Adaptation of the World Health Organization Electronic Mental Health Gap Action Programme Intervention Guide App for Mobile Devices in Nepal and Nigeria: Protocol for a Feasibility Cluster Randomized Controlled Trial

Tatiana Taylor Salisbury, Brandon A Kohrt, Ioannis Bakolis, Mark Jd Jordans, Louise Hull, Nagendra P Luitel, Paul McCrone, Nick Sevdalis, Pooja Pokhrel, Kenneth Carswell, Akin Ojagbemi, Eric P Green, Neerja Chowdhary, Lola Kola, Heidi Lempp, Tarun Dua, Maria Milenova, Oye Gureje, Graham Thornicroft, Tatiana Taylor Salisbury, Brandon A Kohrt, Ioannis Bakolis, Mark Jd Jordans, Louise Hull, Nagendra P Luitel, Paul McCrone, Nick Sevdalis, Pooja Pokhrel, Kenneth Carswell, Akin Ojagbemi, Eric P Green, Neerja Chowdhary, Lola Kola, Heidi Lempp, Tarun Dua, Maria Milenova, Oye Gureje, Graham Thornicroft

Abstract

Background: There is a growing global need for scalable approaches to training and supervising primary care workers (PCWs) to deliver mental health services. Over the past decade, the World Health Organization Mental Health Gap Action Programme Intervention Guide (mhGAP-IG) and associated training and implementation guidance have been disseminated to more than 100 countries. On the basis of the opportunities provided by mobile technology, an updated electronic Mental Health Gap Action Programme Intervention Guide (e-mhGAP-IG) is now being developed along with a clinical dashboard and guidance for the use of mobile technology in supervision.

Objective: This study aims to assess the feasibility, acceptability, adoption, and other implementation parameters of the e-mhGAP-IG for diagnosis and management of depression in 2 lower-middle-income countries (Nepal and Nigeria) and to conduct a feasibility cluster randomized controlled trial (cRCT) to evaluate trial procedures for a subsequent fully powered trial comparing the clinical effectiveness and cost-effectiveness of the e-mhGAP-IG and remote supervision with standard mhGAP-IG implementation.

Methods: A feasibility cRCT will be conducted in Nepal and Nigeria to evaluate the feasibility of the e-mhGAP-IG for use in depression diagnosis and treatment. In each country, an estimated 20 primary health clinics (PHCs) in Nepal and 6 PHCs in Nigeria will be randomized to have their staff trained in e-mhGAP-IG or the paper version of mhGAP-IG v2.0. The PHC will be the unit of clustering. All PCWs within a facility will receive the same training (e-mhGAP-IG vs paper mhGAP-IG). Approximately 2-5 PCWs, depending on staffing, will be recruited per clinic (estimated 20 health workers per arm in Nepal and 15 per arm in Nigeria). The primary outcomes of interest will be the feasibility and acceptability of training, supervision, and care delivery using the e-mhGAP-IG. Secondary implementation outcomes include the adoption of the e-mhGAP-IG and feasibility of trial procedures. The secondary intervention outcome-and the primary outcome for a subsequent fully powered trial-will be the accurate identification of depression by PCWs. Detection rates before and after training will be compared in each arm.

Results: To date, qualitative formative work has been conducted at both sites to prepare for the pilot feasibility cRCT, and the e-mhGAP-IG and remote supervision guidelines have been developed.

Conclusions: The incorporation of mobile digital technology has the potential to improve the scalability of mental health services in primary care and enhance the quality and accuracy of care.

Trial registration: ClinicalTrials.gov NCT04522453; https://ichgcp.net/clinical-trials-registry/NCT04522453.

International registered report identifier (irrid): PRR1-10.2196/24115.

Keywords: LMIC; community mental health; digital technology; eHealth; intervention; mHealth; mental health; mobile phone; primary health care; remote supervision; training.

Conflict of interest statement

Conflicts of Interest: NS is the director of the London Safety and Training Solutions Ltd, which offers training in patient safety, implementation solutions, and human factors to health care organizations.

©Tatiana Taylor Salisbury, Brandon A Kohrt, Ioannis Bakolis, Mark JD Jordans, Louise Hull, Nagendra P Luitel, Paul McCrone, Nick Sevdalis, Pooja Pokhrel, Kenneth Carswell, Akin Ojagbemi, Eric P Green, Neerja Chowdhary, Lola Kola, Heidi Lempp, Tarun Dua, Maria Milenova, Oye Gureje, Graham Thornicroft. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 15.06.2021.

Figures

Figure 1
Figure 1
Feasibility study patient and provider data collection procedure. mhGAP: Mental Health Gap Action Programme; P0: patient pre training assessment; P1: patient baseline health care appointment assessment; P2: patient 3 months post baseline health care appointment; PCW: primary care worker; PCW0: primary care worker baseline assessment; PCW1: primary care worker immediate post training assessment; PCW2: primary care worker 3 months post training assessment; PCW3: primary care worker 8 months post training assessment; S0: Supervisor baseline assessment; S1: Supervisor 8 months post training assessment.
Figure 2
Figure 2
Emilia (E-mhGAP Intervention Guide in Low- and Middle-Income Countries: Proof-of-Concept for Impact and Acceptability) flow chart. e-mhGAP-IG: electronic Mental Health Gap Action Programme Intervention Guide; mhGAP-IG: Mental Health Gap Action Programme Intervention Guide.

References

    1. Steel Z, Marnane C, Iranpour C, Chey T, Jackson JW, Patel V, Silove D. The global prevalence of common mental disorders: a systematic review and meta-analysis 1980-2013. Int J Epidemiol. 2014 Apr;43(2):476–93. doi: 10.1093/ije/dyu038.
    1. GBD 2016 DALYs and HALE Collaborators Global, regional, and national disability-adjusted life-years (DALYs) for 333 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2017 Sep 16;390(10100):1260–344. doi: 10.1016/S0140-6736(17)32130-X.
    1. Wang PS, Aguilar-Gaxiola S, Alonso J, Angermeyer MC, Borges G, Bromet EJ, Bruffaerts R, de GG, de GR, Gureje O, Haro JM, Karam EG, Kessler RC, Kovess V, Lane MC, Lee S, Levinson D, Ono Y, Petukhova M, Posada-Villa J, Seedat S, Wells JE. Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys. Lancet. 2007 Sep 8;370(9590):841–50. doi: 10.1016/S0140-6736(07)61414-7.
    1. Thornicroft G, Chatterji S, Evans-Lacko S, Gruber M, Sampson N, Aguilar-Gaxiola S, Al-Hamzawi A, Alonso J, Andrade L, Borges G, Bruffaerts R, Bunting B, de Almeida JM, Florescu S, de Girolamo G, Gureje O, Haro JM, He Y, Hinkov H, Karam E, Kawakami N, Lee S, Navarro-Mateu F, Piazza M, Posada-Villa J, de Galvis YT, Kessler RC. Undertreatment of people with major depressive disorder in 21 countries. Br J Psychiatry. 2017 Dec;210(2):119–24. doi: 10.1192/bjp.bp.116.188078. doi: 10.1192/bjp.bp.116.188078.
    1. Thornicroft G, Votruba N. Does the United Nations care about mental health? Lancet Psychiatry. 2016 Jul;3(7):599–600. doi: 10.1016/S2215-0366(16)30079-7.
    1. World Health Organization . Comprehensive Mental Health Action Plan 2013-2020. Geneva: World Health Organization; 2013.
    1. Koschorke M, Padmavati R, Kumar S, Cohen A, Weiss HA, Chatterjee S, Pereira J, Naik S, John S, Dabholkar H, Balaji M, Chavan A, Varghese M, Thara R, Thornicroft G, Patel V. Experiences of stigma and discrimination of people with schizophrenia in India. Soc Sci Med. 2014 Dec;123:149–59. doi: 10.1016/j.socscimed.2014.10.035.
    1. Lasalvia A, Zoppei S, Van Bortel T, Bonetto C, Cristofalo D, Wahlbeck K, Bacle SV, Van Audenhove C, van Weeghel J, Reneses B, Germanavicius A, Economou M, Lanfredi M, Ando S, Sartorius N, Lopez-Ibor JJ, Thornicroft G, ASPEN/INDIGO Study Group Global pattern of experienced and anticipated discrimination reported by people with major depressive disorder: a cross-sectional survey. Lancet. 2013 Jan 05;381(9860):55–62. doi: 10.1016/S0140-6736(12)61379-8.
    1. Lempp H, Abayneh S, Gurung D, Kola L, Abdulmalik J, Evans-Lacko S, Semrau M, Alem A, Thornicroft G, Hanlon C. Service user and caregiver involvement in mental health system strengthening in low- and middle-income countries: a cross-country qualitative study. Epidemiol Psychiatr Sci. 2018 Feb;27(1):29–39. doi: 10.1017/S2045796017000634.
    1. Schnyder N, Panczak R, Groth N, Schultze-Lutter F. Association between mental health-related stigma and active help-seeking: systematic review and meta-analysis. Br J Psychiatry. 2017 Apr;210(4):261–8. doi: 10.1192/bjp.bp.116.189464.
    1. Task shifting: rational redistribution of tasks among health workforce teams global recommendations and guidelines. Geneva: World Health Organization; 2007. pp. 1–88.
    1. The mobile economy sub-Saharan Africa 2019. GSM Association. 2019. [2020-06-23]. .
    1. Rijal P. Mobile subscriptions outnumber population. Kathmandu Post. 2016. Jun 14, [2020-07-14]. .
    1. World Health Organization . Global diffusion of eHealth: making universal health coverage achievable, report of the third global survey on eHealth. Geneva: World Health Organization; 2016. pp. 1–156.
    1. Divall P, Camosso-Stefinovic J, Baker R. The use of personal digital assistants in clinical decision making by health care professionals: a systematic review. Health Informatics J. 2013 Mar;19(1):16–28. doi: 10.1177/1460458212446761.
    1. World Health Organization . Recommendations on digital interventions for health system strengthening. Geneva: World Health Organaization; 2019.
    1. World Health Organization . mhGAP Intervention Guide - Version 2.0 - for mental, neurological and substance use disorders in non-specialized health settings. Geneva: World Health Organization; 2019. pp. 1–173.
    1. Dua T, Barbui C, Clark N, Fleischmann A, Poznyak V, van Ommeren M, Yasamy MT, Ayuso-Mateos JL, Birbeck GL, Drummond C, Freeman M, Giannakopoulos P, Levav I, Obot IS, Omigbodun O, Patel V, Phillips M, Prince M, Rahimi-Movaghar A, Rahman A, Sander JW, Saunders JB, Servili C, Rangaswamy T, Unützer J, Ventevogel P, Vijayakumar L, Thornicroft G, Saxena S. Evidence-based guidelines for mental, neurological, and substance use disorders in low- and middle-income countries: summary of WHO recommendations. PLoS Med. 2011 Nov;8(11):e1001122. doi: 10.1371/journal.pmed.1001122.
    1. The World Bank - Nepal Country Profile. World Development Indicators database. [2020-06-23]. .
    1. Luitel NP, Baron EC, Kohrt BA, Komproe IH, Jordans MJ. Prevalence and correlates of depression and alcohol use disorder among adults attending primary health care services in Nepal: a cross sectional study. BMC Health Serv Res. 2018 Mar 27;18(1):215. doi: 10.1186/s12913-018-3034-9.
    1. Luitel NP, Jordans MJ, Kohrt BA, Rathod SD, Komproe IH. Treatment gap and barriers for mental health care: a cross-sectional community survey in Nepal. PLoS One. 2017;12(8):e0183223. doi: 10.1371/journal.pone.0183223.
    1. Luitel NP, Jordans MJ, Adhikari A, Upadhaya N, Hanlon C, Lund C, Komproe IH. Mental health care in Nepal: current situation and challenges for development of a district mental health care plan. Confl Health. 2015;9:3. doi: 10.1186/s13031-014-0030-5.
    1. Annual report 2073-74. Department of Health Services, Kathmandu, Nepal. 2017. [2021-06-01]. .
    1. Chase LE, Marahatta K, Sidgel K, Shrestha S, Gautam K, Luitel NP, Dotel BR, Samuel R. Building back better? Taking stock of the post-earthquake mental health and psychosocial response in Nepal. Int J Ment Health Syst. 2018;12:44. doi: 10.1186/s13033-018-0221-3.
    1. Nigeria Country Profile: The World Bank Group. World Development Indicators database. [2020-06-23]. .
    1. Adewuya AO, Atilola O, Ola BA, Coker OA, Zachariah MP, Olugbile O, Fasawe A, Idris O. Current prevalence, comorbidity and associated factors for symptoms of depression and generalised anxiety in the Lagos State Mental Health Survey (LSMHS), Nigeria. Compr Psychiatry. 2018;81:60–5. doi: 10.1016/j.comppsych.2017.11.010.
    1. Demyttenaere K, Bruffaerts R, Posada-Villa J, Gasquet I, Kovess V, Lepine JP, Angermeyer MC, Bernert S, de Girolamo G, Morosini P, Polidori G, Kikkawa T, Kawakami N, Ono Y, Takeshima T, Uda H, Karam EG, Fayyad JA, Karam AN, Mneimneh ZN, Medina-Mora ME, Borges G, Lara C, de Graaf R, Ormel J, Gureje O, Shen Y, Huang Y, Zhang M, Alonso J, Haro JM, Vilagut G, Bromet EJ, Gluzman S, Webb C, Kessler RC, Merikangas KR, Anthony JC, Von Korff MR, Wang PS, Brugha TS, Aguilar-Gaxiola S, Lee S, Heeringa S, Pennell B, Zaslavsky AM, Ustun TB, Chatterji S. Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. J Am Med Assoc. 2004;291(21):2581–90. doi: 10.1001/jama.291.21.2581.
    1. MIS Report: January 2019. Nepal Telecommunications Authority, Kathmandu, Nepal. [2021-06-01]. .
    1. Spotlight on Nigeria: Delivering a digital future London. GSM Association. 2018. [2020-06-23]. .
    1. Khoja S, Scott R, Husyin N, Durrani H, Arif M, Faqiri F, Hedayat E, Yousufzai W. Impact of simple conventional and Telehealth solutions on improving mental health in Afghanistan. J Telemed Telecare. 2016 Dec;22(8):495–8. doi: 10.1177/1357633X16674631.
    1. Brown T, Wyatt J. Design thinking for social innovation. Develop Outreach. 2010;12(1):29–43. doi: 10.1596/1020-797X_12_1_29. doi: 10.1596/1020-797x_12_1_29.
    1. Proctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, Griffey R, Hensley M. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health. 2011 Mar;38(2):65–76. doi: 10.1007/s10488-010-0319-7.
    1. Jordans MJ, Luitel NP, Kohrt BA, Rathod SD, Garman EC, De Silva M, Komproe IH, Patel V, Lund C. Community-, facility-, and individual-level outcomes of a district mental healthcare plan in a low-resource setting in Nepal: a population-based evaluation. PLoS Med. 2019;16(2):e1002748. doi: 10.1371/journal.pmed.1002748.
    1. Sangha S, George J, Winthrop C, Panchal S. Confusion: delirium and dementia - a smartphone app to improve cognitive assessment. BMJ Qual Improv Rep. 2015;4(1):1592. doi: 10.1136/bmjquality.u202580.w1592.
    1. Weiner BJ. A theory of organizational readiness for change. In: Nilsen P, Birken SA, editors. Handbook on Implementation Science. Cheltenham: Elgar Publishing; 2020. pp. 215–32.
    1. Shea CM, Jacobs SR, Esserman DA, Bruce K, Weiner BJ. Organizational readiness for implementing change: a psychometric assessment of a new measure. Implement Sci. 2014;9:7. doi: 10.1186/1748-5908-9-7.
    1. Weiner BJ, Lewis CC, Stanick C, Powell BJ, Dorsey CN, Clary AS, Boynton MH, Halko H. Psychometric assessment of three newly developed implementation outcome measures. Implement Sci. 2017;12(1):108. doi: 10.1186/s13012-017-0635-3.
    1. Rapley T, Girling M, Mair FS, Murray E, Treweek S, McColl E, Steen IN, May CR, Finch TL. Improving the normalization of complex interventions: part 1 - development of the NoMAD instrument for assessing implementation work based on normalization process theory (NPT) BMC Med Res Methodol. 2018;18(1):133. doi: 10.1186/s12874-018-0590-y.
    1. Finch TL, Girling M, May CR, Mair FS, Murray E, Treweek S, McColl E, Steen IN, Cook C, Vernazza CR, Mackintosh N, Sharma S, Barbery G, Steele J, Rapley T. Improving the normalization of complex interventions: part 2 - validation of the NoMAD instrument for assessing implementation work based on normalization process theory (NPT) BMC Med Res Methodol. 2018;18(1):1–13. doi: 10.1186/s12874-018-0591-x.
    1. Haddad M, Menchetti M, McKeown E, Tylee A, Mann A. The development and psychometric properties of a measure of clinicians' attitudes to depression: the revised Depression Attitude Questionnaire (R-DAQ) BMC Psychiatry. 2015;15:7. doi: 10.1186/s12888-014-0381-x.
    1. Bogardus E. Measuring Social Distance. J Appl Sociol. 1925. [2021-06-01]. .
    1. Link BG, Yang LH, Phelan JC, Collins PY. Measuring mental illness stigma. Schizophr Bull. 2004;30(3):511–41. doi: 10.1093/oxfordjournals.schbul.a007098.
    1. Parrillo V, Donoghue C. Updating the Bogardus social distance studies: a new national survey. Soc Sci J. 2005;42(2):257–71. doi: 10.1016/j.soscij.2005.03.011. doi: 10.1016/j.soscij.2005.03.011.
    1. Link B, Cullen F, Frank J, Wozniak J. The social rejection of former mental patients: understanding why labels matter. Am J Sociol. 1987;92(6):1461–500. doi: 10.1086/228672. doi: 10.1086/228672.
    1. Peters RM, Dadun. Van Brakel WH, Zweekhorst MB, Damayanti R, Bunders JF, Irwanto The cultural validation of two scales to assess social stigma in leprosy. PLoS Negl Trop Dis. 2014;8(11):e3274. doi: 10.1371/journal.pntd.0003274.
    1. Kohrt BA, Mutamba BB, Luitel NP, Gwaikolo W, Mangen PO, Nakku J, Rose K, Cooper J, Jordans MJ, Baingana F. How competent are non-specialists trained to integrate mental health services in primary care? Global health perspectives from Uganda, Liberia, and Nepal. Int Rev Psychiatry. 2018;30(6):182–98. doi: 10.1080/09540261.2019.1566116.
    1. Kohrt BA, Jordans MJ, Rai S, Shrestha P, Luitel NP, Ramaiya MK, Singla DR, Patel V. Therapist competence in global mental health: development of the ENhancing Assessment of Common Therapeutic factors (ENACT) rating scale. Behav Res Ther. 2015;69:11–21. doi: 10.1016/j.brat.2015.03.009.
    1. Fukui S, Rapp CA, Goscha R, Marty D, Ezell M. The perceptions of supervisory support scale. Adm Policy Ment Health. 2014;41(3):353–9. doi: 10.1007/s10488-013-0470-z.
    1. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001 Sep;16(9):606–13.
    1. Kohrt BA, Luitel NP, Acharya P, Jordans MJ. Detection of depression in low resource settings: validation of the Patient Health Questionnaire (PHQ-9) and cultural concepts of distress in Nepal. BMC Psychiatry. 2016;16:58. doi: 10.1186/s12888-016-0768-y.
    1. Adewuya AO, Ola BA, Afolabi OO. Validity of the patient health questionnaire (PHQ-9) as a screening tool for depression amongst Nigerian university students. J Affect Disord. 2006;96(1-2):89–93. doi: 10.1016/j.jad.2006.05.021.
    1. Üstün T, Kostanjsek N, Chatterji S, Rehm J, World Health Organization . In: Measuring health and disability: Manual for WHO disability assessment schedule WHODAS 2.0. Üstün TB, Kostanjsek N, Chatterji S, Rehm J, editors. Geneva: World Health Organization; 2010.
    1. Tol WA, Kohrt BA, Jordans MJ, Thapa SB, Pettigrew J, Upadhaya N, de Jong JT. Political violence and mental health: a multi-disciplinary review of the literature on Nepal. Soc Sci Med. 2010;70(1):35–44. doi: 10.1016/j.socscimed.2009.09.037.
    1. Tol WA, Komproe IH, Jordans MJ, Thapa SB, Sharma B, De Jong JT. Brief multi-disciplinary treatment for torture survivors in Nepal: a naturalistic comparative study. Int J Soc Psychiatry. 2009;55(1):39–56. doi: 10.1177/0020764008091525.
    1. Thapa SB, Hauff E. Perceived needs, self-reported health and disability among displaced persons during an armed conflict in Nepal. Soc Psychiatry Psychiatr Epidemiol. 2012;47(4):589–95. doi: 10.1007/s00127-011-0359-7.
    1. Adewuya AO, Ola BA, Coker OA, Atilola O, Zachariah MP, Olugbile O, Fasawe A, Idris O. Prevalence and associated factors for suicidal ideation in the Lagos State Mental Health Survey, Nigeria. BJPsych Open. 2016;2(6):385–9. doi: 10.1192/bjpo.bp.116.004333.
    1. Robins LN, Wing J, Wittchen HU, Helzer JE, Babor TF, Burke J, Farmer A, Jablenski A, Pickens R, Regier DA. The composite international diagnostic interview. An epidemiologic instrument suitable for use in conjunction with different diagnostic systems and in different cultures. Arch Gen Psychiatry. 1988;45(12):1069–77.
    1. Aldridge LR, Garman EC, Luitel NP, Jordans MJ. Impact of a district mental health care plan on suicidality among patients with depression and alcohol use disorder in Nepal. PLoS One. 2020;15(4):e0231158. doi: 10.1371/journal.pone.0231158.
    1. Muñiz J, Elosua P, Hambleton RK, International Test Commission [International Test Commission Guidelines for test translation and adaptation: second edition] Psicothema. 2013;25(2):151–7. doi: 10.7334/psicothema2013.24.
    1. Paap MC, Lange L, van der Palen J, Bode C. Using the Three-Step Test Interview to understand how patients perceive the St. George's Respiratory Questionnaire for COPD patients (SGRQ-C) Qual Life Res. 2016;25(6):1561–70. doi: 10.1007/s11136-015-1192-3.
    1. Beatty P, Willis G. Research synthesis: the practice of cognitive interviewing. Public Opin Q. 2007;71(2):287–311. doi: 10.1093/poq/nfm006. doi: 10.1093/poq/nfm006.
    1. Braun V, Clarke V, Hayfield N, Terry G. Thematic analysis. In: Liamputtong P, editor. Handbook of Research Methods in Health Social Sciences. Singapore: Springer; 2018. pp. 978–81.
    1. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. doi: 10.1191/1478088706qp063oa. doi: 10.1191/1478088706qp063oa.
    1. Pokhrel P, Karmacharya R, Taylor Salisbury T, Carswell K, Kohrt B A, Jordans M J D, Lempp H, Thornicroft G, Luitel N P. Perception of healthcare workers on mobile app-based clinical guideline for the detection and treatment of mental health problems in primary care: a qualitative study in Nepal. BMC Med Inform Decis Mak. 2021 Jan 19;21(1):21–93. doi: 10.1186/s12911-021-01386-0.

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