Innovation summary

There is strong international consensus that narrowing the treatment gap in low- and middle-income countries requires integrating mental health into primary care.

PRIME is creating high quality research evidence on how best to implement and expand the coverage of mental health treatment programmes in low-resource settings1.

The research was conducted in the following stages:

INCEPTION PHASE

During the inception phase (Year 1-2), PRIME developed integrated mental health care plans (MHCPs) comprising packages of mental health care for delivery in primary health care and maternal healthcare suited to each study country’s unique setting.

IMPLEMENTATION PHASE

During the implementation phase (Years 2-5), PRIME implemented these MHCPs in 5 country district sites and evaluated the feasibility, acceptability and impact of the packages of care in primary health care and maternal health care with four separate studies, including a community survey, facility survey, a cohort study and a case study.

SCALE-UP PHASE

In the scale-up phase (Years 5-7), PRIME scaled up to 94 facilities across the five study countries. The scale-up phase was also evaluated using a case study.

EXTENSION PHASE

During the extension phase (Years 7-8), PRIME is writing up and disseminating its findings, and partnering with other countries beyond the PRIME network. A main goal of PRIME during this final phase is to help make a significant ongoing contribution to a broader investment in mental health and mental healthcare.

We are working hard to refine the intervention packages for each country and this will include strengthening maternal mental health intervention delivery where required. A key challenge has been ensuring adequate quality of care, and PRIME teams are implementing robust Quality Improvement (QI) measures in all countries.

PRIME teams are also actively working with partners in additional LMICs to assist in implementing PRIME’s approach in other countries. This assistance takes on various forms, including presenting workshops, taking part in meetings to share the tools and manuals PRIME has developed.

Impact summary

The PRIME mental healthcare plan has been implemented in 10 facilities and their surrounding communities. By June 2015, 54 service providers working in the district had been trained in the provision of mental healthcare.

In Nepal we found moderate to large improvements in treatment coverage, moderate to large improvements in facility detection and initiation of treatment, and small to moderate improvements in clinical symptoms and functioning for individuals with depression, AUD and psychosis who received care.

“PRIME is launching at the right time in Nepal, since we are also thinking about how best to integrate mental health into primary health care, and scale-up mental health services. It is the intention of the government to prioritise this programme, as it will definitely help.”

 

– Dr Bhim Singh Tinkari, Ministry of Health, Nepal

Innovation details

Health system strengthening in partnership with researchers, Ministries of Health and non-governmental organisations. The program implements and evaluates district level mental health care plans (MHCPs) at health organization, facility and community levels, initially in one district in each country, with a view to scaling up in other districts.

In Nepal, the MHCP consists of twelve packages, divided over community, health facility and organization platforms. The mhGAP Intervention Guide (IG) forms the core of the treatments provided at the health facility, in addition a number of community based interventions are incorporated in the plan (including community sensitization, counselling, home-based care and stigma reduction). The basic structure of the plan is further shaped by the outcomes of the formative study, primarily by the Theory of Change that outlines the key building blocks of the plan.

Furthermore, a strategy has been developed to increase community detection through proactive case-finding. The Community Informant Detection Tool (CIDT) was developed to identify people with probably mental health problem by matching on vignettes that are context sensitive. Evaluation of the CIDT is currently ongoing, with promising initial results.

Finally, we developed the ENhancing Assessment of Common Therapeutic factors (ENACT) scale to meet these needs. The ENACT scale is an 18-item assessment for common factors in psychological treatments, including task-sharing initiatives with non-specialists across cultural settings. ENACT can be used to evaluate therapy quality and association with patient outcomes, as well as for supervision and training purposes.

Key drivers

  • Good cooperation with District Public Health Office (DPHO)
  • Integration of Home Based Care (HBC) is important, and seemingly successful
  • PRIME modules adopted by National Health Training Centre as part of the national curriculum for training of health workers
  • The Community Informant Detection Tool (CIDT) has been developed and used as a strategy to promote help seeking  

Challenges

  • Turnover of key staff, including counselors, health workers and Intervention Coordinator
  • Medication procurement by the Government
  • Research burden on participants
  • Issues with implementing mhGAP, including short consultation time available and some health workers being more actively engaged than others

Partners

Funder

Evaluation methods

A range of quantitative and qualitative methods are being used to evaluate changes in treatment coverage, the impact on mental health, social and economic outcomes for people who receive the MHCPs, as well as to evaluate the acceptability and feasibility of these packages to health care providers and service users. A Theory of Change approach is used to design locally acceptable and feasible MHCPs with the involvement of key stakeholders, and to provide a framework for the comprehensive evaluation of the plans.

In order to assess the effectiveness of community counseling, a pragmatic Randomized Control Trial (RCT) has been embedded in the cohort study for depression and AUD, with both groups receiving all services available in the primary health care centre. This trial aims to evaluate the added value of community-based counselors in addition to the mental health care provided by primary health care workers.

Cost of implementation

DfiD is funding the PRIME consortium £6 million over 6 years.  In addition, national Ministries of Health are providing the human resources required to deliver (parts of) the MHCPs.

Impact details

The PRIME mental healthcare plan has been implemented in 10 facilities and their surrounding communities. By June 2015, 54 service providers working in the district had been trained in the provision of mental healthcare.

In Nepal we found moderate to large improvements in treatment coverage, moderate to large improvements in facility detection and initiation of treatment, and small to moderate improvements in clinical symptoms and functioning for individuals with depression, AUD and psychosis who received care.

Research

Tools

Multimedia

Associates

Mark Jordans Mark Jordans Principal Investigator
Erica Breuer Erica Breuer PRIME Project Manager
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Country

Nepal

Affiliated organizations

Transcultural Psychosocial Organization Nepal (TPO Nepal)

Gallery

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