Innovation summary

Due to a severe shortage of specialist care, most people with mental, neurological and substance use (MNS) conditions in Nigeria do not receive appropriate treatment1. They often end up with traditional and spiritual healers who, at best, provide social support but, at worst, may subject them to physical and other abuses2. The HAPPINESS Project is a multi-component intervention that utilizes community resources, available specialists and a mobile tele-medicine platform to increase access to evidence-based care for MNS conditions. The HAPPINESS Project trains community health workers, nurses and doctors in community health centers to screen people for MNS conditions, provide evidence-based treatments and make referrals for specialist care using WHO’s mhGAP Intervention Guide 2.0. It uses mobile tele-medicine to provide video-based connection between the community health centers and specialists.

Impact summary

  • 500 people screened for MNS conditions as of December 2019
  • 120 MNS cases identified as of December 2019
  • 120 people receiving services through the HAPPINESS Project
  • Cost: $20,000

Since the training, it has become easier for me to diagnose my patients and give the right medications. More patients are turning up…and responding to treatment. Patients’ relatives are happy as well. I am now enjoying my profession because I have job motivation. Bravo to HAPPINESS Project.”

 

- Angela Ekezie (Registered Nurse)

Innovation details

The HAPPINESS Project uses mobile technology to deliver continued medical education, drawing upon a mobile telemedicine platform and electronic health records (EHR) for clinical evaluation, documentation, prescription and connection to specialist care. The platform is fully functional, proprietary, mobile and video-enabled. It is built to function even when internet is patchy or non-existent, making it particularly useful in low-resource settings where internet availability is not always guaranteed. The project is anchored in the community. It is led by community health workers and primary care doctors making it easily accessible, potentially scalable and cost-effective. The project generates several avenues for potential cost savings, including:

  • Less need for long-distance travel
  • Early identification of MNS conditions leading to less intensive and expensive care
  • Utilization of mid-level, non-specialist providers.

The community engagement component of the HAPPINESS intervention promotes recovery, empowerment, advocacy and human rights. We plan to support client-led, self-help groups based in the communities and supported by the primary care teams by utilizing a stepped-care approach to delivery, which is collaborative and task-sharing in nature. Under this model, most people with mild to moderate symptoms are seen in the community by trained non-specialists while people with more severe symptoms are referred to specialists with clear framework for referral, consultation and follow up support. Finally, the project incorporates a Drug Revolving Fund to ensure a stable supply of effective, unadulterated medications at or below market value. 

 

Key drivers

Acceptability: The project has been well received by the majority of stakeholders, including; government agencies, primary care teams, communities and patients.

Adaptation: The mhGAP 2.0 training modules were contextualized and adapted to the local language and culture. For example, training videos and vignettes were developed with the local Igbo language. Names and measures of alcohol and drugs were described in the local parlance. The HAPPINESS Project has been integrated into the existing workflow of the nurses, doctors and community health workers at the primary health centers through the implementation of a jointly developed  standard operating procedure.

Clinical outcomes: There has been an increase in case-finding and treatment initiation for people with MNS disorders.

Challenges

Funding for mobile Internet access at the community centers and for the primary care teams: Due to limited funding, we were unable to rollout the mobile telemedicine app to all the clinics where we trained staff.

Training the teams on using standardized tools, materials and procedures: A lot of commonly used screening instruments were unfamiliar to the trainees. We had to build in extra time to train the teams on the use of these instruments.

Stigma and negative attitudes towards mental health conditions and epilepsy: Initially getting buy-in from political leaders and government officials was challenging due to stigma and negative attitudes to mental health conditions.  We had multiple pre-engagement meetings and education sessions with officials to overcome these issues and gain stakeholder support.







Community and stakeholder buy-in: Although the project has been well received by the primary care teams, clients and their family members of clients as well as some traditional rulers, there remain challenges engaging local faith healers (who see a lot of people with MNS conditions before they access other services), local proprietary patent medicine vendors and traditional healers. Our continuing engagement efforts will focus on these areas.   

Continuation

The next step is to scale up the HAPPINESS Project to all the primary care centers of Imo State and, through ongoing collaboration between CBM International, Yale Global Mental Health Program and other funders, adapt it across Nigeria and West Africa. The focus will be on:

  • Residential training and six-monthly refresher training for primary care teams
  • Maintaining a Drug Revolving Fund to ensure steady availability of medicines
  • Provision of equipment and support for the tele-medicine platform
  • Addressing transport costs associated with monitoring and staff support
  • Provision of salary support for project coordinators, on-site team leaders and additional, part-time psychiatrists
  • Supporting clients to start and maintain self-help and advocacy groups

Partners

Funders

Evaluation methods

The project will be evaluated by the Yale Center for Methods in Implementation and Prevention Science. Monitoring and evaluation will comprise the following elements:

  • Assessing the number of screenings completed and clients initiating treatment
  • Evaluating the performance and accountability for the Drug Revolving Fund
  • Evaluating the referral and consultation framework
  • Evaluating the utility, impact of and acceptability of the mobile telemedicine platform
  • Conducting a cost-effectiveness analysis

Cost of implementation

We have spent about $20,000 to deliver the project. A comprehensive cost-effectiveness analysis will commence December 2020.

Impact details

Through the project we have:

  • Delivered training and refresher trainings for a total of 37 clinicians in 13 primary care centers in 5 local government areas in Imo State.
  • Established a continuity of care framework between primary care teams and available specialists
  • Developed a mobile platform for continuing medical education for the trained clinicians
  • Developed a functional Drug Revolving Fund for the project

Within the past year post and implementing the project, 500 people have been screened and 120 people with MNS conditions have been identified with varied diagnoses. We are still collecting and collating data on clinical outcomes. Initial mixed-method analysis of the impact of the project and training showed that trainees reported significant improvements in the Socializing, Normalizing, and Supernatural Causation subscales of the stigma questionnaire used (p < 0.05). There was also evidence of improvement in the “biopsychosocial beliefs regarding mental illness”. Analysis also showed that The HAPPINESS Project enhanced trainees’ diagnostic and treatment abilities, mental health awareness, and empathy towards patients.

References

  1. Gureje, O., Lasebikan, V. O., Kola, L., & Makanjuola, V. A. (2006). Lifetime and 12-month prevalence of mental disorders in the Nigerian Survey of Mental Health and Well-Being. The British Journal of Psychiatry, 188(5), 465-471.
  2. Esan, O., Appiah-Poku, J., Othieno, C., Kola, L., Harris, B., Nortje, G., ... & Gureje, O. (2019). A survey of traditional and faith healers providing mental health care in three sub-Saharan African countries. Social psychiatry and psychiatric epidemiology, 54(3), 395-403.

Tools

Multimedia

Associates

Theddeus Iheanacho
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Country

Nigeria

Affiliated organizations

HAPPINESS Health Care (HHC) Foundation

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