Innovation summary

In Peru, mental disorders are the main cause of disease burden1. Epidemiological data collected from different regions in Peru report lifetime prevalences between 25 and 50% for any mental disorder2. Evidence has shown these disorders to be associated with reduced treatment adherence, greater disability, and higher mortality in physical diseases3, and groups such as women, victims of political violence, and people living with a physical disease are disproportionately affected4-8. Despite this, typically less than 25% of people with mental disorders receive treatment9.

The goal of this research project was to develop and test an intervention which combines a mobile health strategy - a mental health screening app and motivational SMS - and training of 22 non-specialized primary health care providers to improve the early identification, opportune referral, and access to specialized treatment for people suffering from mental disorders and attending primary health care facilities in Lima, Peru.

 

Impact summary

  • 634 patients were screened for mental disorders by 22 primary health care providers over a period of 9 weeks
  • 22.6% of patients screened positive for mental disorders
  • Of these, 72.4% reported seeking mental health care and 55.1% accessed specialized care (e.g., psychologist); of 35 patients receiving SMS, 86% reported feeling motivated by the SMS to seek mental health care

“We already had a close bond with our patients and they talk to us about personal things, however through the screening, we were able to learn more about them and grow closer. It made me realize that the physical aspect, pills and checkups are not everything. Mental health is fundamental, and it is what we are missing to achieve complete care.”

 

-Jenny, nurse, Chronic Diseases Service

 

​This innovation is funded by Grand Challenges Canada.

Innovation details

Allillanchu is a greeting term in Quechua, a Peruvian native language, which translates into “How are you? How are you feeling?” One of the project’s aims was to incorporate this concern for other people’s emotional wellbeing into primary health care routines. The project sought to make the assessment of patient’s mental health a common practice among primary health care providers (PHCP), specifically those who work with patients with an increased risk of suffering from mental disorders, such as pregnant women and patients with tuberculosis, HIV/AIDS, diabetes, or hypertension.

The intervention consisted of a 9 week pilot with 22 primary health care providers who were first trained and then screened their patients for mental disorders using a screening app installed on tablets made available by the research team.

 

Key components of the intervention

Training of Primary Health Care Providers

The intervention provided tailored mental health training to 22 PHCP, covering the basic concepts of mental health, common mental disorders and co-morbidity with other health conditions, use of the screening app, and how to deliver results in a sensitive and motivational manner. The training sessions were designed in collaboration with a psychotherapist and University professor, based on formative research previously conducted by the research team and the revision of available literature. The methodology was expositive, using audiovisual resources; and participatory, using role-playing and practical exercises.

Mobile Health: Integrated Intervention

The mobile platform for this intervention involved:

  • A mental health screening app, based on a Self Report Questionnaire (SRQ), which automatically calculated scores and provided guidelines to deliver the patients’ results and possible places of referral
  • A web-based data platform which collected information from the screenings and allowed the research team to assess the progress of the intervention and to identify possible problems
  • An SMS delivery app which automatically sent a set of reminder and motivational text messages to patients who screened positive for mental disorders, informed by the web based data platform

 

Key drivers

Engament of key stakeholders

Engagement with key stakeholders at different levels within the health care system allowed operations within health care centers and facilitated health care providers’ engagement.

Use of available human resources

The intervention was delivered within the existing health care system, capitalizing on the current human resources available.

Tailored training sessions

The design of training modules was tailored to the current abilities and needs of participating primary health care providers.

Innovative concept to task-shift care: mHealth

Use of mobile technology optimized the task-shifting of mental health to the primary care level.

 

Challenges

Approvals and commitment

We had difficulty identifying the path to obtaining the necessary approvals to implement the intervention in the health system. We also had some difficulty keeping the PHCP and health authorities involved and engaged with a project that is in development and will not be implemented until months later.

Logistics and recognition of the task within health services

Changes such as rotation of personnel, changes in the routine procedures, workload, introduction of new tasks, etc. within the health services affected the implementation settings. A lack of recognition of the intervention within health services also made it difficult for PHCP to redistribute their workload in order to incorporate the new task in their regular consultations. Finally, shift-based work complicated the assessment of implementation, as PHCP were not present every day.

Lack of specialized care

Specialized care alternatives for referred patients in primary health care were sparse.

Timing of SMS delivery

Effectiveness of the SMSs was difficult to assess, since most of the referred patients accessed specialized care in a shorter time than expected, before receiving the text messages.

 

Continuation

We are planning to scale-up our innovation through two complementary paths: (1) engaging the health system to implement it on a larger scale and (2) applying for more research funding to further validation.

Regarding the first path, we consider the health system to be the main beneficiary of the uptake of this innovation, and a current health system reform is aiming to integrate mental health into primary health care, beginning with the implementation of a mental health screening. Therefore, through dissemination meetings with key stakeholders, we aim to work with them towards addressing the main barriers and to facilitate its scale-up within the health system.

Concerning the second path, we are discussing with Partners in Health Peru to design a research proposal to test the screening app with community health workers.

 

Partners

Implementing Partners

Funder

 

Evaluation methods

Screening Outcomes

The developed Data Collection Platform stored (a) demographic and contact information from the 1772 enrolled patients, and (b) detailed data from the use of the screening app by the 22 PHCP (i.e. logins, screening results, referral of patients, etc.). At the end of the intervention, the database was exported and analyzed using IBM SPSS. The analysis consisted mainly on descriptive statistics.

PHCP Implementation Experience

To understand the experience of the 22 PHCP involved in the implementation, we interviewed them at the mid-point and the end of the 9-week intervention, using semi-structured guides. The interviews’ audio was recorded and transcribed, and the information collected was categorized using matrices based on the main topics of the interview guides. Each category of the matrices includes quotations of the interviewees and a summary of their experiences and perceptions. All data were analyzed by three members of the research team, with subsequent discussion of the information and further interpretations.

Patient Follow-up

The patients’ follow-up allowed us to assess specialized care seeking and access after a positive screening. This phase also used a qualitative approach, which involved semi-structured interviews with 127 of the 143 people (89%) who during the intervention screened positive for mental disorders and were invited to seek specialized care. Interviews were recorded and their content was categorized in a matrix, based on the main themes of the interview guide, and data were analyzed through descriptive statistics.

 

Cost of implementation

We did not conduct cost-effectiveness analysis.

 

Impact details

Our project successfully achieved its aims. It showed that with basic training and support, primary health care providers are willing and able to identify patients with mental disorders during their regular consultations and to motivate them to seek specialized care.

The screening and referral proved effective:

  • Of 634 patients screened during their regular consultations, 143 (22.6%) screened positive for mental disorders; all were referred to specialized care
  • The prevalence of mental disorders was 24.6% among women and 17.1% among men
  • For specific patient groups, the prevalence was 66.7% among HIV/AIDS patients, 35.4% among chronic diseases patients, 19.4% among pregnant women, and 18.1% among TB patients
  • The most common disorder was depression/anxiety, which is grouped into a single category on the screening
  • We interviewed 127 referred patients (89% of the total of patients who screened positive). Notably, 72% reported seeking mental health care and 55% accessed it, mostly with a psychologist (93%)

Regarding SMS delivery, out of the 127 interviewed patients, only 35 (27%) could be asked if the messages motivated them to seek help; of the remaining patients, 20% received specialized care before the SMS delivery began, 17% did not consent to receiving SMS, 14% did not seek care, and 22% had other reasons. Out of the 35 patients, 86% reported feeling motivated by the SMS to seek mental health care.

The 22 PHCP who implemented the screening provided feedback on the viability of the screening and how to improve its implementation. They highlighted as main benefits of the screening:

  • Identifying cases that would otherwise have gone unnoticed
  • Knowing a different side of their patients’ health, beyond their physical conditions
  • Improving the quality of care provided during their appointments
  • Raised awareness of their own mental health state and that of the people around them

All of the PHCP were willing to include the screening app in their daily practices. However, they also pointed out some barriers that should be addressed:

  • Time constraints
  • High workload in certain services
  • Rotation of trained professionals to other services.
  • Lack of recognition of the screening as an activity that is part of their routines
  • Insufficient psychologists to tend to all referred patients

 

References

  1. Velásquez A. [The Burden of Disease and Injuries in Peru and the Priorities of the Universal Assurance Essential Plan]. Rev Peru Med Exp Salud Publica 2009;26(2):222-31.
  2. Instituto Especializado de Salud Mental “Honorio Delgado-Hideyo Noguchi”. Estudio epidemiológico metropolitano en salud mental, 2002. Informe general. Lima: IESM HD-HN; 2002
  3. Rayner L, Price A, Evans A, Valsraj K, Higginson IJ, Hotopf M. Antidepressants for depression in physically ill people. Cochrane Database Syst Rev 2010(3):CD007503.
  4. Instituto Nacional de Salud Mental. Estudio Epidemiológico de Salud Mental en Lima Rural 2007. Anales de Salud Mental 2007;24(1-2):1-247.
  5. Instituto Nacional de Salud Mental. Estudio Epidemiológico de Salud Mental en Lima Metropolitana y Callao. Replicación 2012. Anales de Salud Mental 2013;29(1).
  6. Instituto Nacional de Salud Mental. Estudio Epidemiológico de Salud Mental en la Selva Peruana. Anales de Salud mental 2005;21(1-2):1-214.
  7. Instituto Nacional de Salud Mental. Estudio Epidemiológico de Salud Mental en Fronteras 2005. Anales de Salud Mental 2006;22(1-2):1-227.
  8. Instituto Nacional de Salud Mental. Estudio Epidemiológico de Salud Mental en Ayacucho 2003. Anales de Salud Mental 2004;20(1-2):1-199.
  9. Demyttenaere K, Bruffaerts R, Posada-Villa J, Gasquet I, Kovess V, Lepine JP, et al. Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. JAMA 2004;291(21):2581-90.
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