Alan J Flisher Centre for Public Mental Health

BACKGROUND: The Medical Research Councils' framework for complex interventions has been criticized for not including theory-driven approaches to evaluation. Although the framework does include broad guidance on the use of theory, it contains little practical guidance for implementers and there have been calls to develop a more comprehensive approach. A prospective, theory-driven process of intervention design and evaluation is required to develop complex healthcare interventions which are more likely to be effective, sustainable and scalable. METHODS: We propose a theory-driven approach to the design and evaluation of complex interventions by adapting and integrating a programmatic design and evaluation tool, Theory of Change (ToC), into the MRC framework for complex interventions. We provide a guide to what ToC is, how to construct one, and how to integrate its use into research projects seeking to design, implement and evaluate complex interventions using the MRC framework. We test this approach by using ToC within two randomized controlled trials and one non-randomized evaluation of complex interventions. RESULTS: Our application of ToC in three research projects has shown that ToC can strengthen key stages of the MRC framework. It can aid the development of interventions by providing a framework for enhanced stakeholder engagement and by explicitly designing an intervention that is embedded in the local context. For the feasibility and piloting stage, ToC enables the systematic identification of knowledge gaps to generate research questions that strengthen intervention design. ToC may improve the evaluation of interventions by providing a comprehensive set of indicators to evaluate all stages of the causal pathway through which an intervention achieves impact, combining evaluations of intervention effectiveness with detailed process evaluations into one theoretical framework. CONCLUSIONS: Incorporating a ToC approach into the MRC framework holds promise for improving the design and evaluation of complex interventions, thereby increasing the likelihood that the intervention will be ultimately effective, sustainable and scalable. We urge researchers developing and evaluating complex interventions to consider using this approach, to evaluate its usefulness and to build an evidence base to further refine the methodology. TRIAL REGISTRATION: Clinical trials.gov: NCT02160249.

BACKGROUND: The treatment gap between the number of people with mental disorders and the number treated represents a major public health challenge. We examine this gap by socio-economic status (SES; indicated by family income and respondent education) and service sector in a cross-national analysis of community epidemiological survey data. METHODS: Data come from 16 753 respondents with 12-month DSM-IV disorders from community surveys in 25 countries in the WHO World Mental Health Survey Initiative. DSM-IV anxiety, mood, or substance disorders and treatment of these disorders were assessed with the WHO Composite International Diagnostic Interview (CIDI). RESULTS: Only 13.7% of 12-month DSM-IV/CIDI cases in lower-middle-income countries, 22.0% in upper-middle-income countries, and 36.8% in high-income countries received treatment. Highest-SES respondents were somewhat more likely to receive treatment, but this was true mostly for specialty mental health treatment, where the association was positive with education (highest treatment among respondents with the highest education and a weak association of education with treatment among other respondents) but non-monotonic with income (somewhat lower treatment rates among middle-income respondents and equivalent among those with high and low incomes). CONCLUSIONS: The modest, but nonetheless stronger, an association of education than income with treatment raises questions about a financial barriers interpretation of the inverse association of SES with treatment, although future within-country analyses that consider contextual factors might document other important specifications. While beyond the scope of this report, such an expanded analysis could have important implications for designing interventions aimed at increasing mental disorder treatment among socio-economically disadvantaged people.

BACKGROUND: Despite the increasing popularity of the theory of change (ToC) approach, little is known about the extent to which ToC has been used in the design and evaluation of public health interventions. This review aims to determine how ToCs have been developed and used in the development and evaluation of public health interventions globally. METHODS: We searched for papers reporting the use of "theory of change" in the development or evaluation of public health interventions in databases of peer-reviewed journal articles such as Scopus, Pubmed, PsychInfo, grey literature databases, Google and websites of development funders. We included papers of any date, language or study design. Both abstracts and full text papers were double screened. Data were extracted and narratively and quantitatively summarised. RESULTS: A total of 62 papers were included in the review. Forty-nine (79 %) described the development of ToC, 18 (29 %) described the use of ToC in the development of the intervention and 49 (79 %) described the use of ToC in the evaluation of the intervention. Although a large number of papers were included in the review, their descriptions of the ToC development and use in intervention design and evaluation lacked detail. CONCLUSIONS: The use of the ToC approach is widespread in the public health literature. Clear reporting of the ToC process and outputs is important to strengthen the body of literature on practical application of ToC in order to develop our understanding of the benefits and advantages of using ToC. We also propose a checklist for reporting on the use of ToC to ensure transparent reporting and recommend that our checklist is used and refined by authors reporting the ToC approach.

Three-quarters of the global mental health burden exists in low- and middle-income countries (LMICs), yet the lack of mental health services in resource-poor settings is striking. Task-sharing (also, task-shifting), where mental health care is provided by non-specialists, has been proposed to improve access to mental health care in LMICs. This multi-site qualitative study investigates the acceptability and feasibility of task-sharing mental health care in LMICs by examining perceptions of primary care service providers (physicians, nurses, and community health workers), community members, and service users in one district in each of the five countries participating in the PRogramme for Improving Mental health carE (PRIME): Ethiopia, India, Nepal, South Africa, and Uganda. Thirty-six focus group discussions and 164 in-depth interviews were conducted at the pre-implementation stage between February and October 2012 with the objective of developing district level plans to integrate mental health care into primary care. Perceptions of the acceptability and feasibility of task-sharing were evaluated first at the district level in each country through open-coding and then at the cross-country level through a secondary analysis of emergent themes. We found that task-sharing mental health services is perceived to be acceptable and feasible in these LMICs as long as key conditions are met: 1) increased numbers of human resources and better access to medications; 2) ongoing structured supportive supervision at the community and primary care-levels; and 3) adequate training and compensation for health workers involved in task-sharing. Taking into account the socio-cultural context is fundamental for identifying local personnel who can assist in detection of mental illness and facilitate treatment and care as well as training, supervision, and service delivery. By recognizing the systemic challenges and sociocultural nuances that may influence task-sharing mental health care, locally-situated interventions could be more easily planned to provide appropriate and acceptable mental health care in LMICs.

BACKGROUND: Little is known about how to tailor implementation of mental health services in low- and middle-income countries (LMICs) to the diverse settings encountered within and between countries. In this paper we compare the baseline context, challenges and opportunities in districts in five LMICs (Ethiopia, India, Nepal, South Africa and Uganda) participating in the PRogramme for Improving Mental health carE (PRIME). The purpose was to inform development and implementation of a comprehensive district plan to integrate mental health into primary care. METHODS: A situation analysis tool was developed for the study, drawing on existing tools and expert consensus. Cross-sectional information obtained was largely in the public domain in all five districts. RESULTS: The PRIME study districts face substantial contextual and health system challenges many of which are common across sites. Reliable information on existing treatment coverage for mental disorders was unavailable. Particularly in the low-income countries, many health service organisational requirements for mental health care were absent, including specialist mental health professionals to support the service and reliable supplies of medication. Across all sites, community mental health literacy was low and there were no models of multi-sectoral working or collaborations with traditional or religious healers. Nonetheless health system opportunities were apparent. In each district there was potential to apply existing models of care for tuberculosis and HIV or non-communicable disorders, which have established mechanisms for detection of drop-out from care, outreach and adherence support. The extensive networks of community-based health workers and volunteers in most districts provide further opportunities to expand mental health care. CONCLUSIONS: The low level of baseline health system preparedness across sites underlines that interventions at the levels of health care organisation, health facility and community will all be essential for sustainable delivery of quality mental health care integrated into primary care.

BACKGROUND: The 10-item Centre for Epidemiological Studies Depression Scale (CES-D-10) is a depression screening tool that has been used in the South African National Income Dynamics Study (NIDS), a national household panel study. This screening tool has not yet been validated in South Africa. This study aimed to establish the reliability and validity of the CES-D-10 in Zulu, Xhosa and Afrikaans. The CES-D-10's psychometric properties were also compared to the Patient Health Questionnaire (PHQ-9), a depression screening tool already validated in South Africa. METHODS: Stratified random samples of Xhosa, Afrikaans and Zulu-speaking participants aged 15 years or older (N = 944) were recruited from Cape Town Metro and Ethekwini districts. Face-to-face interviews included socio-demographic questions, the CES-D-10, Patient Health Questionnaire (PHQ-9), and WHO Disability Assessment Schedule 2.0 (WHODAS). Major depression was determined using the Mini International Neuropsychiatric Interview. All instruments were translated and back-translated to English. Construct validity was examined using exploratory factor analysis with varimax rotation. Receiver Operating Characteristics (ROC) curves were used to investigate the CES-D-10 and PHQ-9's criterion validity, and compared using the DeLong method. RESULTS: Overall, 6.6, 18.0 and 6.9% of the Zulu, Afrikaans and Xhosa samples were diagnosed with depression, respectively. The CES-D-10 had acceptable internal consistency across samples (α = 0.69-0.89), and adequate concurrent validity, when compared to the PHQ-9 and WHODAS. The CES-D-10 area under the Receiver Operator Characteristic curve was good to excellent: 0.81 (95% CI 0.71-0.90) for Zulu, 0.93 (95% CI 0.90-0.96) for Afrikaans, and 0.94 (95% CI 0.89-0.99) for Xhosa. A cut-off of 12, 11 and 13 for Zulu, Afrikaans and Xhosa, respectively, generated the most balanced sensitivity, specificity and positive predictive value (Zulu: 71.4, 72.6% and 16.1%; Afrikaans: 84.6%, 84.0%, 53.7%; Xhosa: 81.0%, 95.0%, 54.8%). These were slightly higher than those generated for the PHQ-9. The CES-D-10 and PHQ-9 otherwise performed similarly across samples. CONCLUSIONS: The CES-D-10 is a valid, reliable screening tool for depression in Zulu, Xhosa and coloured Afrikaans populations.

There is a large treatment gap for mental health care in low- and middle-income countries (LMICs), with the majority of people with mental, neurological, and substance use (MNS) disorders receiving no or inadequate care. Health system factors are known to play a crucial role in determining the coverage and effectiveness of health service interventions, but the study of mental health systems in LMICs has been neglected. The 'Emerging mental health systems in LMICs' (Emerald) programme aims to improve outcomes of people with MNS disorders in six LMICs (Ethiopia, India, Nepal, Nigeria, South Africa, and Uganda) by generating evidence and capacity to enhance health system performance in delivering mental health care. A mixed-methods approach is being applied to generate evidence on: adequate, fair, and sustainable resourcing for mental health (health system inputs); integrated provision of mental health services (health system processes); and improved coverage and goal attainment in mental health (health system outputs). Emerald has a strong focus on capacity-building of researchers, policymakers, and planners, and on increasing service user and caregiver involvement to support mental health systems strengthening. Emerald also addresses stigma and discrimination as one of the key barriers for access to and successful delivery of mental health services.

BACKGROUND: Globally mental health problems are a serious public health concern. Currently four out of five people with severe mental illness in Low and Middle Income Countries (LMIC) receive no effective treatment. There is an urgent need to address this enormous treatment gap. Changing the focus of specialist mental health workers (psychiatrists and psychologists) from only service delivery to also designing and managing mental health services; building clinical capacity of the primary health care (PHC) workers, and providing supervision and quality assurance of mental health services may help in scaling up mental health services in LMICs. Little is known however, about the mental health policy and services context for these strategies in fragile-state settings, such as Nepal. METHOD: A standard situation analysis tool was developed by the PRogramme for Improving Mental health carE (PRIME) consortium to systematically analyze and describe the current gaps in mental health care in Nepal, in order to inform the development of a district level mental health care plan (MHCP). It comprised six sections; general information (e.g. population, socio-economic conditions); mental health policies and plans; mental health treatment coverage; district health services; and community services. Data was obtained from secondary sources, including scientific publications, reports, project documents and hospital records. RESULTS: Mental health policy exists in Nepal, having been adopted in 1997, but implementation of the policy framework has yet to begin. In common with other LMICs, the budget allocated for mental health is minimal. Mental health services are concentrated in the big cities, with 0.22 psychiatrists and 0.06 psychologists per 100,000 population. The key challenges experienced in developing a district level MHCP included, overburdened health workers, lack of psychotropic medicines in the PHC, lack of mental health supervision in the existing system, and lack of a coordinating body in the Ministry of Health and Population (MoHP). Strategies to overcome these challenges included involvement of MoHP in the process, especially by providing psychotropic medicines and appointing a senior level officer to facilitate project activities, and collaboration with National Health Training Centers (NHTC) in training programs. CONCLUSIONS: This study describes many challenges facing mental health care in Nepal. Most of these challenges are not new, yet this study contributes to our understanding of these difficulties by outlining the national and district level factors that have a direct influence on the development of a district level mental health care plan.

BACKGROUND: The integration of maternal mental health into primary health care has been advocated to reduce the mental health treatment gap in low- and middle-income countries (LMICs). This study reports findings of a cross-country situation analysis on maternal mental health and services available in five LMICs, to inform the development of integrated maternal mental health services integrated into primary health care. METHODS: The situation analysis was conducted in five districts in Ethiopia, India, Nepal, South Africa and Uganda, as part of the Programme for Improving Mental Health Care (PRIME). The analysis reports secondary data on the prevalence and impact of priority maternal mental disorders (perinatal depression, alcohol use disorders during pregnancy and puerperal psychosis), existing policies, plans and services for maternal mental health, and other relevant contextual factors, such as explanatory models for mental illness. RESULTS: Limited data were available at the district level, although generalizable data from other sites was identified in most cases. Community and facility-based prevalences ranged widely across PRIME countries for perinatal depression (3-50 %) and alcohol consumption during pregnancy (5-51 %). Maternal mental health was included in mental health policies in South Africa, India and Ethiopia, and a mental health care plan was in the process of being implemented in South Africa. No district reported dedicated maternal mental health services, but referrals to specialised care in psychiatric units or general hospitals were possible. No information was available on coverage for maternal mental health care. Challenges to the provision of maternal mental health care included; limited evidence on feasible detection and treatment strategies for maternal mental disorders, lack of mental health specialists in the public health sector, lack of prescribing guidelines for pregnant and breastfeeding women, and stigmatising attitudes among primary health care staff and the community. CONCLUSIONS: It is difficult to anticipate demand for mental health care at district level in the five countries, given the lack of evidence on the prevalence and treatment coverage of women with maternal mental disorders. Limited evidence on effective psychosocial interventions was also noted, and must be addressed for mental health programmes, such as PRIME, to implement feasible and effective services.

As one article in a series on Global Mental Health Practice, Simone Honikman and colleagues from South Africa provide a case study of the Perinatal Mental Health Project, which delivered mental health care to pregnant women in a collaborative, step-wise manner, making use of existing resources in primary care.

This supplement outlines the development and piloting of district mental healthcare plans from five low- and middle-income countries, together with the methods for their design, evaluation and costing. In this editorial we consider the challenges that these programmes face, highlight their innovations and draw conclusions.

BACKGROUND: In South Africa, the escalating prevalence of chronic illness and its high comorbidity with mental disorders bring to the fore the need for integrating mental health into chronic care at district level. AIMS: To develop a district mental healthcare plan (MHCP) in South Africa that integrates mental healthcare for depression, alcohol use disorders and schizophrenia into chronic care. METHOD: Mixed methods using a situation analysis, qualitative key informant interviews, theory of change workshops and piloting of the plan in one health facility informed the development of the MHCP. RESULTS: Collaborative care packages for the three conditions were developed to enable integration at the organisational, facility and community levels, supported by a human resource mix and implementation tools. Potential barriers to the feasibility of implementation at scale were identified. CONCLUSIONS: The plan leverages resources and systems availed by the emerging chronic care service delivery platform for the integration of mental health. This strengthens the potential for future scale up.

The world is undergoing a rapid health transition, with an ageing population and disease burden increasingly defined by disability. In Sub-Saharan Africa the next 40 years are predicted to see reduced mortality, signalling a surge in the impact of chronic diseases. We modelled these epidemiological changes and associated mental health workforce requirements. Years lived with a disability (YLD) predictions for mental and substance use disorders for each decade from 2010 to 2050 for four Sub-Saharan African regions were calculated using Global Burden of Disease 2010 study (GBD 2010) data and UN population forecasts. Predicted mental health workforce requirements for 2010 and 2050, by region and for selected countries, were modelled using GBD 2010 prevalence estimates and recommended packages of care and staffing ratios for low- and middle-income countries, and compared to current staffing from the WHO Mental Health Atlas. Significant population growth and ageing will result in an estimated 130% increase in the burden of mental and substance use disorders in Sub-Saharan Africa by 2050, to 45 million YLDs. As a result, the required mental health workforce will increase by 216,600 full time equivalent staff from 2010 to 2050, and far more compared to the existing workforce. The growth in mental and substance use disorders by 2050 is likely to significantly affect health and productivity in Sub-Saharan Africa. To reduce this burden, packages of care for key mental disorders should be provided through increasing the mental health workforce towards targets outlined in this paper. This requires a shift from current practice in most African countries, involving substantial investment in the training of primary care practitioners, supported by district based mental health specialist teams using a task sharing model that mobilises local community resources, with the expansion of inpatient psychiatric units based in district and regional general hospitals.

BACKGROUND: Developing evidence for the implementation and scaling up of mental healthcare in low- and middle-income countries (LMIC) like Ethiopia is an urgent priority. AIMS: To outline a mental healthcare plan (MHCP), as a scalable template for the implementation of mental healthcare in rural Ethiopia. METHOD: A mixed methods approach was used to develop the MHCP for the three levels of the district health system (community, health facility and healthcare organisation). RESULTS: The community packages were community case detection, community reintegration and community inclusion. The facility packages included capacity building, decision support and staff well-being. Organisational packages were programme management, supervision and sustainability. CONCLUSIONS: The MHCP focused on improving demand and access at the community level, inclusive care at the facility level and sustainability at the organisation level. The MHCP represented an essential framework for the provision of integrated care and may be a useful template for similar LMIC.

BACKGROUND: South Africa is one of the most 'unequal' societies in the world. Despite apartheid ending more than 20 years ago, material inequalities remain interwoven with ethnic/racial inequalities. There is limited research on the prevalence/predictors of common mental disorders (CMD) among young people. Adolescence is a unique time-point during which intervention may lead to improved mental health and reduced social problems later. The study objective was to assess mental health disparities in a representative sample of adolescents growing up in South Africa. METHODS: Cross-sectional associations of race/ethnicity and material disadvantage with CMD and Post Traumatic Stress Disorder (PTSD) were assessed in a stratified random sample representative of school-attendees, aged 14-15 years, in a large metropolitan area of Cape Town. Validated instruments assessed mental disorders; these included: Harvard Trauma Questionnaire (PTSD); Short Moods and Feelings Questionnaire (depression); Zung self-rated anxiety scale (anxiety). Self-ascribed ethnicity was determined using procedures similar to the South African census and previous national surveys. RESULTS: Response rate was 88% (1034 of 1169 individuals). Adolescents experienced a high prevalence of depression (41%), anxiety (16%) and PTSD (21%). A gradient between material disadvantage and CMD/ PTSD was evident across all ethnic/racial groups. Respondents self-identifying as 'black' or 'coloured' were disadvantaged across most indicators. After adjusting for confounders, relative to white children, relative risk (RR) of CMD in black children was 2.27 (95% CI:1.24, 4.15) and for PTSD was RR: 2.21 (95% CI:1.73, 2.83). Relative risk of CMD was elevated in children self-identifying as 'coloured' (RR: 1.73, 95% CI:1.11, 2.70). Putative mediators (violence, racially motivated bullying, social support, self-esteem) partially accounted for differences in CMD and fully for PTSD. CONCLUSIONS: Adolescent mental health inequalities in Cape Town are associated with material disadvantage and self-identification with historically disadvantaged groups.

Introduction Although cash transfer programmes are not explicitly designed to improve mental health, by reducing poverty and improving the life chances of children and young people, they may also improve their mental health. This systematic review and meta-analysis assessed the evidence on the effectiveness of cash transfers to improve the mental health of children and young people in low-income and middle-income countries. Methods We searched Pubmed, EBSCOhost, Scientific Electronic Library Online, ISI Web of Science and Social Sciences Citation Index and grey literature (from January 2000 to July 2020) for studies which quantitatively assessed the impact of cash transfers on mental health in young people (aged 0–24 years), using a design that incorporated a control group. We extracted Cohen’s d effects size and used a random-effects model for the meta-analysis on studies that measured depressive symptoms, I 2 statistic and assessment of study quality. Results We identified 12 116 articles for screening, of which 12 were included in the systematic review (covering 13 interventions) and seven in the meta-analysis assessing impact on depressive symptoms specifically. There was high heterogeneity (I 2 =95.2) and a high risk of bias (0.38, 95% CIs: −5.08 to 5.85; p=0.86) across studies. Eleven interventions (85%) showed a significant positive impact of cash transfers on at least one mental health outcome in children and young people. However, no study found a positive effect on all mental health outcomes examined, and the meta-analysis showed no impact of cash transfers on depressive symptoms (0.02, 95% CIs: −0.19 to 0.23; p=0.85). Conclusion Cash transfers may have positive effects on some mental health outcomes for young people, with no negative effects identified. However, there is high heterogeneity across studies, with some interventions showing no effects. Our review highlights how the effect of cash transfers may vary by social and economic context, culture, design, conditionality and mental health outcome.

BACKGROUND: As part of a situational analysis for a research programme on the integration of mental health care into primary care (Programme for Improving Mental Health Care-PRIME), we conducted a baseline study aimed at determining the broad indicators of the population level of psychosocial distress in a predominantly rural community in Ethiopia. METHODS: The study was a population-based cross-sectional survey of 1497 adults selected through a multi-stage random sampling process. Population level psychosocial distress was evaluated by estimating the magnitude of common mental disorder symptoms (CMD; depressive, anxiety and somatic symptoms reaching the level of probable clinical significance), harmful use of alcohol, suicidality and psychosocial stressors experienced by the population. RESULTS: The one-month prevalence of CMD at the mild, moderate and severe threshold levels was 13.8%, 9.0% and 5.1% respectively. The respective one-month prevalence of any suicidal ideation, persistent suicidal ideation and suicide attempt was 13.5%, 3.8% and 1.8%. Hazardous use of alcohol was identified in 22.4%, significantly higher among men (33.4%) compared to women (11.3%). Stressful life events were widespread, with 41.4% reporting at least one threatening life event in the preceding six months. A similar proportion reported poor social support (40.8%). Stressful life events, increasing age, marital loss and hazardous use of alcohol were associated with CMD while stressful life events, marital loss and lower educational status, and CMD were associated with suicidality. CMD was the strongest factor associated with suicidality [e.g., OR (95% CI) for severe CMD = 60.91 (28.01, 132.48)] and the strength of association increased with increase in the severity of the CMD. CONCLUSION: Indicators of psychosocial distress are prevalent in this rural community. Contrary to former assumptions in the literature, social support systems seem relatively weak and stressful life events common. Interventions geared towards modifying general risk factors and broader strategies to promote mental wellbeing are required.

This paper outlines the main elements and features of a mental health care delivery platform and its delivery channels. These include evidence-based interventions that can be delivered via this platform as well as broader health system strengthening strategies for more effective and efficient delivery of services. The focus is broadly on health systems perspective rather than strictly disorder-oriented intervention analysis. A set of evidence-based interventions within the WHO pyramid framework of self-care, primary care, and specialist care have been identified; the main challenge lies in the translation of that evidence into practice. The delivery of these interventions requires an approach that puts into practice key principles of public health, adopts systems thinking, promotes whole-of-government involvement and is focused on quality improvement. Key strategies for effective translation of evidence into action include collaborative stepped care, strengthening human resources, and integrating mental health into general health care. In order to pursue these principles and strategies using a platform-wide approach, policy makers need to engage with a wide range of stakeholders and make use of the best available evidence in a transparent manner.

AimsSuicidal behaviour is an under-reported and hidden cause of death in most low- and middle-income countries (LMIC) due to lack of national systematic reporting for cause-specific mortality, high levels of stigma and religious or cultural sanctions. The lack of information on non-fatal suicidal behaviour (ideation, plans and attempts) in LMIC is a major barrier to design and implementation of prevention strategies. This study aims to determine the prevalence of non-fatal suicidal behaviour within community- and health facility-based populations in LMIC. METHODS: Twelve-month prevalence of suicidal ideation, plans and attempts were established through community samples (n = 6689) and primary care attendees (n = 6470) from districts in Ethiopia, Uganda, South Africa, India and Nepal using the Composite International Diagnostic Interview suicidality module. Participants were also screened for depression and alcohol use disorder. RESULTS: We found that one out of ten persons (10.3%) presenting at primary care facilities reported suicidal ideation within the past year, and 1 out of 45 (2.2%) reported attempting suicide in the same period. The range of suicidal ideation was 3.5-11.1% in community samples and 5.0-14.8% in health facility samples. A higher proportion of facility attendees reported suicidal ideation than community residents (10.3 and 8.1%, respectively). Adults in the South African facilities were most likely to endorse suicidal ideation (14.8%), planning (9.5%) and attempts (7.4%). Risk profiles associated with suicidal behaviour (i.e. being female, younger age, current mental disorders and lower educational and economic status) were highly consistent across countries. CONCLUSION: The high prevalence of suicidal ideation in primary care points towards important opportunities to implement suicide risk reduction initiatives. Evidence-supported strategies including screening and treatment of depression in primary care can be implemented through the World Health Organization's mental health Global Action Programme suicide prevention and depression treatment guidelines. Suicidal ideation and behaviours in the community sample will require detection strategies to identify at risks persons not presenting to health facilities.

BACKGROUND: Global research suggests that persons with disabilities face barriers when accessing health care services. Yet, information regarding the nature of these barriers, especially in low-income and middle-income countries is sparse. Rural contexts in these countries may present greater barriers than urban contexts, but little is known about access issues in such contexts. There is a paucity of research in South Africa looking at "triple vulnerability" - poverty, disability and rurality. This study explored issues of access to health care for persons with disabilities in an impoverished rural area in South Africa. METHODS: The study includes a quantitative survey with interviews with 773 participants in 527 households. Comparisons in terms of access to health care between persons with disabilities and persons with no disabilities were explored. The approach to data analysis included quantitative data analysis using descriptive and inferential statistics. Frequency and cross tabulation, comparing and contrasting the frequency of different phenomena between persons with disabilities and persons with no disabilities, were used. Chi-square tests and Analysis of Variance tests were then incorporated into the analysis. RESULTS: Persons with disabilities have a higher rate of unmet health needs as compared to non-disabled. In rural Madwaleni in South Africa, persons with disabilities faced significantly more barriers to accessing health care compared to persons without disabilities. Barriers increased with disability severity and was reduced with increasing level of education, living in a household without disabled members and with age. CONCLUSIONS: This study has shown that access to health care in a rural area in South Africa for persons with disabilities is more of an issue than for persons without disabilities in that they face more barriers. Implications are that we need to look beyond the medical issues of disability and address social and inclusion issues as well.