Innovation summary

The World Health Organisation (WHO) declared “monitor community mental health” one of its top ten recommendations for the emerging field of global mental health as early as 2001.1 Yet only a minority of countries collect routine data on mental health from primary care and community residential facilities,2 and most countries in sub-Saharan Africa do not track routine data on mental health at any level of the health system.3

MIND ME (Mental health Information aND Monitoring and Evaluation) is a research project which has developed in collaboration with community mental health programmes in Nigeria to identify best practices in mental health information systems (MHIS) and monitoring and evaluation (M&E). Through rigorous implementation research, MIND ME works with programmes to adapt and pilot a customizable mental health M&E package capable of generating high-quality routine data that can then be integrated into existing health management information systems, to help close the mental health information gap.

Impact summary

  • 40 providers trained in MIND ME record-keeping tools and procedures
  • Routine mental health data reported to Benue State from community and primary care facilities in 17 local government areas

“An estimated 19.2 million people have suffered from a mental health problem in Nigeria at some point in their lives, yet there is no system in place to capture essential data on mental health. That is a number larger than the total population of Burkina Faso or Niger who are being told that their information does not count.”

 

-Grace Ryan, MIND ME Investigator

Innovation details

MIND ME Africa (Mental health INformation aND Monitoring and Evaluation in Africa) is an extension of the Case Studies Project initiated by CBM International and London School of Hygiene and Tropical Medicine (LSHTM) in 2008.5,6 One output of the Case Studies Project was a monitoring and evaluation (M&E) package which was later piloted at two mental health programmes supported by CBM Nigeria (Abuja and Amaudo). This M&E package was designed to generate routine process and outcome data, enabling programmes to evaluate the effectiveness of services in terms of clinical (symptom severity, functioning) and social (quality of life, family attitudes) outcomes.

Key components of the original M&E package include:

  • Paper-based M&E tools for data collection
    • Enrolment form (administered at first visit)
    • Periodic review form (administered at follow-up visits every six months)
    • Routine follow-up form (administered at all other follow-up visits)
  • Field guide instructing frontline workers on how to complete each M&E form
  • Manual of instructions for the general implementation of the M&E system
  • Access database where enrolment and periodic review data could be entered and analysed

In 2013, formative research was conducted by LSHTM in collaboration with the Benue State Comprehensive Community Mental Health Programme (CCMHP), the Benue State Ministry of Health and Human Services, and CBM International to further adapt the M&E package along with a newly drafted mental health information system (MHIS) for roll-out across Benue State.7 The focus of this research was on assessing the feasibility, acceptability and appropriateness of the MHIS/M&E package for use by community psychiatric nurses (CPNs) operating mental health clinics in primary care facilities.

Noting significant challenges both in the initial pilots at Abuja and Amaudo and in the early implementation of the adapted M&E package, the MIND ME research project was formalized in 2014 as a partnership between CBM and LSHTM to identify best practices in mental health M&E and MHIS in Nigeria and in sub-Saharan Africa more broadly. Mixed-methods implementation research is currently being carried out over a series of field visits to CCMHP, in which the process of implementation will be documented and outcomes evaluated. The ultimate aim is to identify best practices in the generation of high-quality routine data for mental health M&E and MHIS in low- and middle-income countries.

The integrated MHIS/M&E package that MIND ME is currently evaluating includes:

  • Adaptations of the original paper-based M&E tools, designed to reduce the burden of data collection on frontline providers
  • Adapted field guide instructing frontline workers on how to complete the new M&E forms
  • Two daily MHIS registers (one for new clients, and one for follow-up clients) and a monthly MHIS report, designed to reduce common errors in data processing
  • Manualized standard operating procedures which streamline the various record-keeping responsibilities of frontline providers, to reduce the burden of additional MHIS/M&E tasks
  • A variety of tools (file logs, appointment cards, receipt templates) designed to improve the efficiency of record-keeping
  • Supervision checklists for routine monitoring of data quality
  • Revised database specifications (new database to be developed and tested in 2015)

MIND ME has also developed training and advocacy materials to support CCMHP in the implementation and scale-up of this MHIS/M&E system. 

Key drivers

Focus on frontline providers

Frontline providers in community and primary care settings often deliver mental health services under difficult conditions, with high workloads and limited resources. The MIND ME system is designed to reduce the burden of monitoring and evaluation on these providers while improving the quality and availability of data at the level of the individual patient and facility, enabling data-driven decision-making. The feasibility, acceptability and appropriateness of the M&E and MHIS tools and procedures have been assessed through formative research and are continuously reviewed through ongoing implementation research. Key considerations thus far have included, for example:

  • Ensuring a minimum dataset, with as few redundancies as possible to avoid “double data collection”
  • Integrating M&E and MHIS into a streamlined system with clear tools and procedures for data collection, processing and reporting, to avoid implementing parallel systems as much as possible
  • Using non-disorder-specific scales (Clinical Global Impression of Severity and Global Assessment of Functioning) as routine clinical outcome measures, rather than a variety of disorder-specific scales, based on CPN feedback
  • Simplifying M&E tools by reducing the number of structured questions, response options and pages
  • Designing MHIS daily registers to reduce the amount of information written out by hand and enable a simple tallying procedure for monthly reporting

Partnering to increase impact

The organisations behind MIND ME offer a range of technical expertise in mental research, programmes and policy, with the potential to translate findings from implementation research undertaken with CCMHP into broader state, national and regional impact, for example:

  • Benue State Ministry of Health and Human Services helped to drive the original piloting of the District Health Information System (DHIS) that was eventually adopted nationwide. The technical expertise and ownership of the MHIS by the Department of Health Planning, Research and Statistics are crucial to ensure that mental health data is integrated into the DHIS for sustainable, routine reporting in Benue State and potentially throughout Nigeria.
  • CBM’s extensive network of mental health programmes throughout West Africa provides a ready structure for the dissemination of best practices as identified through the MIND ME project, to enable regional learning.
  • London School of Hygiene and Tropical Medicine is a centre of excellence in global mental health research, and has been working with CBM on community mental health M&E tools since 2010. This partnership ensures methodological rigour and dissemination to a wider scientific community.

Challenges

Successful implementation of a MHIS/M&E system is dependent on the general quality of programme implementation. For example, weak supply chains, gaps in capacity-building and supervision, and inadequate resource inputs all affect the quality of the data collected. Further, the local social, political and natural environment can present unforeseen challenges, such as communal clashes and strikes that disrupt service delivery and reporting, or fires and floods that could destroy paper-based records at any time.

Some specific issues particular to implementation in Benue State are discussed in a formative research report and briefing,7,8 and are being systematically documented through further implementation research.

Continuation

Discussions are underway to adapt the paper-based MHIS tools for use in in Benue State’s tertiary facilities, and to integrate indicators from the MHIS into the state-level District Health Information System for piloting. This pilot could inform the integration of mental health into health management information systems nationwide.

Best practices identified through implementation research in Nigeria will be applied to the design of a new monitoring and evaluation (M&E) system for use by the Peer Support Worker project of the Butabika-East London NHS Link in Kampala, Uganda. Many of the tools and references used in Nigeria may in fact be adapted for this project, including the MIND ME database currently under development.

Further, learning from MIND ME will be disseminated to other CBM-supported programmes in Nigeria and in West Africa more broadly, where CBM is currently advocating for the inclusion of mental health in national health management information systems. 

Partners

Evaluation methods

Mixed-methods research is being carried out over a two-year period to evaluate the following key variables, following common frameworks8,9 for implementation research:

  • Acceptability
  • Adoption
  • Appropriateness
  • Feasibility
  • Fidelity
  • Implementation cost
  • Coverage
  • Sustainability

Cost of implementation

As described above, the cost of implementation will be assessed as a key outcome variable.

Impact details

Implementation research is ongoing; however, as of the close of 2014:

  • Health workers delivering community mental health services in 17 local government areas across Benue State have been trained in MHIS and M&E, including:
    • 34 community health extension workers posted to primary care facilities who have received prior mhGAP training
    • 6 community psychiatric nurses operating community mental health clinics in primary care or community based rehabilitation facilities

References

  1. WHO (2001). Mental Health: New Understanding, New Hope. World Health Report 2001, World Health Organisation: Geneva, Switzerland.
  2. WHO (2011). World Mental Health Atlas. World Health Organisation: Geneva, Switzerland.
  3. MHaPP (2010). Better Information For Better Mental Health: Developing Mental Health Information Systems in Africa. Policy brief 12, Mental Health and Poverty Project: Cape Town, South Africa.
  4. Cohen A et al. (2011). Three Models of Community Mental Health Services in Low-Income Countries. Int J Ment Health Systems, 5(3).
  5. Cohen A et al. (2012). Case Study Methodology to Monitor & Evaluate Community Mental Health Programs in Low-Income Countries. Case Studies Project, London School of Hygiene and Tropical Medicine: London, UK.
  6. Ryan G (2013). Formative Research to Scale Up Community Mental Health Monitoring and Evaluation in Benue State, Nigeria (MSc Dissertation). London School of Hygiene and Tropical Medicine, United Kingdom.
  7. Ryan G et al. (2014). More Data, Not More Headaches: Findings of Formative Research to Scale Up Community Mental Health Monitoring and Evaluation in Benue State, Nigeria. Policy Brief 1, MIND ME Project: London, UK.
  8. Peters D et al. (2013). Implementation Research: What it is and how to do itBMJ, 347:f6753.
  9. Proctor et al. (2011). Outcomes for Implementation Research: Conceptual Distinctions, Measurement Challenges, and Research Agenda. Adm Policy Ment Health, 38:65-76.
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