Food Insecurity Work Impairment And The Impact Of Integrated Mental Health Care Among People With Severe Mental Disorders In South Ethiopia

Background rnIn many low-income countries, food insecurity is a pressing concern and thus ensuring food rnsecurity for all segments of the population is a high priority. In a recent global analysis of 149rncountries, the prevalence of any food insecurity ranged from 18.3% in the East Asian region torn76.1% in sub-Saharan Africa. In Ethiopia, both chronic and transitory (seasonal) food insecurityrnare persistent problems for a large segment of the population and in 2012, there was an 82.3%rnprevalence of household-level food insecurity in a zone in southern Ethiopia. Ending hunger andrnachieving food security is one of the United Nation’s Sustainable Developmental Goals (SDG) tornbe achieved by 2030. rnMental illness is associated consistently with poverty, but its association with food insecurity inrnpeople with severe mental disorders (SMD; psychotic disorders and bipolar disorder) is not wellrnunderstood. Primary care-based integrated mental health care supported by interventions atrncommunity and health system levels, has emerged as an important approach to address the largerntreatment gap for people with SMD. However, little is known about the impact of integrated mentalrnhealth care on food insecurity status. rnObjectives rnThe general objective of this study was to investigate the association between severe mental rndisorder and food insecurity in a rural Ethiopian district before and after improved access to mentalrnhealth care. rnMethods rnStudy Design: The study involved two designs: (1) Sub-study-1 was a cross-sectional community-rnbased, comparative study which aimed to explore the association between SMD and foodrninsecurity. Sub-study-2 was a cross-sectional, community-based study of factors associated withrnfood insecurity and work impairment in people with SMD only. (2) Sub-study-3 was a before-afterrnstudy which aimed to evaluate the impact of an integrated mental health care programme on foodrninsecurity status in people with SMD when compared to the general population, over a period ofrn12 months. rnParticipants: The participants of the study were residents in Sodo district, south Ethiopia. 1)rnpersons with SMD identified by community key informants, referred to primary care, assessed byrnprimary care health workers who had been trained to deliver frontline mental health care, and reassessedrnbyrnarnmentalrnhealthrnspecialistrnusingrnarnstructuredrnclinicalrninterviewrn(thernOperationalrnCriteriarnrnforrnrnResearch interview guide) to confirm the diagnosis of psychosis or bipolar disorder, 2)rnrespondents from households of persons with SMD, and 3) a comparison group of householdsrnwhich did not include a person with SMD. rnAssessments: At baseline (T1), when the mental health care programme was being implemented,rnand at a twelve month follow-up (T2) assessment, trained lay data collectors assessed foodrninsecurity status using a validated version of the Household Food Insecurity Access Scale (HFIAS9).rnrnAt T1 and T2, work impairment was assessed by trained psychiatric nurses using thernLongitudinal Interval Follow-up Evaluation-Range of Impaired Functioning Tool. Disability wasrnmeasured using the World Health Organisation Disability Assessment Schedule 2.0. A range ofrnother demographic, socio-economic and psychosocial measures were also used. rnStatistical analysis: In sub-study-1, multiple logistic regression was conducted to test thernhypothesis that the presence of a household member with SMD was associated with food insecurityrnin that household. Potential confounders identified a priori were included into the model. In substudy-2,rnmultiplernlogisticrnregressionrnwasrnusedrntornexplorernthernfactorsrnassociatedrnwithrnseverernfoodrnrninsecurityrnrnand work-related impairment in persons with SMD. Variables included in thernmultivariable model were those anticipated to have associations with the outcome variables on thernbasis of existing literature. Potential effect modification by strata was explored using the MantelHaenszelrnrntest of homogeneity. For sub-study-3, a Poisson working model with sandwichrnestimators of the standard errors was used to estimate a risk ratio for change in food insecurityrnstatus in SMD cases and the comparison households between baseline and 12 months. Multiplernlinear regression was used to identify factors associated with change in food insecurity scores inrnthe SMD group. To examine potential effect modification of disability between clinical attendancernand food insecurity, an interaction term was included in the final multivariable model and arnlikelihood ratio test was used to investigate improvement in model fit. Path analysis was used tornexplore the possible mechanisms linking food insecurity and predictor variables. rnResults rnA total of 292 people with SMD, 292 respondents from households of people with SMD and 284rnrespondents from comparison households were included in the study at baseline. At follow-up,rn239 people with SMD, 239 respondents from households of people with SMD and 273 respondentsrnfrom comparison households were included in the final analysis. rnParticipant Characteristics: Persons with SMD were more likely to be younger, had fewerrnchildren, to have attended formal education and be female, unemployed, unmarried and not thernhousehold head than respondents from comparison households without a person with SMD. rnBaseline (cross-sectional) studies: Sub-study-1: Severe household food insecurity was reportedrnby 32.5% of people with SMD and 15.9% of respondents from comparison households: adjustedrnodds ratio 2.82 (95% confidence interval 1.62 to 4.91). Higher annual income was associatedrnindependently with lower odds of severe food insecurity. Sub-study-2: In the multivariable modelrnin people with SMD, severe food insecurity was associated with poor social support, experiencernof negative discrimination, higher disability and lower household annual income, but not withrnsymptom severity. Work impairment was associated significantly with symptom severity andrndisability, but not with discrimination. rnFollow-up study: (Sub-study-3): Improvement in food security status 12 months after engagingrnwith care was observed in 43.5% of households of a person with SMD compared to 30.2% ofrncontrol households (adjusted risk ratio 1.68; 95%CI 1.24, 2.26). The proportion of households inrnthe “severe food insecurity” category declined from 71/237 (29.9%) at baseline to 37/237 (15.6%)rnat twelve months among the SMD group; whereas it declined from 37/273 (13.5%) at baseline torn26/273 (9.5%) at twelve months among the comparison group. In people with SMD, improvementrnin food security status was associated with being a household head at baseline assessment, lowerrnbaseline disability and physical impairment scores. In a path model, change in symptom severityrnwas indirectly associated with follow-up food insecurity status via an impact on reducing workrnimpairment and discrimination (p

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