Effect of collaborative care between traditional and faith healers and primary health-care workers on psychosis outcomes in Nigeria and Ghana (COSIMPO): a cluster randomised controlled trial

Summary

Background

Traditional and faith healers (TFH) provide care to a large number of people with psychosis in many sub-Saharan African countries but they practise outside the formal mental health system. We aimed to assess the effectiveness and cost-effectiveness of a collaborative shared care model for psychosis delivered by TFH and primary health-care providers (PHCW).

Methods

In this cluster-randomised trial in Kumasi, Ghana and Ibadan, Nigeria, we randomly allocated clusters (a primary care clinic and neighbouring TFH facilities) 1:1, stratified by size and country, to an intervention group or enhanced care as usual. The intervention included a manualised collaborative shared care delivered by trained TFH and PHCW. Eligible participants were adults (aged ≥18 years) newly admitted to TFH facilities with active psychotic symptoms (positive and negative syndrome scale [PANSS] score ≥60). The primary outcome, by masked assessments at 6 months, was the difference in psychotic symptom improvement as measured with the PANSS in patients in follow-up at 3 and 6 months. Patients exposure to harmful treatment practices, such as shackling, were also assessed at 3 and 6 months. Care costs were assessed at baseline, 3-month and 6-month follow-up, and for the entire 6 months of follow-up. This trial was registered with the National Institutes of Health Clinical Trial registry, NCT02895269.

Findings

Between Sept 1, 2016, and May 3, 2017, 51 clusters were randomly allocated (26 intervention, 25 control) with 307 patients enrolled (166 [54%] in the intervention group and 141 [46%] in the control group). 190 (62%) of participants were men. Baseline mean PANSS score was 107·3 (SD 17·5) for the intervention group and 108·9 (18·3) for the control group. 286 (93%) completed the 6-month follow-up at which the mean total PANSS score for intervention group was 53·4 (19·9) compared with 67·6 (23·3) for the control group (adjusted mean difference −15·01 (95% CI −21·17 to −8·84; 0·0001). Harmful practices decreased from 94 (57%) of 166 patients at baseline to 13 (9%) of 152 at 6 months in the intervention group (–0·48 [–0·60 to −0·37] p<0·001) and from 59 (42%) of 141 patients to 13 (10%) of 134 in the control group (–0·33 [–0·45 to −0·21] p<0·001), with no significant difference between the two groups. Greater reductions in overall care costs were seen in the intervention group than in the control group. At the 6 month assessment, greater reductions in total health service and time costs were seen in the intervention group; however, cumulative costs over this period were higher (US $627 per patient vs $526 in the control group). Five patients in the intervention group had mild extrapyramidal side effects.

Interpretation

A collaborative shared care delivered by TFH and conventional health-care providers for people with psychosis was effective and cost-effective. The model of care offers the prospect of scaling up improved care to this vulnerable population in settings with low resources.

Funding

US National Institute of Mental Health.

Introduction

With schizophrenia alone being responsible for about 7% of years lived with disability, psychotic disorders are a major cause of disability as well of considerable burden to families and caregivers globally.¹ In many low-income and middle-income countries as well as in poorly resourced parts of high-income countries, many people with psychotic disorders receive health care from complementary alternative health-care providers, including traditional and faith healers (TFH).2, 3, 4 In much of sub-Saharan Africa, factors such as scarcity of mental health specialists, nearness to the community, and shared belief about the causes and treatment of psychosis make TFH the preferred sources of care.5, 6, 7, 8 These realities have often led to calls for the integration of traditional healers into mainstream health services,⁹ with several countries including the idea of integration in their national policies.

Research in context

Evidence before this study

We searched PubMed and PsychINFO from Sept 25, 2012, to Oct 1, 2014, for studies exploring the feasibility, effectiveness, and cost-effectiveness of collaboration between complementary alternative health care providers, specifically traditional and faith healers, and conventional health-care providers in the care of people with psychosis. We imposed no language restrictions. Our search terms included “severe mental disorders”, “psychosis”, “traditional healers”, “faith healers”, “mental health providers”, “collaboration”, “integration”, and “low and middle-income countries”. We also hand searched reference lists of papers and books identified by this search. Several journal articles provided information about the profile of patients in the care of traditional and faith healers, with evidence that people with psychosis were commonly among these patient groups. There was also information about diagnostic and treatment approaches as well as observation that, even though the care provided often led to improvement in the clinical condition of the patients, some of the treatment practices were potentially harmful and not always in conformity with the human rights of patients. A need to develop approaches to facilitate collaboration between the healers and conventional health care providers was frequently emphasised even though there was also scepticism about whether collaboration could work given discordant views about the nature of psychopathology between healers and conventional providers. Other than collaborative efforts involving the engagement of traditional healers in the provision of care, specifically counselling, to people with HIV, no systematic study had been done to test whether healers and conventional providers can collaborate in the care of people with psychosis and no previous randomised controlled trial of the effectiveness and cost-effectiveness of collaboration between healers and providers has been done.

Added value of this study

To our knowledge, this is the first randomised controlled trial of the effectiveness and cost-effectiveness of a collaborative shared care for psychosis delivered by traditional and faith healers and conventional primary care providers. Prespecified primary and secondary outcomes, assessed at 6 months following trial entry, included psychotic symptoms, disability, self-stigma, course of illness, duration of admission, quality of work performance, living condition, and having harmful or inhumane treatments. Findings show that most outcomes were better with a model of care in which primary care providers worked collaboratively with traditional and faith healers to deliver care to people with psychotic disorders compared to care as usual. Collaborative shared care was successfully implemented between healers and conventional providers and was cost-effective.

Implications of all the available evidence

Our findings suggest that collaboration between healers and conventional providers can be designed and implemented, and that collaboration has the potential for delivering effective and cost-effective care to the large population of people in need of care for psychosis in low-income and middle-income countries. However, more research is needed to examine the factors that might be relevant for scaling up such collaborative shared care model into routine service for people with psychosis.

Although there is interest in integration,⁹ which implies the inclusion of TFH in the formal health system, a more cautious programme of collaboration has been suggested to be tested for its feasibility and effectiveness in promoting better outcomes for patients.² One of the main reasons for that caution is the concern that some TFH use treatment approaches that are potentially harmful or that verge on human rights infringements of vulnerable patients with serious mental disorders, such as shackling, use of untested or unknown concoctions, and forced prolonged fasting,10, 11 even though some of these practices also sometimes occur in institutional care. TFH include people whose healing practice is guided by traditional religion, Christianity, or Islam, as well as those who subscribe to no particular faith, and eclecticism is common.

Although there is some evidence that a collaborative care programme with TFH can be feasible, especially in the care of people with HIV,12, 13 no study has examined the clinical effectiveness of such a programme for severe mental health conditions. In a series of formative studies, we had systematically explored strategies that might promote trust and facilitate collaboration between healers and formal health-care providers.14, 15 This trial, Collaborative Shared Care to Improve Psychosis Outcome (COSIMPO), using cluster randomisation to avoid contamination, aims to determine the effectiveness of such collaboration in improving the clinical outcome of people with psychosis.¹⁶ We hypothesised that a collaborative intervention delivered by TFH and conventional primary health-care providers would be more effective and cost-effective than care as usual for people with psychotic disorders. Typically, TFH do not engage with biomedical health providers in their usual or routine practice.