Innovation summary

Liberia, Nepal and Uganda are post-conflict countries with a substantial burden of mental disorders and lack of community-based mental health services. Prior post-conflict humanitarian efforts have focused on PTSD and common mental disorders, whereas severe mental and neurological disorders have been neglected. Mental health beyond facilities (mhBeF) aims to develop an evidence-based Comprehensive Community-based Mental Health Services (CCMHS) package, in accordance with the Mental Health Gap Action Program (mhGAP), for persons with severe mental disorders and epilepsy in three post-conflict countries.

mhBeF consists of:

  • Multi-tiered and multi-sectoral community program to complement clinical initiatives
  • Inclusion of an mHealth component to facilitate clinical decision-making and monitoring
  • Implementation and evaluation of effectiveness of the CCMHS package to provide evidence for global scale-up
  • Inclusion of a savings and credit economic component in a community health platform

Impact summary

  • 74 primary health care workers, 53 community resource persons and 16 mid-level mental health workers & social workers were trained in total
  • 800 contacts (screening, diagnosis, treatment and/or referral) with people with severe mental disorders each month  in Uganda and 120 in Liberia and Nepal
  • Cost effectiveness study will be conducted at the end of the research study

“For instance when I was admitted (in the General Ward of Lira Hospital), I was the only mental patient at the time; but when that Mental Health Unit was built [at Lira Hospital], so many people started going there….in the past those who could afford the cost of transport and upkeep were going to Butabika Hospital; most of our people in the north were being neglected because that service was not within their reach.”

 

-Service user, Uganda

Innovation details

Mental health beyond facilities (mhBeF) aims to develop and implement an evidence-based Comprehensive Community-based Mental Health Services (CCMHS) package for persons with severe mental disorders and epilepsy in three post-conflict countries.

The project has a focus on capacity building in health services and research with a cross-national design to promote exchange and innovation through South-South collaboration among the three countries. mhBeF develops a model that has potential for broad application, taking into account the diverse cultural, economic, and resource needs of LAMIC.

The components of the Comprehensive Community Based Mental Health Services (CCMHS) Package include:

Capacity Building

Two levels of community-engaged groups will be trained: low-level health professionals, engaged in community-based health activities, and community resource persons, engaged in community outreach activities. The training will focus on three components:

  • The supervision and clinical-liaison model
  • Integration into existing country-specific efforts to promote mental health care in primary care
  • A South-South collaborative approach where lessons learned among the three countries are engaged to promote practices with elements generalizable across low and middle income countries
Social Capital and Family and Community Acceptance
 
Appropriate interventions, determined from formative activities, will aim to empower vulnerable households to identify, manage and respond to mental disorders and societal factors contributing to prevalence of mental disorders. Households will be encouraged to access services that enhance their social protection (through empowerment activities: information dissemination, socio-economic empowerment and social safety net strengthening) leading to mitigation of effects of external shocks on the mental health needs of these households.
 
Anti-Stigma Activities
 
Targeted stigma reduction activities will be conducted with health workers, persons with severe mental disorders and epilepsy and their families to reduce stigma in clinical and community settings and within the home. The activities will differ in each country.
 
In addition to the CCMHS package delivery, mhBeF will also document the implementation and evaluate the effectiveness and cost of the package.

 

Key drivers

Integration & Buy-In

  • Consulted with the partners, such as the Ministry of Health and at the District level at the planning stage and continuously during implementation
  • Carried out formative research that included all stakeholder perspectives
  • Provide regular updates to the key stakeholders at the Ministry of Health and the District level
  • Working through the established health system, working with already in place health care workers
  • Encouraging health units/Districts/public sector to provide the necessary inputs, especially drugs

Challenges

Varying Cultural Contexts

  • Though the selected sites have similar sized populations and scarce health and mental health resources, there is a potential challenge of varying cultural contexts. To counter this challenge, mhBeF  developed a modular curriculum including training manuals that have been customized and adapted to the context of each country

Technical Challenges

  • Movement (from one Unit to another, maternity leave, to another district), of the trained personnel; refresher trainings have been organized.
  • HCW not familiar with the basics of a smart phone; developed a manual that covers the basics, as well as the “how to” work with the mhBeF software. Also provide on-going support and refresher trainings as need arises.
  • Internet coverage and availability of electricity; software can store data when it is offline, HCW have to travel to nearest large town to access internet at least once a week, and solar charges are available and inexpensive.

Continuation

mhBeF has been developed with replication and scale-up in mind. If it proves effective, the plan would be to  (a) scale up to include other disorders that have not been included; (b) scale up to include children;  (c) scale up to cover the whole country, in Uganda, Liberia and Nepal; and (d) provide support to replication in other LMICs. 

There is also potential to collaborate with other initiatives that are developing mental health care plans (e.g. PRIME). 

Partners

Evaluation methods

The intervention employed a controlled evaluation, using pre- post and follow-up measurements of individual beneficiaries through clinical assessment, self-report and caregiver report. The pre and post training evaluations were used to measure the impact of the training for different cadres in terms of knowledge, attitudes, stigma and competencies. Tools used included:

  • Stigma: Mental Illness Clinician’s Attitude scale (MICA1) and Social Distance
  • Knowledge & attitudes: mhGAP questionnaire2
  • Competency: Task-sharing Adherence and Specific Competence Rating Scale (TASC-R)3

An individual outcome evaluation on the other hand was used to evaluate the impact of the comprehensive community based mental health care package on improved individual clinical symptoms, functioning impairment and economic outcomes. Furthermore, the intervention was controlled in order to study the added value of peer support groups in the overall care package.

The primary outcome for this evaluation is change in functioning for combined SMDs & epilepsy.

Cost of implementation

$2,379,402 USD funding over three years 

Impact details

Identified and Trained health care workers (HCW), community resource persons (CoRPs), and community development officers (CDO) for the delivery of the CCMHS Package:

  • Uganda: 20 HCW, 20 CoRPS, 5 CDOs and 4 Social workers were identified and trained
  • Liberia: 10 HCW, 10 CoRPS and 2 CDOs were identified and trained
  • Nepal: 20 HCW, 24 CoRPs, 4 CDOs were identified and trained

HCWs will screen, diagnose, treat and/or refer (contacts):

  • Uganda: 800 persons with severe mental disorders and epilepsy each month (by month 16 – 4,800 contacts; month 22 – 9,600 contacts, month 34 – 19,200 contacts)
  • Nepal and Liberia: 150 persons with severe mental disorders and epilepsy each month (by month 16 – 900 contacts; month 22 – 1,800 contacts, month 34 – 3,600 contacts

Patient Support Groups (PSG) are established:

  • Uganda: 10 PSGs consisting of at least 10 patients and carers in each in Uganda
  • Liberia and Nepal: 5 PSGs

Community Resource Persons (CoRPS) and Patient Support Groups (PSG) implement targeted anti-stigma activities:

  • 20 health care workers (or 20% depending on catchment area) involved in the project and 5 members of any other group (journalist, police, local leaders or teachers) (or 5% depending on target group size in catchment area) will be reached by month 36, with 15% change in pre- and post- tests
  • 10% increase in number of referrals to a mental health trained primary care worker, CoRPS, or CDS by the stakeholder group (other health workers, teachers, police) between months 22 and 36
  • Content of locally and nationally available media will reflect a greater representation of positive messages and fewer negative messages
  • 75% of persons with severe mental disorders or epilepsy and caregiver participants in patient support groups will receive self-stigma reduction training 

References

  1. Patel V et al (2011) Lay health worker led intervention for depressive and anxiety disorders in India: impact on clinical and disability outcomes over 12 months. British Journal of Psychiatry, 199(6):459-466.
  2. Patel V et al (2010) Effectiveness of an intervention led by lay health counsellors for depressive and anxiety disorders in primary care in Goa, India (MANAS): a cluster randomised controlled trial. Lancet, 376(9758):2086-2095.
  3. Rahman A et al (2008) Cognitive behaviour therapy based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial. Lancet, 372(9642):902-909.
  4. Thornicroft G et al (2010) WPA guidance on steps, obstacles and mistakes to avoid in the implementation of community mental health care. World Psychiatry, 9(2):67-77.
  5. Patel V et al (2010) Effectiveness of an intervention led by lay health counsellors for depressive and anxiety disorders in primary care in Goa, India (MANAS): a cluster randomised controlled trial. Lancet, 376(9758):2086-2095. 

Research

Multimedia

Reports

Associates

Florence Baingana
Mark Jordans Mark Jordans
Brandon Kohrt Brandon Kohrt
Image of J. Cooper Janice Cooper

Comments

Submitted by Shumi Kanno on Monday, 23rd March 2015
Mental health services have been rarely accessible at local levels in my country until recently.I believe such innovative effort can bring better recovery for mentally ill people.
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