Health and Children (2001) Making Knowledge Work for Health. A Strategy for Health Research. Stationery Office, Dublin.
Department of Health and Children (2004) Health Information: A National Strategy. Stationery Office, Dublin.
Department of Health (2004) Final Report. Research for Patient Benefit Working Party. www.dh.gov.uk/PolicyAndGuidance/Research And Development//Research and Development AZ/Priorities for Research
Department of Health (2002) Research Governance Framework for Health and Social Care. www.dh.gov.uk/PolicyAndGuidance/ Research and Development European Parliament (2001) Directive 2001/20/EC Good Practice in Clinical Trials. Official Journal of the European Communities.
Fitton (2002) Establishing the Mental Health Research Network. The National Institute for Mental Health in England, Manchester.
Health Research Board (2000) Making Knowledge Work for Health. Consultation Document. Health Research Board, Dublin.
Healy, D. & Cattell, D. (2003) The interface between authorship, industry and science in the domain of therapeutics. British Journal of Psychiatry, 183, 22-27.
Jorm, A.F., Griffiths, K., Christensen, H and Medway, J. (2002) Research priorities in mental health Part I: An evaluation of the current research effort against the criteria of disease burden and health system costs. Australian and New Zealand Journal of Psychiatry, 36, 322-326.
Lavikainen, J., Lahtinen, E and Lehtinen, V. (2001) Public Health Approach on Mental Health in Europe. National Research and Development Centre for Welfare and Health, STAKES, Finland.
Medical Council (2004) A guide to ethical conduct and behaviour. Sixth edition. Medical Council, Dublin.
Mental Health Commission (2003) Strategic Plan 2004-2005. Mental Health Commission, Dublin.
Moncrieff, J. (2003) Is psychiatry for sale? Maudsley Discussion Paper. Institute of Psychiatry, London.
Northern Ireland Association for Mental Health & Sainsbury Centre for Mental Health (2004) Counting the Cost: The economic and social costs of mental illness in Northern Ireland. Northern Ireland Association for Mental Health Sheikh, A.A. (2002) Genetic Research and Human Biological Samples. Health Research Board, Dublin.
Straub, R.E. Jiang, Y., McClean, C. J., et al. (2002) Genetic variation in the 6p22.3 gene DTNBP1, the human ortholog of the mouse dysbindin gene, is associated with schizophrenia. American Journal of
Human Genetics, 71(2): 337-48.
The President’s New Freedom Commission on Mental Health (2003) Achieving the Promise: Transforming Mental Health Care in America.
Final Report. www.mentalhealthcommission.gov
Thornicroft, G., Bindman, J., Goldberg, D., Gournay, K and Huxley, P. (2002) Creating the infrastructure for mental health research. Psychiatric Bulletin, 26, 403-406.
Tyrer, P. (2002) Commentary: research into health services needs a new approach. Psychiatric Bulletin, 26, 406-407.
World Health Organisation (2001) Mental Health - New Understanding, New Hope. World Health Organisation, Geneva.
World Medical Association (1964) Declaration of Helsinki. Ethical Principles for Medical Research Involving Human Subjects. www.wma.net
