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BJPsych Open (2020) |
6, e77, 1-11. doi: 10.1192/bjO.2020.60 |
Background |
Globally, mental, neurological and substance-use disorders are among the leading causes of disability, contributing to 10.4% global disability-adjusted life-years.1 The burden of these disorders has consistently risen in the context of major demographic and socio-political transitions.2 Although there is an increasing ... |
In Nepal, there is no nationally representative data on prevalence of mental disorders, however, studies conducted with specific populations or populations affected by conflict or humanitarian emergency reported high prevalence rates of mental disorders (i.e. depression, 14.0-80%; anxiety, 22.9-81.0%; and alcohol use d... |
Mental Health Gap Action Programme |
Evidence shows that mental health services can be delivered effectively by trained non-specialists healthcare providers through community |
based programmes.9,10 The integration of mental health services in community and primary healthcare (PHC) settings has also been advocated as a strategy to reduce the treatment gap, particularly in LMICs, where mental health specialists are limited. The WHO launched the Mental Health Gap Action Programme (mhGAP) in 200... |
The community-level intervention packages included a community sensitisation programme, case detection in the community by using the Community Informant Detection Tool (CIDT),14 treatment adherence support through home-based care and community counselling. The health-facility-level packages included training and superv... |
Aims |
Our prior studies demonstrated a significant impact of the district MHCP on treatment coverage, detection of mental disorders in |
primary care and initiation of minimally adequate treatment after diagnosis and small-to-moderate effect sizes on individual-level treatment outcomes after introduction of the district MHCP.15 These research findings and the available literature on mental healthcare describe what ‘works and what did not work’, but ther... |
Method |
Setting |
Nepal, one of the poorest countries in South Asia, has a total population of approximately 26.4 million and life expectancy at birth of 69.1 years. Nepal’s gross national income per capita at purchasing power parity was $2500 in 2017, ranking 193 out of 226 countries. The district MHCP was implemented in Chitwan, a dis... |
Study design |
We used the ToC approach16 to develop the district MHCP and an evaluation framework.17 A ToC describes how a programme or an intervention brings desired long-term outcomes through a logical sequence of short-term and intermediate outcomes.18 In recent years, ToC has increasingly been used for designing and refining int... |
The MHCP was evaluated using multiple methods, including pre- and post-community- and health-facility-based surveys, cohort studies and process evaluations of implementation of the care plans.1 Pre- and post-cross-sectional community surveys were conducted to assess changes in treatment contact coverage, pre- and post-... |
The case study evaluated the input and process indicators defined by the ToC,21 which are not otherwise captured by the community, facility detection surveys and cohort studies described in the paragraph above.15 The case study assessed; (a) the social, political, economic and cultural context that may affect the imple... |
Data analysis |
The data were analysed using the following methods. Descriptive statistics such as percentages and proportions were used to analyse the quantitative process and input data from the facility, community and district profiles and the implementation logs. For the training evaluation data, we compared calculated percentages... |
Ethics |
This study received ethical approval from the Nepal Health Research Council (Ref. No. 162/2015), the national ethical body of the government of Nepal; the ethical review board of WHO Geneva, and the University of Cape Town (HREC Ref: 412/2011). Written and oral information was provided to each of the study participants... |
Results |
What was achieved? |
Mental health case-load in PHC |
Figure 1 presents the proportion of the total patients attending primary care that received mental healthcare. The proportion was very low (0.15%) before implementation of the MHCP and increased to 3.24% 3 years after implementation. The trained health workers also reported in the qualitative interviews that before int... |
‘In the older days, mental health was not seen as a problem, people were thinking that it doesn’t need any sort of treatment. But later, the TPO [Transcultural Psychosocial Organisation] visited different healing places like traditional healers, and community leaders, volunteers, and then people started to learn about ... |
Figure 2 shows the longitudinal trend of service utilisation for different disorders. Overall, the number of patients receiving mental healthcare increased substantially after the mhGAP-based training was initiated in early 2014. The number of patients receiving treatment for psychosis remained highest in most of the q... |
‘In my experience, among the regular cases in this facility, the hardest to manage are the AUD cases because many patients go home and start drinking again, they relapse often. Then, we feel bad as service providers because the service users start again. The service users will not come back for treatment because they w... |
Continued care |
Table 2 presents details of the follow-up visits of patients receiving mental health services from PHC. On average, patients visited |
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https://doi.org/10.1192/bjo.2020.60 Published online by Cambridge University Press |
health facilities 7.1 times for follow-up, and there was a large variation in the number of follow-up visits by disorder. For example, people with epilepsy made an average of 14 visits, whereas it was only 5.0 visits for depression, 12.2 visits for psychosis and 3.0 visits for AUD. To motivate patients to come for foll... |
In the qualitative interviews, both patients and caregivers highlighted that the availability of mental health services (both psychological and pharmacological) free of charge was the most important facilitating factor for follow-up care in their community. One of the caregivers expressed that he was ‘extremely happy’ ... |
Progress towards other indicators |
Table 3 presents the indicators for other MHCP components, intended outcome indicators and supporting evidence. It shows that the programme was successful in achieving most of the indicators defined by the ToCs. Out of six health-organisation-level indicators, four indicators (67%) were fully achieved. Six new psychotr... |
home visits did not achieve the intended outcome relating to dropout rate (Table 3). |
Evaluation of training |
Table 4 presents pre- and post-training evaluation results among prescriber-level health workers. The results demonstrated significant improvement in mental-health-related knowledge, attitudes and clinical competencies after the 10 days of mhGAP-based training. However, at the post-training evaluation, only 71% mean kn... |
The improvements in knowledge, attitudes and competencies among health workers have also been supported by the experience of the patients and caregivers. Many patients reported that the health workers were knowledgeable and skilful. The caregivers held the perception that if the health workers were not competent, there... |
What was implemented? |
Table 5 presents the overview of the district MHCP, implementation processes for each of the intervention packages, the role of PRIME, and the barriers and facilitating factors for successful implementation. The MHCP was implemented within the existing community and PHC system. Medical officers, health assistants |
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https://doi.org/10.1192/bjo.2020.60 Published online by Cambridge University Press |
and auxiliary health workers were responsible for detection and management of mental disorders by using the mhGAP Intervention Guide in PHC facilities. Staff nurses and auxiliary nurse midwives provided psychosocial support in the health facilities. FCHVs and community counsellors implemented the treatment packages in ... |
The PRIME team provided support for implementation of the packages, including organising training and workshops, managing logistics for training and supervision, and encouraging trained health workers in mental health services delivery. As there was no provision of psychosocial counsellors in the governmental PHC and c... |
What were barriers and facilitating factors? |
Health organisation level |
Table 5 presents the barriers and facilitating factors for implementation of each MHCP component. The major barriers for effective implementation of the health-organisation-level intervention packages included mental health not being a government priority, |
no mental health focal unit/person in the MoH, and lack of basic psychotropic medicines in the free drug list. A memorandum of understanding between PRIME and MoH facilitated the appointment of a senior-level MoH officer to coordinate PRIME activities and procurement of new psychotropic medicines through PRIME. Another... |
Health facility level |
The major challenges for implementation of health-facility-level intervention packages included low mental health literacy among PHC workers, heavy workload among PHC workers, frequent transfer of the trained health workers, mental health stigma among service providers, lack of adequate physical facilities, particularl... |
Community level |
The major barriers for implementation of the community-level intervention packages included limited mental health awareness, low perceived needs for mental healthcare and high level of stigma. The facilitating factors for successful implementation at this level included: involvement of FCHVs, use of CIDT as a strategy ... |
Discussion |
The uniqueness of this case study is that it evaluated the impact of a comprehensive district-level MHCP and assessed the barriers and facilitating factors for successful implementation of a MHCP in a real-world setting. The MHCP included four priority disorders, namely psychosis, depression, epilepsy and AUD, recommen... |
The area-based approach, which we followed in our study, has also been used in other countries such as Nigeria, Mozambique and Afghanistan, for development and evaluation of mental health services in primary and community care settings. In Nigeria28 and Afghanistan29 the intervention was tested with priority mental dis... |
The results show that the number of people receiving primarycare-based mental health services increased significantly after the introduction of the MHCP. On average, patients visited facilities 7.1 times for follow-up care despite a large variation in this number by disorder. About one-third of the patients initiating ... |
Psychotropic medicines were available most of the time in the health facilities, which contrasts with most of the previous studies34-36 where supply of psychotropic medicines was one of the major barriers for integration of mental health services in primary care. In Nepal, procurement and distribution of medicines requ... |
Impact on policy and legislation |
The PRIME results and best practices have been used in policies, treatment protocols and guidelines, and training materials by the MoH. First, the PRIME results and best practices have been used in the community mental health care package, which was developed by the Primary Health Care Revitalization Division to facili... |
Finally, the National Health Training Center, with technical support from Transcultural Psychosocial Organisation Nepal, has developed training manuals and facilitator guides for both PHC and community healthcare workers. These included a training manual for non-prescribers on psychosocial support, a training manual an... |
Limitations |
This study has some limitations. First, the evaluation of the MHCP was conducted in ten health facilities in Chitwan. The selection of the district and the area within the district may limit the generalisability of the findings. Second, because of the lack of a baseline on organizational readiness to change, we could n... |
Policy and practice implications |
Community level |
First, despite the efforts made at the community level to sensitise community members on mental health issues and available services through community awareness and sensitisation programmes, our |
analysis of the outcomes of the programme published elsewhere showed no significant changes in the treatment coverage and barriers to mental healthcare after implementation of the district MHCP.6 A possible explanation could be that the sensitisation and awareness programme primarily aimed to increase mental health lit... |
Second, it was found that most people receiving mental health treatment from PHCs had a low socioeconomic status. Evidence suggests mental illness and poverty create a vicious cycle that affects the life of people living in poverty and with mental illness throughout the lifespan. Therefore, the programme would have bee... |
Third, only FCHVs were trained on the CIDT, but this approach can be used with other community stakeholders such as mothers’ groups, traditional healers and teachers in the impact in future programmes. This is supported by a study on the accuracy of the CIDT that demonstrated CIDT as an effective tool for detection of ... |
Fourth, considering the low mental health literacy of non-prescribers and their busy schedule, there is a need for community counsellors to look after psychological intervention in the community. A randomised control trial embedded within the PRIME cohort study demonstrated that a psychological intervention (i.e. HAP) ... |
Health facility level |
First, the 10-day training for prescriber-level health workers was divided into two parts: psychosocial support (5 days) and mhGAP-disorder-specific training (5 days). The psychosocial part of the training was facilitated by a psychologist or an experienced psychosocial counsellor, whereas the mhGAP part was delivered ... |
Second, it was not always possible to involve the same psychiatrist in both training and supervision of a trained PHC workers. However, health workers were more comfortable contacting psychiatrists through mobile phone or other means of communication to get support if the same psychiatrist both trained and supervised t... |
Third, the training participants were taken to the district hospital for interaction with actual patients in the initial phase of the mhGAP training. In the later phase, patients were invited to the training venue. Inviting patients to the training venue was much more effective in clarifying various aspects of mental h... |
Fourth, in most of the health facilities, there was no private place for clinical consultation. Because of stigma, patients with mental illness were hesitant to disclose their problems in front of other people; therefore, a separate room should be made available in each health facility for clinical consultation and psy... |
Fifth, despite a very high prevalence of mental health problems among pregnant and postnatal women in Nepal, the data shows that only a small number of them received mental health services from trained health workers. A possible reason could be that pregnant or postnatal women generally consult with non-prescriber-leve... |
Finally, despite the tremendous efforts made by FCHVs to minimise the drop-out rate, about a quarter of the patients initiating primary-care-based mental health services did not come for follow-up. According to FCHVs, patients felt uncomfortable when they made multiple home visits to remind patients about their follow-... |
Health organisation level |
First, the PRIME results are based on a model of training all prescribing health workers in a facility, including medical officers (doctors), health assistants and auxiliary health workers. However, the recent treatment protocol endorsed by MoH does not include training auxiliary health workers. Except for a few auxili... |
Second, one of the reasons reported for the high drop-out rate was availability of limited psychotropic medicines (i.e. one medicine for each disorder) in primary care and irregular supply of the medicines. Similarly, frequent transfer of trained health workers was also reported to be another important reason for drop-... |
regular provision of minimally adequate psychotropic medicines in PHC facilities and regulation of frequent transfer of the trained health workers could help to minimise the high drop-out rate in the impact in future programmes. |
Finally, the psychiatrists’ case conference, which was initiated by PRIME for supervision of trained health workers, was found to be effective in building the clinical capacity of the trained healthcare workers and providing specialists care for patients with severe mental health problems. Currently there is no mental ... |
In conclusion, despite the various contextual challenges, the MHCP resulted in achievement of most of the outcome indicators. The key lessons learned from this study for future integration of mental health services within primary care include the provision of targeted interventions to increase demand for services, and ... |
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