S-MhINT: Southern African Research Consortium for Mental health INTegration

Outline:

The Southern African Research Consortium for Mental health INTegration (S-MhINT) is a NIH funded research and capacity-building consortium in Southern Africa that aims to use implementation science to strengthen regional mental health integration into primary health, antenatal, and chronic care platforms in under-resourced areas of eastern South Africa, central Mozambique and southern Tanzania.

The S-MhINT is made up of three core components:

Administrative Core aims to establish and engage a trans-disciplinary research consortium of academics, government representatives and non-governmental organizations in South Africa, Mozambique and Tanzania to address the burden of common mental disorders in primary health care settings. The Administrative Core (AC) manages all operations including developing and maintaining monitoring systems for all S-MhINT activities and milestones, and a process evaluation of the partnership.

The Scale-Up Study aims to examine multi-level influences on the uptake, implementation, effectiveness and sustainability of an existing scale-up of an integrated mental health package for chronic disorders project (MhINT) at primary health care level in South Africa. The study is currently based in the Newcastle District of Amajuba. The Scale-Up Study is the primary research focus of the S-MhINT Project.

Capacity Building aims to build implementation science and dissemination research capacity in South Africa, Mozambique and Tanzania, recruiting service providers, managers and policy makers as trainees, providing real-world opportunities, mentorship and necessary knowledge to conduct optimal scale-up of evidence-based integrated mental health care.

Progress:

  • The S-MhINT has received UKZN ethical approval and DoH approval has been received from KZN DoH.
  • The start-up meeting with co-investigators took place on 6 – 7 December 2017.

Activities: In Year 1 and Year 2 we have strived to develop and maintain the infrastructure of S-MhINT to facilitate a collaborative, multi-component approach for building implementation research capacity.

Administrative Core:

Year 1:
Appropriate staff (Project Director, Data Manager, Fieldwork Supervisor and Research Assistants) have been hired in the Scale-Up study and IRB approval has been obtained from the Biomedical Research Ethics Committee (BF190/17, received 2 May 2017) at UKZN as well as the South African Department of Health. Recertification of the IRB Approval was also received in April 2018. Ethics approval will be sought once the capacity building trainees have developed their proposals.

Start-Up Meeting: A 4-day SMhINT Start-Up meeting took place in Durban, South Africa (4th -7th December). The meeting provided an excellent opportunity for all the partners from the different countries to meet and learn from each other. The meeting was particularly useful for partner countries to get an overview of our work in South Africa and how research activities can link to the SMhINT project. It was also valuable to learn about our partner country needs around Capacity Development. The meeting created a platform for the DoH officials from the different countries to learn and collaborate with each other.

Year 2:
The Admin-Core has continued to provide executive coordination of the overall project to ensure operations are on track and to deal with complex issues as they arise. The AC has also to date ensured that SMhINT resources facilitate rigorous implementation procedures and methods. The AC has been responsible for managing finances and communication as well as operational issues across research and capacity building activities.

A steering committee meeting is held monthly and comprises of each component (Scale-Up, Capacity Building, Admin Core Executive). The steering committee meetings are important as they provide oversight of the work of the scale-up study as well as capacity building oversight and strategic planning. The SMhINT infrastructure has also allowed for the collaboration of international implementation science experts on the development and the support of the Scale-up study.

A 3-day annual meeting took place in Beira, Mozambique (24-27 September 2018). The meeting was opened by a Mozambican Ministry of Health representative who expressed the ministries support of the SMhINT project. The meeting provided an excellent platform to report on progress to date in all the components and to discuss the way forward in terms of the Scale-Up Study and the Capacity Building Component. The collaboration of implementation science experts within the team was extremely valuable in discussing complex real world challenges and mapping the way forward for the next 6 months. The meeting also provided the opportunity for the SMhINT team to meet the Mozambican Capacity Building Trainees. The Capacity Building Trainees gave a short presentation of their work and research interests. The first Capacity Building Trainee workshop was held on the 4th day of the meeting and was led by the Mozambican team.

The AC directors (Petersen, Rao and Bhana) have been participating in the NIMH quarterly Inter-Hub meetings. The three AC Directors will also be attending the Annual Scale-Up Hubs Meeting next week from 27-30 November 2018 in New Delhi, India.
At the annual meeting in Beira the need for a SMhINT project website was raised. We have since been developing the website and it will be live by June 2019. We have also developed a publication policy to keep track of project publications and a project logframe to guide investigators in keeping track deliverables.

We are currently planning our Annual Meeting which will take place in Tanzania on the 21-23 October 2019. The meeting is a platform for sharing learnings and innovations across the three countries and to plan the way forward for Year 3. We will also meet the Tanzanian Capacity Building Trainees who will have the opportunity of presenting their protocols on day 3 of the meeting.

Scale-Up:

Year 1:
Several activities were completed in Year 1 of the project.

Facility engagement: The Start-Up meeting in December was key to engaging with Department of Health provincial managers and this allowed for successful gate keeper entry at a district and primary health care facility level. The MhINT programme has also been running in one health district for the past 6 months and currently facilitating development in a second health district. Ten fieldworkers were also hired and trained.
Several activities under Aim One of the Scale-Up component have been completed: Primary data collection: Cohort recruitment and data collection is on track and started in April 2017. The electronic data platform has been established. Qualitative data collection: The costing data collection is running concurrently with the cohort data collection. Secondary data collection focused RE-AIM indicators are being closely tracked in implementing facilities.

Year 2:
Primary data collection: Baseline recruitment of patients began on 10 April 2018 and was completed on 30 September 2018. Follow up data collection has been completed in Site 1 (3 month follow up rate of 74, 5% and 9 month follow-up rate of 67%).

Other data elements of the RE-AIM framework have been regularly collected and all data for the first case study evaluation of the scaled-up integrated care model in one sub-district will be completed by the end of September 2019 and CFIR interviews by December 2019. Sixty eight professional nurses were interviewed using a quantitative nurse tool which includes The Organizational Readiness for Implementing Change (ORIC) measure and the Mental Illness: Clinicians’ Attitudes (MICA) scale. The costing data collection is running concurrently with the cohort data collection and a time-motion study was conducted in September 2018.

Following the continuous quality improvement process that we have engaged with to strengthen the system to enable integrated care, we were requested by the KwaZulu-Natal provincial Department of Health to add a community layer to the package as well as a facility-based screening tool (The Brief Mental Health (BMH) screening tool that we validated in 2018) to strengthen demand for services. We have thus been working on the following:

i) A Community Mental Health Education and Detection (CMED) tool that will assist the existing ward-based PHC outreach teams (WPHCBOTS) comprised of community health workers (CHWs) to identify chronic care patients with comorbid mental health disorders on their household visits.

ii) Strengthening processes to enable timely follow-up of chronic patients lost to care and patient re-engagement, especially of chronic patients with HIV and/or TB with comorbid CMDs and tracking of health improvement via routine data such as blood pressure in hypertensive patients, viral load suppression rates in HIV patients and sputum conversion rates in TB patients

iii) We will start our second cohort in 2020 where we will assess whether the strengthened MhINT intervention (that incorporates screening at a PHC facility level using the BMH, as well as a community package that comprises strengthened processes for retention in care of chronic patients with comorbid CMDs) as well as other lessons emerging from the first phase of evaluation results in improved uptake and outcomes of the MhINT integration package.

Broader provincial scale-up: The MhINT model for integrated primary mental health care has been adopted by the King Cetswayo district in KwaZulu-Natal and currently being scaled up by the Department of Health in this district.

Capacity Building:

The Capacity Building component has progressed well with all three countries (South Africa, Mozambique, and Tanzania) having recruited their trainees and developed their Capacity Building programme.

In year 2 of this project, we have completed several activities and achieved many objectives as the project progresses. On September 24th-27th, we conducted a 4-day S-MhINT meeting in Beira, Mozambique. During this meeting our Capacity Building Steering Committee (CBSC) met to discuss and develop project timelines, procedures, and policies, with a particular focus on curriculum and training design for the upcoming year. The CBSC continues to conduct monthly meetings to share updates, collaborate on training materials, and discuss project progress and objectives. During the S-MhINT meeting in Beira, the team was also able to attend introduction presentations from the 10 newly-recruited Mozambican trainees.
In total 10 trainees have been recruited from Mozambique, 8 trainees have been recruited from Tanzania, and 16 from South Africa.

Each country has autonomy in developing training curriculum and materials that they feel best suit the unique, context-specific needs of their trainees, mentors, and potential projects. However, we have developed an online eLearning portal to facilitate the sharing of resources and provide access to online courses relevant to implementation science training. The eLearning portal includes access to courses adapted from the University of Washington, including Ethical Conduct and Academic Integrity, Health Information Management and Applied Epidemiology and Implementation Science. We have situated these on a Moodle platform at UKZN. We are in the process of reviewing the content and technical aspects of the courses with our larger team. The courses will be finalised at our annual meeting in October.

Specific updates from each country are as follows:

South Africa: We are working closely with the KZN Department of Health at a provincial and district level to co-create our implementation science curriculum with integration of mental health into primary health care as our central focus. We have enrolled all the district mental health coordinators on the capacity building programme that will use implementation science to assist the coordinators to develop and implement district mental health plans in all the 11 districts of KwaZulu-Natal over the course of the two year programme. This programme has received endorsement from the KwaZulu-Natal Department of Health at the highest level as well as all the district managers of the 11 districts.

The second workshop took place last week in Durban focusing on an introduction to implementation science, qualitative research methods and orientation to SMhINT.

Mozambique: Trainees are working on their protocols and workshops are underway.

Tanzania: Trainees are working on their protocols and workshops are underway. An Implementation Science Module is also being added to the Master of Public Health curriculum. Preparations are underway for the annual meeting in October where the Tanzanian trainees will have an opportunity to present their protocols and meet the SMhINT investigators.

Project News

The Mental Health Integration Programme (MhINT) and the Southern African Research Consortium for Mental health INTegration (S-MhINT) teams, led through the CRH, crated a video which addresses anxieties healthcare workers may face in the wake of COVID-19. Click HERE to read an article published in the UKZNDabaOnline about the video.

Click HERE to visit the CRH’s data-free COVID-19 hub.