Innovation summary

In Malawi and Tanzania, lack of awareness and poor knowledge about common mental disorders contributes to pervasive stigmas that prevent young people from seeking help when needed. This, combined with the dearth of health care providers trained to effectively treat young people with mental disorders, has created an environment where many young people suffer in silence. 

This program combines empirically validated methods in school-based mental health literacy, training of community-based health care providers, and behavior change communications to:

  • Raise awareness, improve knowledge and decrease stigma of common mental disorders with a focus on Depression
  • Create demand for effective, easily accessible community-based adolescent mental health care
  • Improve knowledge, attitudes and health seeking behaviors among youth
  • Develop an integrated pathway to care across education and health sectors
  • Build the capacity of community-based health care providers to assess, diagnose and treat adolescent depression

 

Impact summary

Key indicators primarily assess enhanced mental health literacy and improved early identification of youth with Depression in schools.

  • More than 500,000 young people were reached through the radio program; over 400 teachers and 200 community health providers were trained; over 3,000 young people approached teachers about mental health concerns; and over 1,000 received treatment in community health clinics
  • School interventions significantly improved mental health literacy outcomes for teachers and resulted in direct referrals from schools to community clinics (on average 4 students referred to community health clinics per teacher)
  • All health care providers and teachers trained showed significant improvements to knowledge, personal help-seeking and decreases in stigma
  • Community mental health care for youth now available; about 10% of youth attending clinics diagnosed and successfully treated for Depression

“I lost both parents and I have suffered from depression for a long time without realizing that it was depression and an illness...but with the Nkhawa Njee radio program I managed to pick myself up, and something good happened—I am still at school. I am no longer worried and depressed. Thank you so much guys. Keep it real"

 

-Ben Wakulu Mwale, regular listener to program in Malawi

This innovation is funded by Grand Challenges Canada.

Innovation details

The innovative model brings together three integrated elements:

  1. Awareness-building and decreased stigma through a radio-based drama and interactive mobile phone interventions
  2. School-based mental health literacy and identification of young people with mental disorders for teachers and students alike
  3. Capacity-building for diagnosis and effective treatment of young people with Depression in community health clinics through competency-oriented training of health providers

Raising Awareness Through Interactive Radio

Interactive Radio Programs

3 stations in Malawi and 1 station in Tanzania broadcast a weekly 30-minute youth radio program with messages about mental health and Depression. This radio program included a syndicated, serialized radio soap opera that delivered messages about mental health, sexual and reproductive health, and substance abuse. Called “Nkhawa Njee” in Malawi and “Positive Mood” in Tanzania, the radio programs have gained immense popularity by using an “edutainment” approach that combines serious issues with entertainment. Mental health exerts participated in program design sessions to ensure accuracy of mental health content, and the radio producers did what they do best—create a program that attracted hundreds of thousands of listeners.

Mobile phone software allowed young people to leave comments and questions for radio hosts or mental health experts, and participate in quizzes and polls intended to assess comprehension of key messages free of charge. Beep for referral service is available, where young people can miss call an automated interactive voice response system free of charge, where they can get information about the closest health facility with a trained mental health provider and the name of that person.

Radio Listener Clubs

To link the programs to school-based mental health literacy interventions, Radio Listener Clubs were 
were established in a select number of secondary schools in the target districts of Malawi and Tanzania. Listener club members met weekly to listen to the program together. Following the
radio program, discussions were facilitated by trained peer educators or classroom teachers.

School-based Mental Health Literacy

An adolescent mental health curriculum guide used in Canadian schools (the Guide) was translated and adapted to the local context in Malawi and Tanzania (the African Guide) by mental health experts. The African has 7 modules: 1) Understanding Mental Health and Mental Illness; 2) The Stigma of Mental Illness; 3) Information on Specific Mental Illnesses; 4) Experiences of Mental Illness; 5) Seeking Help and Finding Support; 6) The Importance of Positive Mental Health; and 7) Counseling Treatments for Depression.

Once adapted and translated, teachers in schools in Malawi and Tanzania were trained to integrate the African Guide into their classrooms. Teachers used the African Guide to teach about mental health in the schools and were taught how to identify youth at risk for Depression. Additionally, schools were encouraged to link to local community health care providers to refer students identified as at-risk, and peer educators received training to facilitate peer sessions about mental health as a part of the weekly Radio Listener Clubs.

Health System Capacity Strengthening

A national team of Master Trainers and a number of health care provider trainers have been trained in an Adolescent Depression Identification and Mitigation Program that was adapted for the local context from a  program certified in Canada by the Canadian College of Family Practice. In addition, trainers complete a facilitated e-course to enhance learned competencies. Trainers were recruited through the Ministry of Health’s Non-Communicable Disease Department in both countries. They are psychiatric nurses and medical officers, representatives from the Ministry of Health, and trained psychiatrists and psychologist from medical colleges. Trainers provide training and support to community-based health care providers in the diagnosis and effective management of youth with depression.

Key drivers

Collaboration and Approval from Specific Ministries

Close collaboration with the Ministry of Health in both countries has been established and linkages with Ministries of Education are underway. The project team works with a core group of master trainers who help design and facilitate all training activities. They are heavily involved in adapting materials, validating screening and clinical management tools, and reviewing the content of the radio program, and are all linked to the respective Ministries of Health. This ensures that the innovative program has input from key local leaders and linkages to key decision makers in the Ministry of Health.

National Advisory Committee Established

National Advisory Committees have been established in both countries. These are comprised of the master trainers and key ministry representatives and help the project implementation group establish links between different sectors (education, health and youth) that typically do not work together. This helps increase the possibility that mental health becomes a cross-cutting theme shared across government domains and allows for senior decision-makers to be aware of the establishment of a horizontally integrated pathway to youth mental health care. This helps to ensure sustainability over time and also allows for more effective implementation by involving academics, clinicians and policy-makers that have different types of expertise to offer.

Challenges

Challenges in Partnerships

Partnership challenges led to substantial mid-stream modifications to the project. This included replacing some of the original partners with others, re-focusing efforts to engage Ministries of Health and to exchange one country of operation for another. 

Lack of Resources for Those Seeking Help

Initially, necessary medications were not available, psychotherapeutic capacity was limited, and there was a lack of basic clinical competencies among community health professionals to provide mental health care to young people. These have been significantly improved and there is now evidence that a horizontal linkage between schools and community clinics has the capacity to provide both medication and psychotherapy interventions to young people with Depression. 

Lack of Expertise in Psychiatry in Project Countries

In Malawi, there is only one psychiatrist in Malawi and though there are 25 in Tanzania, none have sub-specialty expertise in youth mental health. Further, in both countries psychiatrists live in urban cities, far away from the districts of interest for this project. Mental health care for young people with Depression is essentially non-existent, and psychiatric nurses, who are the backbone of specialty mental health care, do not have the competencies to identify, diagnose or effectively treat Depression in young people. Similarly, community health providers do not have these competencies, so there is essentially no place for young people with Depression to go to receive the care they need.

Continuation

The proof of concept has now been established and key goals met. Relationships with Ministries of Health have developed and resulted in a number of significant improvements, including: wider availability of medication appropriate for young people with Depression; beginning of enhanced training in professional schools for psychiatric nurses;  embedding of this work in developing national mental health policies and plans.

Partners

Evaluation methods

We have used a number of different evaluation techniques, ranging from a prospective cohort design assessing impact of training on teacher and health provider competencies and also on health outcomes of young people with depression treated in a clinical context, to a cluster-randomized controlled trial assessing the impact of radio programming on young people's mental health literacy. To evaluate the impact of training interventions for teachers and community health care providers, we have carried out repeat quantitative measures using a before-and-after design. We have also conducted qualitative assessment of impact in select participating schools and a post-project debriefing with key stakeholders.

Currently we have published three papers in peer reviewed journals, with two currently in press. Eight more are due to be submitted before the close of 2016.

Cost of implementation

Initial cost analysis suggests implementation costs are low.

Impact details

As of November 2016 (see Final Report in the Resources section of this Case Study for details):

  • The radio program significantly improved mental health literacy measures in young listeners
  • School interventions have significantly improved mental health literacy outcomes for teachers and resulted in direct referrals from schools to community clinics (on average four students referred to community health clinics per teacher)
  • Health care provider training significantly improved health care providers’ knowledge and attitudes towards mental health
  • All health care providers and teachers trained showed significant improvements to knowledge, personal help-seeking and decreases in stigma
  • Community mental health care for youth now available; about 10% of youth attending clinics were diagnosed and successfully treated for Depression

The radio program is estimated to have reached at least 500,000 young people in Malawi and Tanzania with crucial information about mental health. The radio program significantly improved mental health literacy measures in young listeners: 80% of young people who have listened regularly to the radio program to date demonstrate improvements in knowledge about mental health and Depression, and a reduction in stigmatizing attitudes that often prevent people from asking for help.

School interventions have also significantly improved mental health literacy outcomes for teachers and resulted in direct referrals from schools to community clinics (on average four students referred to community health clinics per teacher). Teachers trained to use a mental health curriculum guide in their classrooms demonstrate significant improvements in their own knowledge and attitudes about mental health. On a knowledge assessment, teachers’ scores improved by 30% from baseline (58.3 to 76.3). Attitudes toward mental health and depression also improved (36.8 to 44.3), demonstrating reduction in stigma.

Similar results were found in the preliminary analysis of data from teachers in Tanzania. A paper in press shows positive results achieved by training health care providers in mental health care competencies.

The school-based approach has been successfully rolled out in high-income countries, and the results from this program demonstrate its applicability in low resource settings such as Malawi and Tanzania.  

The combination of a school-based approach with a mass media approach is cost effective, reaching hundreds of thousands of young people through the radio program, and thousands of young people through listening clubs in schools. In addition, a national certified adolescent training program in the diagnosis and treatment of adolescent Depression for primary care physicians has been successfully adapted, implemented and has shown positive results. Thus, there is now available (for the first time, to the best of the programme’s knowledge) a mental health training program validated for African settings which effectively addresses the need to enhance community health care workers and psychiatric nurses’ competencies in the identification and treatment of Depression in young people.

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Country

Malawi, Tanzania, United Republic of

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