The development and evaluation of a community-based rehabilitation intervention for people with schizophrenia in Ethiopia.

Background: Community-based rehabilitation (CBR) is a promising intervention to address the complex needs of people with schizophrenia in low-income countries, in particular the high levels of disability, problems accessing treatment and stigma experienced by this group. There have been few randomised controlled trials of communitybased psychosocial interventions for schizophrenia using non-specialist workers, and none which have utilised a community mobilisation approach or that are set in low-income countries. This thesis presents the intervention development, piloting and evaluation plans of a CBR intervention for people with schizophrenia in Ethiopia. Methods: A theory of change approach was used. Intervention development work, including a situational analysis, qualitative interviews and participatory workshops, was conducted to design the CBR intervention. The intervention was manualised and ten non-specialists were trained to deliver CBR. Ten people with schizophrenia and their caregivers received CBR in a 12 month pilot study. Qualitative, process and quantitative data were collected. The protocol for a cluster randomised trial to evaluate CBR, refined on the basis of the pilot findings, was produced. Results: CBR delivered by non-specialists is an acceptable approach for people with schizophrenia in rural Ethiopia. This CBR intervention is likely to be feasible but this requires evaluation on a larger scale. CBR may improve functioning in people with schizophrenia through maximising family and community support, supporting income-generating activities, facilitating access to medication, and increasing hope. However, contextual factors, including poverty and inaccessible anti-psychotic medication, may be beyond the capacity of CBR to overcome. Conclusion: A community-based intervention such as CBR should be provided for people with schizophrenia in low-income countries, alongside accessible anti-psychotic medication. There are indications that CBR can impact on functioning but a randomised controlled trial remains essential. The trial analysis will help to determine the ‘active ingredients’ of CBR that should be prioritised in scaling up.