Introduction

A mental health treatment gap persists for children and adolescents in sub-Saharan Africa which have limited treatment capacity relative to high income countries [1]. The World Health Organization’s Mental Health Gap Action Plan and the push for mental health to be included in the Millennium Development Goals have raised the profile of child mental health but comparatively few studies address the importance of screening tools for mental health conditions in these settings [1]. In high-income countries, attention deficit hyperactivity disorder (ADHD) is one of the most prevalent and highly investigated conditions in child and adolescent mental health [2].

Studies focused on sub-Saharan Africa highlight the prevalence of ADHD to range from 5.5% to 8.7% among school children in Congo [3]. A more recent meta-analysis by Ayano and colleagues in 2020 focusing on studies conducted in the African setting, showed a pooled prevalence of ADHD in children and adolescents to be 7.47% [4]. The disorder places the child at increased risk for school failure and dropout, juvenile delinquency, criminality, substance abuse, sexual risk behaviors, and, as a possible consequence, HIV and other sextually transmitted infections [5,6]. According to the Global Burden of Disease, ADHD is responsible for 500,000 disability-adjusted life years (DALYs), 0.2% of the burden of all mental health disorders [7].

Given the prevalence and impact of ADHD, strategies to integrate ADHD screening in general medical care are needed. One tool that has been validated for identification of ADHD in African settings, the Kiddie Schedule for Affective Disorder and Schizophrenia-Present and Life time version (KSADS-PL). Despite its efficacy in rural Kenya, there is no known research exploring challenges on using KSADS-PL in routine practice in similar resource limited settings throughout the region [8]. Therefore, there is a need to identify barriers and possible solutions informing strategies to improve the uptake of the KSADS-PL in routine clinical practice among psychiatric settings that treat children at risk of ADHD. The current study aimed to describe the facilitators, barriers and their potential solutions to the uptake of the KSADS-PL at Muhimbili National Hospital (MNH) in Dar es Salaam, Tanzania.

Materials and methods

Data management and analysis

All interviews were conducted in Swahili, audio-recorded, and supplemented with field notes taken during or just after the interviews. Audio recordings were transcribed and translated into English using a one-step approach (i.e., Swahili sentences within the interview were transcribed directly into English by a bilingual transcriptionist), while field notes were expanded and used to write summaries that fitted within the transcripts.

Thematic analysis was facilitated by Dedoose Version 9.0.54 and aided by the CFIR constructs. Naeem and colleagues (2023) describe thematic analysis as a process guiding researchers’ selection of keywords and quotations, coding, identification of themes, interpretation, and the development of a conceptual model [11]. Accordingly, two senior qualitative study staff developed a codebook originating from questions on the interview guides and additional codes were added as themes emerged. We used both inductive and deductive approaches to identify facilitators or barriers to KSADS-PL utilization. Deductive codes were created before coding began and were generated them from the interview guide. For example, codes like ‘barriers to KSADS-PL uptake’ were created from the question “What might be the possible barriers or things that hinder the implementation process for K-SADS-PL use at your clinic?”.

Inductive codes were generated once coding began, emanating from the data itself. For example, we decided we needed a code for “perceived increased workload” due to providers describing fears regarding increased workload following KSADS-PL integration. Coded themes were further developed by coding summaries and matrices to better understand mental health providers’ readiness towards the introducing KSADS-PL use at the clinic. Table 1 below summarizes codes and subcodes which were addressed in the current study.

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Table 1. Barriers, facilitators and potential solutions to implementing KSADS at child and adolescent clinic, MNH.

https://doi.org/10.1371/journal.pone.0323502.t001

Results

We were unable to complete four of the planned key informant interviews with stakeholders at the clinic, and we only completed 11 out of the planned 20 in-depth interviews due to the COVID-19 pandemic. In-depth interviews included a nursing block manager (n = 1), psychiatrists (n = 4), and a clinical psychologist (n = 1), psychiatry resident trainee (n = 1), a registrar (n = 1), social worker (n = 1), nurse (n = 1), and occupational therapist (n = 1).

Discussion

The current study intended to add to the literature on the use of the KSADS-PL as an evidence-based assessment tool for screening and diagnosing ADHD among children and adolescents in Tanzania. We used CFIR domains and constructs to categorize facilitators, barriers, and their solutions regarding the implementation of the KSADS-PL. In our sample, we found that all the interviewed providers showed a willingness to use KSADS-PL. Providers conveyed their motivation to help children they routinely see at the clinic, and they felt a level of satisfaction seeing their clients improve after engaging in treatment. Most providers mentioned about their current use of the DSM-5 as a diagnostic guideline, highlighting their knowledge on ADHD diagnostic criteria; because the KSADS-PL represents a DSM-5 based tool, MNH providers would likely possess some knowledge regarding the tool’s items [12].

To address barriers related to costs associated with mass producing paper copies of the KSADS-PL, some of providers suggested the use of electronic version. Their suggestion can be strengthened by findings from Townsend and colleagues (2020), who focused on development of computerized versions of KSADS (KSADS-COMP). They concluded that use of clinician-administered KSADS-COMP indicates utility in clinical settings, as it can also shorten administration due to its ability to score automatically [13]. Regarding additional barriers described in our results section, it is likely not realistic to suggest that governing bodies in resource-constrained health systems provide additional funds to hospitals to increase staffing, material resources, and physical space [14]. With regard to the literature base, the implications of these results may be best addressed through innovative implementation strategies to address barriers within the inner setting like task-shifting, champions, train-the-trainer models, and organizational coaching [15,16].

Our findings reflected similar conclusions from the implementation and mental health literature, indicating how a barrier like limited knowledge can be addressed by provision of training to providers; and then, continuing to build their capacity through provision of ongoing technical assistance [16–18]. Therefore, initial and ongoing provider trainings, provision of technical assistance, and supervision may facilitate uptake of the KSADS-PL in this setting. Precedence for similar strategies exist within the region. For example, in a study done in Tanzania by Mwendwa and colleagues that aimed to improve the human resource management (HRM) function at district and health facility level through the Support, Train and Empower Managers (STEM) project to foster the capacity of managers to support and supervise their staff in Tanzania [19]. Their findings showed how training and supervision support the implementation of STEM as an evidence-based intervention, and ultimately enabled an environment for management to support staff and improve their morale and retention. Another study from Malawi concluded that an mhGAP training package could be delivered to large numbers of non-specialist health care workers, and was successful at improving their knowledge, confidence, and case detection rate of mental health disorders. Using a “train the trainers” model may also ensure that the knowledge and skills of district mental health teams are updated and strengthened, remaining as a resource within the district [20].

Inadequacy of both human and material resources such as staff and medications, lack of mental health training, lack of physical space, and a lack of coordination within healthcare systems have been highlighted as barriers to implementing evidence-based health interventions in low and middle-income countries like Tanzania [21]. Providers reported that most of the health facilities in Tanzania experience understaffing and added that the majority lack trained mental health providers. “Task shifting” may be employed to implement evidence-based interventions like use of KSADS-PL. Task shifting involves the use of non-specialized staff to perform duties of specialized staff, and has been widely adopted in sub-Saharan Africa across various fields of health [22,23]. Suggestions from our participants aligned with these concepts when they described how providers from all cadres including nurses, social workers, occupational therapists, general practitioners’ residents, clinical psychologists, and psychiatrists could benefit from the ability to screen and diagnose ADHD using the KSADS-PL.

While task shifting in theory represents a solution to the lack of trained mental health specialists, recent work from the region describes how task shifting alone may not adequately address inner and outer setting barriers. Akiba et al. (2023) described how chronic disease clinic provider fidelity to administering a newly integrated depression screening tool varied based on several factors related to clinic leadership and implementation climate [24]. These results suggest that task shifting might succeed best when paired with additional implementation strategies aimed at addressing additional health systems barriers. In a recent review of task shifted interventions throughout sub-Saharan Africa, Okoroafor and Christmals (2023) concluded that task shifting represents a viable solution to shortages of medical specialists (e.g., psychiatrists) [25]. However, the authors caution that due to the complexities of health systems in the region, needs assessments to better understand implementation contexts should precede any additional strategies. Okoroafor and Christmas (2023) note that once barriers are understood, strategies like workforce capacity building and provision of necessary implementation tools (e.g., job aids) are likely to follow. These suggestions align closely with our study results where providers describe the importance of adequate and ongoing training to address turnover, as well as the availability of the KSADS-PL.

While our results describe unattended barriers that might be overcome through additional implementation strategies, more work regarding which specific strategies as well as their feasibility and acceptability within the study clinic are required. Going forward, a research agenda that utilizes a structured approach to developing implementation strategies like the CFIR-ERIC matching tool could help identify the most pragmatic next steps for KSADS-PL implementation at MNH [26].

To the best our knowledge, this study was the first to assess providers’ views about facilitators, barriers and possible solutions to the use of KSADS-PL in Tanzania. A sub-Saharan African based study by Olatunji et al. (2023) highlighted various obstacles faced by children with ADHD in sub-Saharan Africa, focusing on the lack of awareness and stigma surrounding the disorder, limited access to mental health services, and inadequate education and support as barriers to ADHD diagnosis and treatment [27]. The review article suggests public awareness campaigns, training for healthcare professionals, integration of mental health services, addressing affordability and accessibility, telemedicine and digital health platforms, and stakeholder collaboration as useful ways to address the barriers. Similar barriers like lack of awareness to ADHD, limited number of trained mental health providers, and limited material and human resources comprise the results of our current study. Interviewees proposed similar solutions like awareness campaigns, training providers, making services available and accessible, involvement of multiple stakeholders, and use of online assessment methods. However, due to differences in health systems between nations, and the unique nature of each clinic or hospital, preliminary qualitative efforts to better understand unique barriers in each setting are required before implementing wholesale solutions.

Our study findings should be understood within the context of a number of limitations. First, our study was conducted at the only child and adolescent clinic in the country, potentially leaving out some of the barriers and facilitators to the introduction of KSADS-PL into child and adolescent facilities in Tanzania more widely. Nevertheless, as providers at the only tertiary mental health facility in the country, they retain a high level of influence on how screening and diagnosis of child and adolescent mental health disorders might operate over other facilities throughout the country. Secondly, although providers reported that introducing KSADS-PL as feasible with suggested solutions to the identified barriers, we feel that this suggestion is theoretical and requires testing and evaluation.

Conclusion

Providers reported high levels of feasibility for the KSADS-PL and expressed a need for such a tool on behalf of their clients. At the same time, they identified several barriers relating to human and material resources associated with costs that MNH may struggle to provide (e.g., training and ongoing supervision). While researcher from the region have called for large scale task-shifting efforts to address the dearth of psychiatric service providers [28], several systematic reviews have shown that task-shifting alone is not sufficient to bridge the mental health disorder treatment gap in LMICs, suggesting a need for context-specific adaptations for an implementation strategy to be applied successfully [26].

Literature on implementation strategies is bolstered by research efforts into the barriers and facilitators related to their implementation across contexts [14]. The current study adds to the knowledge base regarding barriers and facilitators to the uptake of KSADS-PL at a large national hospital in Tanzania. While our study represents an important first step in highlighting the feasibility of KSADS-PL implementation in this setting, subsequent research focused on addressing additional barriers like provider workload, turnover, and inadequate materials are still required on the path towards scale-up.

Supporting information

Acknowledgments

We are sincerely thankful to providers who participated in the study. We are also thanking Muhimbili National Hospital for providing us a conducive atmosphere to do the study at the child and adolescent clinic.