E-MhGAP Intervention guide in Low and middle income countries: proof-of-concept for Impact and Acceptability (Emilia project)

Layperson summary

The context for the Emilia proposal is the 'mental health treatment gap'. This is the difference between the number of people with mental illness needing treatment and care, and the number who actually receive help. At present this gap is huge. Over 80% of people with severe mental disorders in low and middle income countries (LMICs) receive no treatment at all. The aim of the Emilia project is to assess if it is possible to produce a version of the World Health Organisation (WHO) Mental Health Global Action Programme Intervention Guide that is easily usable on smart phones and tablet devices, for use in this project by primary care staff in Nepal and Nigeria. We intend to assess if this electronic form of guidance is suitable for use in other LMICs, where over 85% of the world's population live.

We will compare the training, support and supervision given to primary health care using the paper version and the electronic version
of the WHO Mental Health Global Action Programme Intervention Guide (mhGAP IG).
We will assess if the electronic version is more practical to use (ie more feasible) by answering the following questions. Is the
electronic version more feasible to use in terms of:

1. greater staff acceptability
2. more often leading to an evidence-based intervention
3. a greater proportion of patients with depression are identified by primary care staff
4. being affordable and cost-effective
5. delivering better clinical support and supervision to primary care staff
6. leading to less stigma related to people with mental illness among primary care staff

3. Research plan, methodology and data

3.1 Research methodology and timelines
3.1.1 Overview. The Emilia project is a proof-of-concept study of the feasibility of implementing the e-version of the mhGAP Intervention Guide, and will address the 6 research questions given at 1.3.
3.1.2 Study sites. The study will take place in 2 sites: in Nepal (low income) and Nigeria (lower-middle income country), with each site including a range of urban and rural settings (see 3.5).
3.1.3 Intervention condition. The e-version of the mhGAP IG v2.0 is now being developed by the WHO and will be launched in October 2017, in both iOS and Android versions suitable for smart phones and tablets. The e-version intervention includes the following components: (i) separate translation and country adaptation in Nepal and Nigeria10; (ii) further development of the e-version of the mhGAP IG v2.0; (iii) development of a supplementary e-mhGAP IG module for Remote Supervision and Support which will be designed to allow two-way data sharing between the PHC mhGAP IG user and his/her supervisor, and for this data to be accessible offline; (iv) delivery of initial training to PHC staff for the detection and treatment of people with types of mental disorder included in the mhGAP IG; (v) delivery of ongoing supervision/support with e-mhGAP platform, and (vi) system support to address, for example, system errors that users uncover (bugs), user error, and devices malfunctioning/becoming unserviceable.

5. Exploitation, dissemination and expected impact

5.1 Approach to impact and knowledge transfer. The pathway to impact of this study is that the scientific knowledge gained from this study will inform the manualisation of this e-intervention, the proof-of-concept and feasibility study of Emilia, and is intended to lead to a future multi-site clinical trial, to contribute knowledge to later reduce the mental help gap. The Emilia partnership will establish a harmonised set of measures, agree its future research strategy, establish reciprocal knowledge sharing arrangements, develop individual career development plans for each early- and intermediate-career researcher, and build a shared data infrastructure.

5.2. Intended future research proposals. The Emilia proposal is designed both to directly conduct high quality research in this funded period, and to provide the foundations for strong grant applications for a future large scale, multi-site RCT of the e-mhGAP IG. The PI has a strong track record in both global mental health and RCTs, having led 6 large-scale international studies related to the former, and 14 RCTs to date.

5.3. Potential hypotheses for future RCTs. In PHC settings in LMICs: (i) After relevant training, is the e-version of the mhGAP IG significantly more often put into clinical practice than the paper version? (ii) Is a greater proportion of people with the conditions included in the mhGAP IG, and who require treatment, identified by staff using the e-version than by staff using the paper version? (iii) Are the outcomes for those people with relevant mental disorders, and who are treated, significantly better from treatment by staff trained to use the e-version than the paper version? (iv) Is the quality of supervision and support provided to PHC staff significantly better for use of the e-version than for the paper version? (v) Is the use of the e-version significantly more cost-effective than use of the paper version in relation to primary patient outcomes?