Attitudes to depression among community health workers in Kenya

Human resources devoted to health systems in subSaharan Africa are scarce, and in order to bring health care to the population, strategic primary care structures have evolved. The Kenyan primary health care system has several tiers. The first tier consists of a community health worker, an unpaid volunteer, who receives some regular training from their local primary health care centre to which they are attached. Duties of the community health worker have hithero been focussed on physical health and include health promotion activities, identifying illness, referral to primary health care centres, and supporting those who are ill. The second and third tiers are the dispensary and primary health care centres and the fourth tier is the district hospital. This study sets out to examine the knowledge, attitude and practice pertaining to depression among volunteer community health workers in Kenya, in order to inform policy and implementation. Depressive illness is under-diagnosed and under-treated in primary health care setting throughout the world (Üstün & Sartorius, 1993). There have been a number of studies of the fourth tier of Kenya’s primary care system. A Kenyan study of attenders at rural and semi-urban district hospitals reported prevalence rates of 26% and 31% for psychiatric morbidity in rural and urban settings respectively (Dhapdale et al., 1983). A further Kenyan study of 200 attenders at two district hospital outpatient reported a prevalence rate of 32% for psychiatric morbidity (Dhapdale & Ellison, 1983); of these 35% had a diagnosis of depressive illness and 27% anxiety neurosis. An additional Kenyan study of attenders at district hospitals reported a prevalence rate of 63% for psychiatric morbidity (Sebit, 1996); the proportion of those with depressive illness and neurotic disorders was 34% and 20%. Another Kenyan study of 881 attenders at four district hospitals reported a prevalence rate of 9.2% for depressive disorders (Dhapdale et al., 1989); this doubled if anxiety and phobic neuroses were included. There have been fewer studies of Kenya’s third tier. One study of 140 attenders at a suburban “walk-in” primary health care clinic, based on clinical diagnosis, reported a prevalence rate of 20% for psychiatric morbidity (Ndetei & Muhangi, 1979), while another reported a prevalence rate amongst consecutive attenders of 46% (Kiima, 1979 MMed thesis); although the precise prevalence rates for depressive illness and anxiety disorder were not provided, the authors reported that these two diagnostic categories accounted for most of the psychiatric morbidity, and that nonetheless depression and anxiety were never recorded by the health workers as a reason for consultation. Similarly an examination of primary health care consultation records in a number of other primary health care clinics in Kenya (authors, unpublished data) also showed that depression and anxiety were never recorded as a reason for consultation. A study comparing the attitudes of general practitioners and psychiatrists to depression, using the Depression Attitude Questionnaire (Botega et al., 1992), from the United Kingdom reported that general practitioners were less comfortable then psychiatrists in managing depression and found the work less rewarding and harder than psychiatrists (Kerr et al., 1995). Another United Kingdom study of general practitioners, using the same questionnaire, reported the measure of ease of identifying depression reported in this questionnaire did not match their actual clinical practice (Dowrick et al., 2000). A study comparing the attitudes of general practitioners and psychiatrists to depression, using the Depression Attitude Questionnaire (Botega et al., 1992), from Brazil reported that: 42% of general practitioners believed that it was difficult to differentiate unhapiness from depressive illness; over 60% of general practitioners reported that antidepressants produced satisfactory treatment response, but would refer patients needing antidepressants or psychotherapy would be referred to a specialist; and about 50% found depression “heave gonig” and “unrewarding” (Botega & Silveria, 1996). An Australian study of general practitionLetters to the Editor