E-MhGAP Intervention guide in Low and middle income countries: proof-of-concept for Impact and Acceptability (Emilia project)
Lead Research Organisation:
King's College London
Department Name: Health Service and Population Research
Abstract
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
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
Technical Summary
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.
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.
Planned Impact
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?
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?
Organisations
- King's College London (Lead Research Organisation)
- Transcultural psychosocial Organization (Collaboration)
- London School of Economics and Political Science (University of London) (Collaboration)
- World Health Organization (WHO) (Collaboration)
- University of Sussex (Collaboration)
- George Institute for Global Health (Collaboration)
- National Institute of Mental Health and Neurosciences (Collaboration)
- University of Ibadan (Collaboration)
- George Washington University (Collaboration)
- Peking University Sixth Hospital (Collaboration)
- Ulm University Medical Center (Collaboration)
Publications
Lund C
(2020)
Task-sharing of psychological treatment for antenatal depression in Khayelitsha, South Africa: Effects on antenatal and postnatal outcomes in an individual randomised controlled trial.
in Behaviour research and therapy
Ahuja S
(2018)
Mental health information systems in resource-challenged countries: experiences from India.
in BJPsych international
Gronholm PC
(2023)
Assessing the priority of human rights and mental health: the PHRAME approach.
in BJPsych open
Semrau M
(2019)
Strengthening mental health systems in low- and middle-income countries: recommendations from the Emerald programme.
in BJPsych open
Ayuso-Mateos JL
(2019)
Effective methods for knowledge transfer to strengthen mental health systems in low- and middle-income countries.
in BJPsych open
Thornicroft G
(2019)
Health system strengthening for mental health in low- and middle-income countries: introduction to the Emerald programme.
in BJPsych open
Ahuja S
(2019)
Experience of implementing new mental health indicators within information systems in six low- and middle-income countries.
in BJPsych open
Chisholm D
(2019)
Mental health financing challenges, opportunities and strategies in low- and middle-income countries: findings from the Emerald project.
in BJPsych open
Pokhrel, P.
(2021)
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
in BMC Med Inform Decis Mak
Pokhrel P
(2021)
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.
in BMC medical informatics and decision making
Das-Munshi J
(2020)
Gaps and challenges: WHO treatment recommendations for tobacco cessation and management of substance use disorders in people with severe mental illness.
in BMC psychiatry
Forthal S
(2019)
Rural vs urban residence and experience of discrimination among people with severe mental illnesses in Ethiopia.
in BMC psychiatry
Fekadu A
(2019)
The psychosis treatment gap and its consequences in rural Ethiopia.
in BMC psychiatry
Bitta MA
(2018)
Suicide in a rural area of coastal Kenya.
in BMC psychiatry
Tol WA
(2019)
Can mental health treatments help prevent or reduce intimate partner violence in low- and middle-income countries? A systematic review.
in BMC women's health
Rao R
(2020)
Alcohol consumption of UK members of parliament: cross-sectional survey.
in BMJ open
Stoll N
(2022)
Mental health and mental well-being of Black students at UK universities: a review and thematic synthesis.
in BMJ open
Vigo D
(2020)
Burden of Mental, Neurological, Substance Use Disorders and Self-Harm in North America: A Comparative Epidemiology of Canada, Mexico, and the United States.
in Canadian journal of psychiatry. Revue canadienne de psychiatrie
Lagunes-Cordoba E
(2021)
Mental Health Service Users' Perceptions of Stigma, From the General Population and From Mental Health Professionals in Mexico: A Qualitative Study.
in Community mental health journal
| Description | For now the use of technology is proving to be useful in helping heath workers diagnose mental health disorders |
| Exploitation Route | Too early to say |
| Sectors | Communities and Social Services/Policy,Digital/Communication/Information Technologies (including Software),Education,Electronics,Environment,Financial Services, and Management Consultancy,Healthcare,Government, Democracy and Justice,Pharmaceuticals and Medical Biotechnology,Security and Diplomacy |
| Description | Too early to say but the study will impact the increase of the effectiveness of public services and policy, and will enhance quality of life and health. |
| Description | WHO co-ownership of the project |
| Geographic Reach | Multiple continents/international |
| Policy Influence Type | Contribution to new or Improved professional practice |
| Description | E-MhGAP Intervention guide in Low and middle income countries: proof-of-concept for Impact and Acceptability (Emilia project) |
| Organisation | Transcultural Psychosocial Organization |
| Country | Nepal |
| Sector | Charity/Non Profit |
| PI Contribution | Coordination of research programme |
| Collaborator Contribution | Individual research site coordination and site lead |
| Impact | Current publications are listed in the publication section. Further papers are currently in submission. |
| Start Year | 2018 |
| Description | E-MhGAP Intervention guide in Low and middle income countries: proof-of-concept for Impact and Acceptability (Emilia project) |
| Organisation | University of Ibadan |
| Country | Nigeria |
| Sector | Academic/University |
| PI Contribution | Coordination of research programme |
| Collaborator Contribution | Individual research site coordination and site lead |
| Impact | Current publications are listed in the publication section. Further papers are currently in submission. |
| Start Year | 2018 |
| Description | E-MhGAP Intervention guide in Low and middle income countries: proof-of-concept for Impact and Acceptability (Emilia project) |
| Organisation | World Health Organization (WHO) |
| Country | Global |
| Sector | Public |
| PI Contribution | Coordination of research programme |
| Collaborator Contribution | Individual research site coordination and site lead |
| Impact | Current publications are listed in the publication section. Further papers are currently in submission. |
| Start Year | 2018 |
| Description | Indigo Partnership |
| Organisation | George Institute for Global Health |
| Department | George Institute for Global Health (India) |
| Country | India |
| Sector | Charity/Non Profit |
| PI Contribution | Coordination of research programme |
| Collaborator Contribution | Individual research site coordination and site lead |
| Impact | Current publications are listed in the publication section. Further papers are currently in submission. |
| Start Year | 2019 |
| Description | Indigo Partnership |
| Organisation | George Washington University |
| Country | United States |
| Sector | Academic/University |
| PI Contribution | Coordination of research programme |
| Collaborator Contribution | Individual research site coordination and site lead |
| Impact | Current publications are listed in the publication section. Further papers are currently in submission. |
| Start Year | 2019 |
| Description | Indigo Partnership |
| Organisation | London School of Economics and Political Science (University of London) |
| Country | United Kingdom |
| Sector | Academic/University |
| PI Contribution | Coordination of research programme |
| Collaborator Contribution | Individual research site coordination and site lead |
| Impact | Current publications are listed in the publication section. Further papers are currently in submission. |
| Start Year | 2019 |
| Description | Indigo Partnership |
| Organisation | National Institute of Mental Health and Neurosciences |
| Country | India |
| Sector | Hospitals |
| PI Contribution | Coordination of research programme |
| Collaborator Contribution | Individual research site coordination and site lead |
| Impact | Current publications are listed in the publication section. Further papers are currently in submission. |
| Start Year | 2019 |
| Description | Indigo Partnership |
| Organisation | Peking University Sixth Hospital |
| Country | China |
| Sector | Hospitals |
| PI Contribution | Coordination of research programme |
| Collaborator Contribution | Individual research site coordination and site lead |
| Impact | Current publications are listed in the publication section. Further papers are currently in submission. |
| Start Year | 2019 |
| Description | Indigo Partnership |
| Organisation | Transcultural Psychosocial Organization |
| Country | Nepal |
| Sector | Charity/Non Profit |
| PI Contribution | Coordination of research programme |
| Collaborator Contribution | Individual research site coordination and site lead |
| Impact | Current publications are listed in the publication section. Further papers are currently in submission. |
| Start Year | 2019 |
| Description | Indigo Partnership |
| Organisation | Ulm University Medical Center |
| Country | Germany |
| Sector | Hospitals |
| PI Contribution | Coordination of research programme |
| Collaborator Contribution | Individual research site coordination and site lead |
| Impact | Current publications are listed in the publication section. Further papers are currently in submission. |
| Start Year | 2019 |
| Description | Indigo Partnership |
| Organisation | University of Sussex |
| Department | Brighton and Sussex Medical School |
| Country | United Kingdom |
| Sector | Academic/University |
| PI Contribution | Coordination of research programme |
| Collaborator Contribution | Individual research site coordination and site lead |
| Impact | Current publications are listed in the publication section. Further papers are currently in submission. |
| Start Year | 2019 |
| Description | Indigo Partnership |
| Organisation | World Health Organization (WHO) |
| Country | Global |
| Sector | Public |
| PI Contribution | Coordination of research programme |
| Collaborator Contribution | Individual research site coordination and site lead |
| Impact | Current publications are listed in the publication section. Further papers are currently in submission. |
| Start Year | 2019 |
| Title | WHO mhGAP intervention guide |
| Description | This project will 1. test the feasiblity of the WHO mhGAP Intervention Guide (smartphone version) and 2 develop and test the feasiblity of a remote supervision smartphone app suitable for use by primary care staff in low and middle income countries |
| Type Of Technology | Webtool/Application |
| Year Produced | 2020 |
| Impact | the project is still ongoing at present |
| Title | WHO mhGAP intervention guide |
| Description | This project will 1. test the feasiblity of the WHO mhGAP Intervention Guide (smartphone version) and 2 develop and test the feasiblity of a remote supervision smartphone app suitable for use by primary care staff in low and middle income countries |
| Type Of Technology | Webtool/Application |
| Year Produced | 2020 |
| Impact | the project is still ongoing at present |
| Title | WHO mhGAP intervention guide (phase 2) |
| Description | This project is currently develop and test the feasibility of a remote supervision smartphone app suitable for use by primary care staff in low and middle income countries |
| Type Of Technology | Webtool/Application |
| Year Produced | 2021 |
| Impact | the project is still ongoing at present; the expected impact is to aid healthcare workers in using the mhGAP more accurately and efficiently |
| Description | Development and pilot testing of a mobile phone-based application for primary health care workers in Nepal |
| Form Of Engagement Activity | A formal working group, expert panel or dialogue |
| Part Of Official Scheme? | No |
| Geographic Reach | Local |
| Primary Audience | Policymakers/politicians |
| Results and Impact | The aim of this meeting was to share the progress of Emilia project and engage the local stakeholders in the ongoing project activities |
| Year(s) Of Engagement Activity | 2020 |
| Description | Emilia Program Launching Meeting with Government Stakeholders |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | Regional |
| Primary Audience | Policymakers/politicians |
| Results and Impact | Emilia project launching meeting was conducted among the senior provincial government officers. The aim of this program was to inform senior governmental officials about the Emilia project and make sure that their engaged in the project is crucial. |
| Year(s) Of Engagement Activity | 2020 |
| Description | Implementation and roll-out of the WHO mhGAP and e-mhGAP in Nepal: WHO mhGAP forum-2021 |
| Form Of Engagement Activity | Participation in an activity, workshop or similar |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Professional Practitioners |
| Results and Impact | Vertually presented the development process, content of the mhGAP app, and pilot trial |
| Year(s) Of Engagement Activity | 2021 |