Reducing Stigma Among Healthcare Providers (RESHAPE-cRCT) (RESHAPE-cRCT)

Reducing Stigma Among Healthcare Providers to Improve Mental Health Services: Cluster Randomized Controlled Trial (RESHAPE-cRCT)

A growing number of trials have demonstrated treatment effectiveness for mental illness by non-specialist providers, such as primary care providers, in low-resource settings. A barrier to scaling up these evidence-based practices is the limited uptake from trainings into service provision and lack of fidelity to evidence-based practices among non-specialists. This arises, in part, from stigma among non-specialists against people with mental illness. Therefore, interventions are needed to address attitudes among non- specialists. To address this gap, REducing Stigma among HeAlthcare Providers to improvE Mental Health services (RESHAPE), is an intervention for non-specialists in which social contact with persons with mental illness is added to training and supervision programs. A cluster randomized control trial will address primary objectives including changes in stigma (Social Distance Scale) and improved quality of mental health services, operationalized as accuracy of identifying patients with mental illness in primary care. The control condition is existing mental health training and supervision for non-specialists delivered through the Nepal Ministry of Health's adaptation of the World Health Organization mental health Gap Action Programme. The intervention condition will incorporate social contact with people with mental illness into existing training and supervision. Participants in the cluster randomized control trial will be the direct beneficiaries of training and supervision (primary care providers) and indirect beneficiaries (their patients). Primary care workers' outcomes include stigma (Social Distance Scale), knowledge (mental health Gap Action Programme knowledge scale), implicit attitudes (Implicit Association Test), clinical self-efficacy (mental health Gap Action Programme knowledge scale), and clinical competence (Enhancing Assessment of Common Therapeutic factors) to be assessed pre-training, post-training, and at 3- and 6-month follow-up. Accuracy of diagnoses will be determined through the Structured Clinical Interview for the Diagnostic and Statistical Manual version 5, which will be assessed at 3 months after patient enrollment. Patient outcomes include functioning, quality of life, psychiatric symptoms, medication side effects, barriers to care, and cost of care assessed at enrollment and 3 and 6 months. This study will inform decisions regarding inclusion of persons living with mental illness in training primary care providers.

Study Overview

• Status: Recruiting
• Conditions: Depressive Disorder; Psychotic Disorders; Alcohol Use Disorder; Mental Disorder; Anxiety Disorder
• Intervention / Treatment: Other: mental health Gap Action Programme; Other: Reducing Stigma among Healthcare Providers (RESHAPE)

Detailed Description

There continues to be a major gap between the global burden of persons with mental illness and the number of patients receiving adequate treatment. In the U.S. and other high-income countries, approximately 1 out of 5 persons receives minimally adequate care. In lower-middle income countries, it ranges from 1 out of 27 to 1 out of 100 persons. To address this gap in low- and middle-income countries, a key strategy has been the use of primary care health workers to detect and deliver of care for mental illness. The World Health Organization has developed the mental health Gap Action Programme to train primary care workers to detect mental illness and deliver evidence-supported treatment. However, research to date suggests that implementation strategies for mental health Gap Action Programme are inadequate as evidenced by low detection rates. In Nepal, fewer than half of persons with mental illness were correctly identified by mental health Gap Action Programme-trained primary care workers. A potential barrier to effective implementation of primary care detection is stigma among primary care workers against persons with mental illness.

Our preliminary work suggests that reducing primary care workers' stigma against persons with mental illness may improve accurate detection of mental illness. A version of the mental health Gap Action Programme training that includes a stigma reduction component was developed: REducing Stigma among HealthcAre ProvidErs (RESHAPE). In RESHAPE, persons with mental illness (i.e., service users) are trained to share recovery stories, conduct myth-busting sessions, and promote mental health advocacy. A pilot cluster randomized controlled trial was conducted in Nepal comparing standard mental health Gap Action Programme training delivered psychiatrists and psychosocial specialists with a mental health Gap Action Programme training delivered by both specialists and service users (RESHAPE). Consistent with high-income country literature demonstrating that interaction with service users reduces stigma more effectively that only providing knowledge, stigma was lower among the RESHAPE- arm trained health workers. The pilot results also suggest that reducing stigma may improve detection of mental illness. Therefore, involvement of mental health service users in training primary care workers may reduce stigma, and that stigma reduction may mediate improved detection of mental illness. If these findings are confirmed in an appropriately powered cluster randomized controlled trial, this service user collaborative implementation strategy could make a major contribution to improving primary care detection in low- and middle-income countries, as well as in the U.S. A hybrid implementation-effectiveness (type-3) cluster randomized controlled trial will be in Nepal comparing mental health Gap Action Programme standard implementation with the RESHAPE implementation strategy. Our team of U.S. and Nepali researchers, in partnership with the Nepal Ministry of Health, demonstrated the feasibility of the cluster randomized controlled trial design and identified strategies for cost effectiveness modeling. Target conditions will be depressive disorder, psychotic disorders, and alcohol use disorder.

Aim 1 - To evaluate the impact of the RESHAPE service user engagement on stigma among primary care workers. Hypothesis: Primary care workers in the RESHAPE arm will have less stigma toward persons with mental illness (measured with the Social Distance Scale) 3 months after training compared with primary care workers in the standard training.

Aim 2 - To evaluate the impact of the RESHAPE training on accuracy (sensitivity and specificity) of detection, as measured by the proportion of true positive and true negative diagnoses among patients presenting to primary care facilities, as confirmed by a psychiatrist's structured clinical interview; and to evaluate stigma as a mediator of differences in accuracy. Hypothesis: Primary care workers in the RESHAPE arm will have greater accuracy of detecting mental illness. Secondary analyses: implementation arm differences in patient quality adjusted life years and cost utility will be evaluated.

• Study Type: Interventional
• Enrollment (Estimated): 1300
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Brandon Kohrt, MD, PhD; Phone Number: 2027412896; Email: bkohrt@gwu.edu

Study Locations

• Nepal
  • Province 4
    • Pokhara, Province 4, Nepal
      • Recruiting
      • Transcultural Psychosocial Organization Nepal
      • Contact: Dristy Gurung, MSc; Phone Number: +977 1-4424082; Email: dristy.1.gurung@kcl.ac.uk

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 16 years and older (Child, Adult, Older Adult)
• Accepts Healthy Volunteers: Yes

Description

**Primary Care Providers**

Inclusion Criteria:

• All health workers from the facilities included in the study will be invited to participate
• Health workers will be between 21 and 65 years of age based on employment criteria
• within the government health system.
• All participants will need to have Nepali language competency,
• be actively engaged in care provision in their health cluster,
• have a valid certificate of practice from the Ministry of Health
• Health workers will need to have permission from their health supervisor to attend the entire duration of the training,

Exclusion Criteria:

• any prior citations on their clinical practice licensure or any other government credentialing violations.

**Patients**

Inclusion Criteria:

• All patients (with non-emergency medical needs) presenting to the primary care
• any of the following groups:
• (a) any mental illness diagnosis including depression, psychosis (bipolar disorder with a manic episode, schizophrenia, major depressive disorder with psychotic features, and alcohol use disorder with psychosis) and alcohol use disorder; plus the other conditions included in Nepal's mental health Gap Action Programme: anxiety, conversion, epilepsy, dementia, child and adolescent, other substance abuse (these patients are included because misdiagnosis is common with regard to missing or overdiagnosing one condition in place of another mental illness); comorbid conditions are also acceptable;
• (b) any patients screening above cut-off scores on the tools; and
• (c) 10% of patients who are negative on all of the above criteria.
• any patients previously treated for mental illness would be included
• age range will be 16 years or older, with no upper age limit (mental health Gap Action Programme training covers child and adolescent through mental illnesses affecting elderly population).
• all participants will be able to speak Nepali
• able to complete the research interview with the research assistants who will read all of the assessment tools.

Exclusion Criteria:

• Patients with immediate medical needs requiring referral and emergency services (e.g., serious injury; pre-eclampsia; dehydration; status epilepticus)
• patients needing acute psychiatric services (e.g., suicide attempts, alcohol withdrawal, psychosis/mania that cannot be managed in a community setting) who are referred for immediate hospitalization
• Patients under the age of 16 years old will be excluded

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Health Services Research
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Triple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Implementation as Usual; Primary care providers will be trained in the 7-day curriculum of the mental health Gap Action Programme adapted by the Nepal Ministry of Health.	Other: mental health Gap Action Programme; The mental health Gap Action Programme is a training program for primary care providers in mental health services. The curriculum has been developed by the World Health Organization and was adapted in Nepal and certified by the Ministry of Health.
Experimental: RESHAPE; Primary care providers will be trained in the 7-day curriculum of the mental health Gap Action Programme, plus they will have co-facilitation by mental health service users providing recovery testimonials as well as aspirational figures presenting testimonies and conducting myth-busting sessions.	Other: mental health Gap Action Programme; The mental health Gap Action Programme is a training program for primary care providers in mental health services. The curriculum has been developed by the World Health Organization and was adapted in Nepal and certified by the Ministry of Health.; Other: Reducing Stigma among Healthcare Providers (RESHAPE); Mental health service users are trained using Photo Voice to develop recovery story testimonials. They then participate in primary care providers mental health Gap Action Programme training. In addition, aspirational figures are trained to provider testimonials and conduct myth-busting.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Social Distance Scale (SDS)	12-item scale of willingness to interact with persons with mental illness, minimum = 0, maximum = 72, higher score is worse outcome	6 months post training
Structured Clinical Interview for Diagnostic and Statistical Manual 5 (SCID-5)	Accuracy of clinical decision making (this a diagnostic tool, there are no maximum or minimum scores, the objective is to determine if an appropriate diagnosis is selected that will lead to appropriate management)	3-months post-patient enrollment

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
mental health Gap Action Programme knowledge test	Multiple-choice assessment from mental health Gap Action Programme training materials; minimum = 0, maximum = 100, higher is better outcome	6 months post-training
mental health Gap Action Programme knowledge test	Multiple-choice assessment from mental health Gap Action Programme training materials, minimum = 0, maximum = 100, higher is better outcome	3 months post-training
mental health Gap Action Programme knowledge test	Multiple-choice assessment from mental health Gap Action Programme training materials, minimum = 0, maximum = 100, higher is better outcome	immediately after the training
mental health Gap Action Programme self-efficacy assessment	Self-reported clinical efficacy for mental health services, minimum = 0; maximum = 5, higher score is better outcome	6-months post-training
mental health Gap Action Programme self-efficacy assessment	Self-reported clinical efficacy for mental health services, minimum = 0; maximum = 5, higher score is better outcome	3-months post-training
mental health Gap Action Programme self-efficacy assessment	Self-reported clinical efficacy for mental health services, minimum = 0; maximum = 5, higher score is better outcome	immediately after the training
Implicit Association Test	Computer-based neuropsychological assessment of implicit bias related to mental illness, there is no maximum or minimum score, score is D-score based on comparison of timing; positive scores equal more bias	6-months post-training
Implicit Association Test	Computer-based neuropsychological assessment of implicit bias related to mental illness, there is no maximum or minimum score, score is D-score based on comparison of timing; positive scores equal more bias	3-months post-training
Implicit Association Test	Computer-based neuropsychological assessment of implicit bias related to mental illness, there is no maximum or minimum score, score is D-score based on comparison of timing; positive scores equal more bias	immediately after the training
Enhancing Assessment of Common Therapeutic factors	Observed structured clinical evaluation using a standardized role play, minimum score = 0, maximum = 100, higher scores are better	6 months post-training
Enhancing Assessment of Common Therapeutic factors	Observed structured clinical evaluation using a standardized role play, minimum score = 0, maximum = 100, higher scores are better	3 months post-training
Enhancing Assessment of Common Therapeutic factors	Observed structured clinical evaluation using a standardized role play, minimum score = 0, maximum = 100, higher scores are better	immediately after the training
Social Distance Scale	12-item scale of willingness to interact with persons with mental illness, minimum = 0, maximum = 72, higher score is worse outcome	3 months post training
Social Distance Scale	12-item scale of willingness to interact with persons with mental illness, minimum = 0, maximum = 72, higher score is worse outcome	immediately after the training
Patient: World Health Organization Disability Assessment Scale	Assessment of daily functioning, minimum = 12, maximum = 60; higher score is worse	6-months post enrollment
Patient: World Health Organization Disability Assessment Scale	Assessment of daily functioning, minimum = 12, maximum = 60; higher score is worse	3-months post enrollment
Patient Health Questionnaire 9	Depression symptoms, minimum = 0, maximum = 27, higher score is worse	6-months post enrollment
Patient Health Questionnaire 9	Depression symptoms, minimum = 0, maximum = 27, higher score is worse	3-months post enrollment
Patient: Generalized Anxiety Disorder 7	Anxiety symptoms, minimum = 0, maximum = 21, higher score is worse	6 months post enrollment
Patient: Generalized Anxiety Disorder 7	Anxiety symptoms, minimum = 0, maximum = 21, higher score is worse	3 months post enrollment
Patient: Positive and Negative Symptoms of Schizophrenia	Psychosis symptoms, minimum = 0, maximum = 56, higher score is worse	6 months post enrollment
Patient: Positive and Negative Symptoms of Schizophrenia	Psychosis symptoms, minimum = 0, maximum = 56, higher score is worse	3 months post enrollment
Patient: Alcohol Use Disorder Identification Test	Alcohol Use Disorder symptoms, minimum = 0, maximum = 40, higher score is worse	6-months post enrollment
Patient: Alcohol Use Disorder Identification Test	Alcohol Use Disorder symptoms, minimum = 0, maximum = 40, higher score is worse	3-months post enrollment
Patient: Euroqol 5 dimension 5 level	Quality of life symptoms, minimum = 5, maximum=25, higher score is worse	6-months post enrollment
Patient: Euroqol 5 dimension 5 level	Quality of life symptoms, minimum = 5, maximum=25, higher score is worse	3-months post enrollment
Patient: Cost of Service Receipt Inventory	Costs of care to patients, there is no maximum or minimum score, the outcome is total costs	6-months post-enrollment
Patient: Cost of Service Receipt Inventory	Costs of care to patients, , there is no maximum or minimum score, the outcome is total costs	3-months post-enrollment
Patient: Enhancing Assessment of Common Therapeutic factors	Common factors use by primary care provider, minimum score = 0, maximum = 15, higher score is better	6-months post-enrollment

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Abnormal involuntary movement scale	Abnormal movements associated with antipsychotic medication, minimum score = 0, maximum score = 40, higher score is worse	3-months post-treatment initiation
Antidepressant side-effect checklist	Side effects of antidepressant medication, minimum score = 0, maximum score = 63, higher score is worse	3-months post-treatment initiation

Collaborators and Investigators

• Sponsor: George Washington University
• Collaborators: King's College London; Duke University; Transcultural Psychosocial Organization Nepal
• Investigators: Principal Investigator: Brandon A Kohrt, MD, PhD, George Washington University

Publications and helpful links

General Publications

• Kohrt BA, Turner EL, Gurung D, Wang X, Neupane M, Luitel NP, Kartha MR, Poudyal A, Singh R, Rai S, Baral PP, McCutchan S, Gronholm PC, Hanlon C, Lempp H, Lund C, Thornicroft G, Gautam K, Jordans MJD. Implementation strategy in collaboration with people with lived experience of mental illness to reduce stigma among primary care providers in Nepal (RESHAPE): protocol for a type 3 hybrid implementation effectiveness cluster randomized controlled trial. Implement Sci. 2022 Jun 16;17(1):39. doi: 10.1186/s13012-022-01202-x.

Study record dates

Study Major Dates

• Study Start (Actual): February 22, 2022
• Primary Completion (Estimated): December 1, 2024
• Study Completion (Estimated): December 1, 2024

Study Registration Dates

• First Submitted: February 19, 2020
• First Submitted That Met QC Criteria: February 21, 2020
• First Posted (Actual): February 25, 2020

Study Record Updates

• Last Update Posted (Actual): February 23, 2024
• Last Update Submitted That Met QC Criteria: February 22, 2024
• Last Verified: February 1, 2024

More Information

Terms related to this study

• Keywords: Primary care; Mental health; Developing countries; Stigma
• Additional Relevant MeSH Terms: Chemically-Induced Disorders; Alcohol-Related Disorders; Substance-Related Disorders; Mood Disorders; Schizophrenia Spectrum and Other Psychotic Disorders; Alcoholism; Depressive Disorder; Psychotic Disorders; Anxiety Disorders; Mental Disorders
• Other Study ID Numbers: R01MH120649 (U.S. NIH Grant/Contract)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: Information will be shared through National Institute of Mental Health Data Archives
• IPD Sharing Time Frame: Data will become available after publication of the primary and secondary outcomes manuscripts
• IPD Sharing Access Criteria: Managed through the National Institute of Mental Health Data Archives
• IPD Sharing Supporting Information Type: STUDY_PROTOCOL; SAP; ICF; ANALYTIC_CODE

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No