Evaluating process and clinical outcomes of a primary care mental health integration project in rural Rwanda: a prospective mixed-methods protocol

Abstract

IntroductionIntegrating mental healthcare into primary care can reduce the global burden of mental disorders. Yet data on the effective implementation of real-world task-shared mental health programmes are limited. In 2012, the Rwandan Ministry of Health and the international healthcare organisation Partners in Health collaboratively adapted the Mentoring and Enhanced Supervision at Health Centers (MESH) programme, a successful programme of supported supervision based on task-sharing for HIV/AIDS care, to include care of neuropsychiatric disorders within primary care settings (MESH Mental Health). We propose 1 of the first studies in a rural low-income country to assess the implementation and clinical outcomes of a programme integrating neuropsychiatric care into a public primary care system.Methods and analysisA mixed-methods evaluation will be conducted. First, we will conduct a quantitative outcomes evaluation using a pretest and post-test design at 4 purposively selected MESH MH participating health centres. At least 112 consecutive adults with schizophrenia, bipolar disorder, depression or epilepsy will be enrolled. Primary outcomes are symptoms and functioning measured at baseline, 8 weeks and 6 months using clinician-administered scales: the General Health Questionnaire and the brief WHO Disability Assessment Scale. We hypothesise that service users will experience at least a 25% improvement in symptoms and functioning from baseline after MESH MH programme participation. To understand any outcome improvements under the intervention, we will evaluate programme processes using (1) quantitative analyses of routine service utilisation data and supervision checklist data and (2) qualitative semistructured interviews with primary care nurses, service users and family members.Ethics and disseminationThis evaluation was approved by the Rwanda National Ethics Committee (Protocol #736/RNEC/2016) and deemed exempt by the Harvard University Institutional Review Board. Results will be submitted for peer-reviewed journal publication, presented at conferences and disseminated to communities served by the programme.

Validity, Reliability, and Diagnostic Cut-off of the Kinyarwandan Version of the Hamilton Depression Rating Scale in Rwanda

“…This is particularly important since use of these scales by trained nurses and other non-specialist staff is pivotal for scaling up mental health care in Rwanda and to a broader extent, in low-income countries, it increases the number of staff that can provide such care (Belkin et al, 2011;Sweetland et al, 2014). In 2012, the Rwandan Ministry of Health, in collaboration with Partners in Health, adapted a program for primary care nurses providing training to participate in the clinical care of people with mental disorders (Smith et al, 2017). In this stepped-up pathway, trained staff can participate more and more in screening and triage, engagement, follow-up, and monitoring, as well as referral when and where required (Sweetland et al, 2014).…”

Evaluating the delivery of Problem Management Plus in primary care settings in rural Rwanda: a study protocol using a pragmatic randomised hybrid type 1 effectiveness-implementation design

“…Both scales have demonstrated high levels of validity and reliability across multiple cultures and countries and have been translated into Kinyarwanda and used in previous studies in Rwanda. 19 20 21 Routine demographic information will also be recorded at each data collection point.…”

Outcomes of a primary care mental health implementation program in rural Rwanda: A quasi-experimental implementation-effectiveness study

“…The initial protocol for this study is published at doi: 10.1136/bmjopen-2016-014067 [18] and is available in S1 and S2 Files.…”

“…Based on past follow up rates for studies in other clinical domains, it was estimated that 80% of patients would be retained in the study and analysed, and that 50% of those would experience a clinically significant improvement. [18] Statistical analysis. For outcome measures, we calculated change in GHQ-12 and WHO--DAS II Brief scores after two and six months, relative to baseline, and tested whether this change was different from zero using a paired t-test.…”