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

INTRODUCTION: To address the know-do gap in the integration of mental health care into primary care in resource-limited settings, a multi-faceted implementation program initially designed to integrate HIV/AIDS care into primary care was adapted for severe mental disorders and epilepsy in Burera Dist...

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Autores principales: Smith, Stephanie L., Franke, Molly F., Rusangwa, Christian, Mukasakindi, Hildegarde, Nyirandagijimana, Beatha, Bienvenu, Robert, Uwimana, Eugenie, Uwamaliya, Clemence, Ndikubwimana, Jean Sauveur, Dorcas, Sifa, Mpunga, Tharcisse, Misago, C. Nancy, Iyamuremye, Jean Damascene, Dusabeyezu, Jeanne d’Arc, Mohand, Achour A., Atwood, Sidney, Osrow, Robyn A., Aldis, Rajen, Daimyo, Shinichi, Rose, Alexandra, Coleman, Sarah, Manzi, Anatole, Kayiteshonga, Yvonne, Raviola, Giuseppe J.
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Public Library of Science 2020
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7035003/
https://www.ncbi.nlm.nih.gov/pubmed/32084663
http://dx.doi.org/10.1371/journal.pone.0228854
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author Smith, Stephanie L.
Franke, Molly F.
Rusangwa, Christian
Mukasakindi, Hildegarde
Nyirandagijimana, Beatha
Bienvenu, Robert
Uwimana, Eugenie
Uwamaliya, Clemence
Ndikubwimana, Jean Sauveur
Dorcas, Sifa
Mpunga, Tharcisse
Misago, C. Nancy
Iyamuremye, Jean Damascene
Dusabeyezu, Jeanne d’Arc
Mohand, Achour A.
Atwood, Sidney
Osrow, Robyn A.
Aldis, Rajen
Daimyo, Shinichi
Rose, Alexandra
Coleman, Sarah
Manzi, Anatole
Kayiteshonga, Yvonne
Raviola, Giuseppe J.
author_facet Smith, Stephanie L.
Franke, Molly F.
Rusangwa, Christian
Mukasakindi, Hildegarde
Nyirandagijimana, Beatha
Bienvenu, Robert
Uwimana, Eugenie
Uwamaliya, Clemence
Ndikubwimana, Jean Sauveur
Dorcas, Sifa
Mpunga, Tharcisse
Misago, C. Nancy
Iyamuremye, Jean Damascene
Dusabeyezu, Jeanne d’Arc
Mohand, Achour A.
Atwood, Sidney
Osrow, Robyn A.
Aldis, Rajen
Daimyo, Shinichi
Rose, Alexandra
Coleman, Sarah
Manzi, Anatole
Kayiteshonga, Yvonne
Raviola, Giuseppe J.
author_sort Smith, Stephanie L.
collection PubMed
description INTRODUCTION: To address the know-do gap in the integration of mental health care into primary care in resource-limited settings, a multi-faceted implementation program initially designed to integrate HIV/AIDS care into primary care was adapted for severe mental disorders and epilepsy in Burera District, Rwanda. The Mentoring and Enhanced Supervision at Health Centers (MESH MH) program supported primary care-delivered mental health service delivery scale-up from 6 to 19 government-run health centers over two years. This quasi-experimental study assessed implementation reach, fidelity, and clinical outcomes at health centers supported by MESH MH during the scale up period. METHODS: MESH MH consisted of four strategies to ensure the delivery of the priority care packages at health centers: training; supervision and mentorship; audit and feedback; and systems-based quality improvement (QI). Implementation reach (service use) across the 19 health centers supported by MESH MH during the two year scale-up period was described using routine service data. Implementation fidelity was measured at four select health centers by comparing total clinical supervisory visits and checklists to target goals, and by tracking clinical observation checklist item completion rates over a nine month period. A prospective before and after evaluation measured clinical outcomes in consecutive adults presenting to four select health centers over a nine month period. Primary outcome assessments at baseline, 2 and 6 months included symptoms and functioning, measured by the General Health Questionnaire (GHQ-12) and the World Health Organization Disability Assessment Scale (WHO-DAS Brief), respectively. Secondary outcome assessments included engagement in income generating work and caregiver burden using a quantitative scale adapted to context. RESULTS: A total of 2239 mental health service users completed 15,744 visits during the scale up period. MESH MH facilitated 70% and 76% of supervisory visit and clinical checklist utilization target goals, respectively. Checklist item completion rates significantly improved overall, and for three of five checklist item subgroups examined. 121 of 146 consecutive service users completed outcome measurements six months after entry into care. Scores improved significantly over six months on both the GHQ-12, with median score improving from 26 to 10 (mean within-person change 12.5 [95% CI: 10.9–14.0] p< 0.0001), and the WHO-DAS Brief, with median score improving from 26.5 to 7 (mean within-person change 16.9 [95% CI: 14.9–18.8] p< 0.0001). Over the same period, the percentage of surveyed service users reporting an inability to work decreased significantly (51% to 6% (p < 0.001)), and the proportion of households reporting that a caregiver had left income-generating work decreased significantly (41% to 4% (p < 0.001)). CONCLUSION: MESH MH was associated with high service use, improvements in mental health care delivery by primary care nurses, and significant improvements in clinical symptoms and functional disability of service users receiving care at health centers supported by the program. Multifaceted implementation programs such as MESH MH can reduce the evidence to practice gap for mental health care delivery by nonspecialists in resource-limited settings. The primary limitation of this study is the lack of a control condition, consistent with the implementation science approach of the study. STUDY REGISTRATION: ISRCTN #37231.
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spelling pubmed-70350032020-02-28 Outcomes of a primary care mental health implementation program in rural Rwanda: A quasi-experimental implementation-effectiveness study Smith, Stephanie L. Franke, Molly F. Rusangwa, Christian Mukasakindi, Hildegarde Nyirandagijimana, Beatha Bienvenu, Robert Uwimana, Eugenie Uwamaliya, Clemence Ndikubwimana, Jean Sauveur Dorcas, Sifa Mpunga, Tharcisse Misago, C. Nancy Iyamuremye, Jean Damascene Dusabeyezu, Jeanne d’Arc Mohand, Achour A. Atwood, Sidney Osrow, Robyn A. Aldis, Rajen Daimyo, Shinichi Rose, Alexandra Coleman, Sarah Manzi, Anatole Kayiteshonga, Yvonne Raviola, Giuseppe J. PLoS One Research Article INTRODUCTION: To address the know-do gap in the integration of mental health care into primary care in resource-limited settings, a multi-faceted implementation program initially designed to integrate HIV/AIDS care into primary care was adapted for severe mental disorders and epilepsy in Burera District, Rwanda. The Mentoring and Enhanced Supervision at Health Centers (MESH MH) program supported primary care-delivered mental health service delivery scale-up from 6 to 19 government-run health centers over two years. This quasi-experimental study assessed implementation reach, fidelity, and clinical outcomes at health centers supported by MESH MH during the scale up period. METHODS: MESH MH consisted of four strategies to ensure the delivery of the priority care packages at health centers: training; supervision and mentorship; audit and feedback; and systems-based quality improvement (QI). Implementation reach (service use) across the 19 health centers supported by MESH MH during the two year scale-up period was described using routine service data. Implementation fidelity was measured at four select health centers by comparing total clinical supervisory visits and checklists to target goals, and by tracking clinical observation checklist item completion rates over a nine month period. A prospective before and after evaluation measured clinical outcomes in consecutive adults presenting to four select health centers over a nine month period. Primary outcome assessments at baseline, 2 and 6 months included symptoms and functioning, measured by the General Health Questionnaire (GHQ-12) and the World Health Organization Disability Assessment Scale (WHO-DAS Brief), respectively. Secondary outcome assessments included engagement in income generating work and caregiver burden using a quantitative scale adapted to context. RESULTS: A total of 2239 mental health service users completed 15,744 visits during the scale up period. MESH MH facilitated 70% and 76% of supervisory visit and clinical checklist utilization target goals, respectively. Checklist item completion rates significantly improved overall, and for three of five checklist item subgroups examined. 121 of 146 consecutive service users completed outcome measurements six months after entry into care. Scores improved significantly over six months on both the GHQ-12, with median score improving from 26 to 10 (mean within-person change 12.5 [95% CI: 10.9–14.0] p< 0.0001), and the WHO-DAS Brief, with median score improving from 26.5 to 7 (mean within-person change 16.9 [95% CI: 14.9–18.8] p< 0.0001). Over the same period, the percentage of surveyed service users reporting an inability to work decreased significantly (51% to 6% (p < 0.001)), and the proportion of households reporting that a caregiver had left income-generating work decreased significantly (41% to 4% (p < 0.001)). CONCLUSION: MESH MH was associated with high service use, improvements in mental health care delivery by primary care nurses, and significant improvements in clinical symptoms and functional disability of service users receiving care at health centers supported by the program. Multifaceted implementation programs such as MESH MH can reduce the evidence to practice gap for mental health care delivery by nonspecialists in resource-limited settings. The primary limitation of this study is the lack of a control condition, consistent with the implementation science approach of the study. STUDY REGISTRATION: ISRCTN #37231. Public Library of Science 2020-02-21 /pmc/articles/PMC7035003/ /pubmed/32084663 http://dx.doi.org/10.1371/journal.pone.0228854 Text en © 2020 Smith et al http://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/) , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
spellingShingle Research Article
Smith, Stephanie L.
Franke, Molly F.
Rusangwa, Christian
Mukasakindi, Hildegarde
Nyirandagijimana, Beatha
Bienvenu, Robert
Uwimana, Eugenie
Uwamaliya, Clemence
Ndikubwimana, Jean Sauveur
Dorcas, Sifa
Mpunga, Tharcisse
Misago, C. Nancy
Iyamuremye, Jean Damascene
Dusabeyezu, Jeanne d’Arc
Mohand, Achour A.
Atwood, Sidney
Osrow, Robyn A.
Aldis, Rajen
Daimyo, Shinichi
Rose, Alexandra
Coleman, Sarah
Manzi, Anatole
Kayiteshonga, Yvonne
Raviola, Giuseppe J.
Outcomes of a primary care mental health implementation program in rural Rwanda: A quasi-experimental implementation-effectiveness study
title Outcomes of a primary care mental health implementation program in rural Rwanda: A quasi-experimental implementation-effectiveness study
title_full Outcomes of a primary care mental health implementation program in rural Rwanda: A quasi-experimental implementation-effectiveness study
title_fullStr Outcomes of a primary care mental health implementation program in rural Rwanda: A quasi-experimental implementation-effectiveness study
title_full_unstemmed Outcomes of a primary care mental health implementation program in rural Rwanda: A quasi-experimental implementation-effectiveness study
title_short Outcomes of a primary care mental health implementation program in rural Rwanda: A quasi-experimental implementation-effectiveness study
title_sort outcomes of a primary care mental health implementation program in rural rwanda: a quasi-experimental implementation-effectiveness study
topic Research Article
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7035003/
https://www.ncbi.nlm.nih.gov/pubmed/32084663
http://dx.doi.org/10.1371/journal.pone.0228854
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