Training primary care physicians to use the mhGAP-IG in Tunisia

Innovation summary

Continuing mental health training programs are a political priority in Tunisia to address the rise in mental health disorders since the 2010-2011 Revolution^1-4 and primary care physicians’ deficits in mental health capacities^5,6.

A training based on the mhGAP-IG (version 1.0)⁷ was implemented in the Greater Tunis area (February-April 2016). Tunisian Ministry of Health members chose specific training modules considered priority conditions: general principles of care, depression, psychosis, suicide/self-harm, and substance use disorders. These modules were adapted to meet the Greater Tunis area’s primary care realities.

The mhGAP-based training lasted six weeks for a total of 19 hours, and sessions were offered once a week. The first five sessions consisted of lectures, role plays, and discussions on the chosen modules (17 hours). The last session offered two-hour support, animated by trainers. It encouraged trainees to present challenging mental health cases and engage in further role plays.

Impact summary

112 primary care physicians were randomized to either Group 1 (n=52) or Group 2 (n=60)
The training had a statistically significant short-term impact on mental health knowledge (6.3/10 to 7.5/10, p < 0.001), attitudes (29.4/66 to 24.9/66, p = 0.005), and self-efficacy (5.3/10 to 7.2/10, p < 0.001) scores, but not on self-reported practice (i.e., the importance that primary care physicians allocate to mental health care per week (p = 0.82) and primary care physicians’ referrals (in percentage) to specialized services per week (p = 0.080)).
- When comparing pre-training results and results 18-months after training, most of these changes were maintained.
- Primary care physicians also reported a statistically significant decrease in referral rates to specialized services 18-months after training in comparison to pre-training (64.3 to 39.0, p < 0.001).

“Before I thought all these [mental health] pathologies should be referred to psychiatrists, psychologists, child psychiatrists, or others. The training helped me demystify things and made me take care of those patients.”
- (Participant 5)

Innovation details

To address the rise in mental health disorders, substance use disorders, and suicide rates in Tunisia, mental health training programs targeting primary care physicians are a political priority. While these programs have been offered in the past, training implementation was previously conducted non-systematically. In addition, these training programs were general and thematic lectures about mental health and illness, with limited interactive components and mental health resources for trainees.

An mhGAP-based training (version 1.0)⁷ was implemented between February and April 2016 in the Greater Tunis area of Tunisia. The training’s goal was to improve primary care physicians’ mental health knowledge, attitudes, self-efficacy, and self-reported practice. The training included modules on general principles of care, depression, psychosis, self-harm/suicide, and alcohol/drug use disorders, adapted to the local primary care context using the mhGAP’s Adaptation Guide. Training sessions were facilitated by Tunisian psychiatrists and supported by primary care physicians working to promote continuing mental health training in the Greater Tunis area (i.e., tutors). In total, the training program last 6-weeks (19 hours). Training sessions, offered once a week for 5 weeks (17 hours), included general lectures, role plays, and group discussions. These were followed by a support session (2 hours) where trainer-psychiatrists facilitated clinical case discussions and role plays. We evaluated the program’s impact on primary care physicians’ mental health knowledge, attitudes, self-efficacy, and self-reported practice, immediately following and 18 months after training.

Key drivers

Collaborations

Developing collaborative partnerships between Canadian and Tunisian organizations helped create and support an mhGAP-based training and an evaluation program that met the practical and research needs of the country. Collaborations with Tunisian mental health champions (i.e., members of the Ministry of Health in Tunisia: WM, FC) could facilitate training sustainability over time. Ongoing collaborations also facilitated the sharing of research findings locally.

Windows of opportunities

Commitment to improving access to needed mental health services was endorsed by the Tunisian Ministry of Health, particularly by the development of the 2013 Tunisian National Strategy for the Promotion of Mental Health⁵, the creation of the Committee for Mental Health Promotion in 2015, and the Ministry of Health’s passing of a decree for the inclusion of a mandatory two-month mental

health internship in post-graduate medical school that had previously been optional for future family physicians. This political commitment to mental health facilitated and supported the development of collaborative mental health partnerships, the implementation of an mhGAP-based training, and the training’s accompanying evaluation.

Challenges

Staff turnover

Members of the World Health Organization (WHO) office in Tunisia initially involved in the study (which commenced in 2015) left for other functions in 2016.

Difficulty obtaining certain documents

Some of the mhGAP-training components were unavailable to the research team at the time of implementation. For example, the accompanying training material (i.e., PowerPoints, facilitator guides and participant guides) for the module on conditions related specifically to stress was not available in the language in which medical training was provided and was therefore excluded from the training program.

Compatibility of the innovation

While many standard modules of the mhGAP-IG⁷ include therapeutic interventions as part of the management skills to be developed by trainees (i.e. behavioural activation, interpersonal therapy, cognitive-behavioural therapy, contingency management therapy, family counselling/therapy, interpersonal psychotherapy, and motivational enhancement therapy), trainings in such therapies in Tunisia are reserved for psychologists or psychiatrists. As a result, psychotherapy is very rarely conducted by primary care physicians in Tunisia, which may result in further promoting the pharmacological guidelines of the mhGAP-based training. This reality may challenge the mhGAP-based training’s self-sufficiency as a package in offering a diverse set of complementary and necessary interventions for mental illness in the country.

Contextual factors

Primary care physicians highlighted: legislation preventing the prescription of certain molecules listed in the mhGAP-IG; stigma towards the treatment of substance use disorders and psychosis in primary care settings; logistical issues in mental healthcare delivery in primary care settings (i.e., lack of time, deficits in amounts of medication); and challenges with collaboration within and across healthcare organizations⁸.

Continuation

An mhGAP-based training was offered after the research project to two other Tunisian regions: Bizerte (a governorate in the North of Tunisia) and Gafsa (a governorate in the South of Tunisia). An mhGAP-based training scale-up to additional governorates in Tunisia is planned for 2020.

Partners

World Health Organization (Tunisia)
Ministry of Health, Tunisia (through collaborations with Dr. Wahid Melki and Dr. Fatma Charfi)

Funders

Institut de recherche en santé publique de l’Université de Montréal – Nouvelles Initiatives
MITACS Globalink (research fellowship, #IT06835), awarded to Jessica Spagnolo
Jessica Spagnolo was supported by Fonds de recherche du Québec - Santé (FRQS) (project #33774)
World Health Organization (Tunisia)

Evaluation methods

To evaluate the training program, we relied on two different methodologies:

1. An exploratory trial with a combination of designs

A randomized controlled trial was used to assess the training’s short-term impact. Primary care physicians were randomly assigned to one of two groups:

The intervention group (Group 1) or the control group (Group 2). Group 1 received the training from 9 February to 15 March 2016. A delayed-intervention strategy was employed through a one-group pretest-posttest design to assess the impact of the training offered to Group 2. This strategy ensured that both groups would receive the training (a request by Tunisian collaborators given accessibility issues to mental health training) but at different times.

Group 2 received the training from 29 March to 27 April 2016. A repeated measures design was used to assess the training’s long-term impact. This design relied on the pooling of Groups 1 and 2 over three time periods, as they were comparable on all characteristics.

Outcomes for Capacity-building

Training outcomes were measured by self-administered questionnaires, included:

Mental health knowledge (a questionnaire that accompanies the mhGAP training)⁷
Attitudes towards mental health and the field of mental health (MICA-4)⁹

Self-efficacy in detecting, treating, and managing mental health problems (a questionnaire developed for the purposes of the study)

Self-reported mental health practice (practice characteristic questionnaire, developed for the purposes of the study).

2. A case study design

We conducted a case study to identify contextual factors that interacted with the implemented training program to influence its expected outcomes in the Greater Tunis area of Tunisia. Data was collected by interviewing eighteen trainees from Group 1.

Cost of implementation

Costs attributed to implementing the mhGAP-based training included: fees related to reserving a conference room in Tunis for the training sessions; fees related to ordering and photocopying the mhGAP Intervention Guide⁷; and a stipend provided to the trainers for their teaching role.

Impact details

Provider (short-term) impacts:

Overall, 112 primary care physicians were randomized to either Group 1 (n=52) or Group 2 (n=60).
Forty-five primary care physicians completed the training in Group 1, and they were controlled by 47 primary care physicians assigned to Group 2.
The training had a statistically significant short-term impact on mental health knowledge, attitudes, and self-efficacy scores, but not on self-reported practice.
Forty-seven primary care physicians assigned to Group 2 then received the training, of which 43 completed the program.
Findings show that the mhGAP-based training’s impact on mental health knowledge (p = 0.745), attitudes (p = 0.687), self-efficacy (p = 0.477), and self-reported practice (i.e., the importance that primary care physicians allocate to mental health care per week (p = 0.736) and primary care physicians’ referrals (in percentage) to specialized services per week (p = 0.462)) was statistically similar in Group 1 and in Group 2.

Provider (long-term) impacts:

Training outcomes were re-assessed 18-months after both groups completed the training. Fifty-nine primary care physicians completed self-administered questionnaires 18 months after the training.
When comparing pre-training results and results 18-months after training, changes in mental health knowledge, attitudes, and self-efficacy scores were maintained.
Primary care physicians also reported a decrease in referral rates to specialized services 18-months after training in comparison to pre-training.

Contextual factors interacting with the training to influence provider impacts:

Participants identified more barriers than facilitators when describing contextual factors influencing the
mhGAP-based training’s expected outcomes⁸.
These contextual factors interacted with the implemented training to influence knowledge about pharmacological treatments and symptoms of mental illness, confidence in providing treatment, negative beliefs about certain mental health conditions, and the understanding of PCPs’ role in mental health care delivery.