Title

Implementation strategy in collaboration with people with lived experience of mental illness to reduce stigma among primary care providers in Nepal (RESHAPE): protocol for a type 3 hybrid implementation effectiveness cluster randomized controlled trial

Authors

Brandon A. Kohrt, Division of Global Mental Health, Department of Psychiatry, George Washington University, Washington D.C., USA. bkohrt@gwu.edu.
Elizabeth L. Turner, Department of Biostatistics and Bioinformatics and Duke Global Health Institute, Duke University, Durham, NC, USA.
Dristy Gurung, Transcultural Psychosocial Organization Nepal (TPO Nepal), Pokhara, Nepal.
Xueqi Wang, Department of Biostatistics and Bioinformatics and Duke Global Health Institute, Duke University, Durham, NC, USA.
Mani Neupane, Transcultural Psychosocial Organization Nepal (TPO Nepal), Pokhara, Nepal.
Nagendra P. Luitel, Transcultural Psychosocial Organization Nepal (TPO Nepal), Kathmandu, Nepal.
Muralikrishnan R. Kartha, King's Health Economics, IOPPN, King's College London, London, UK.
Anubhuti Poudyal, Department of Sociomedical Sciences, Columbia University, New York, NY, USA.
Ritika Singh, Division of Global Mental Health, Department of Psychiatry, George Washington University, Washington, D.C., 20036, USA.
Sauharda Rai, Jackson School of International Studies and Department of Global Health, University of Washington, Seattle, USA.
Phanindra Prasad Baral, Non-communicable Disease and Mental Health Section, Epidemiology and Disease Control Division (EDCD), Department of Health Services (DoHS), Ministry of Health and Population (MoHP), Kathmandu, Nepal.
Sabrina McCutchan, Duke Global Health Institute, Duke University, Durham, NC, USA.
Petra C. Gronholm, Centre for Global Mental Health and Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
Charlotte Hanlon, Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
Heidi Lempp, Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK.
Crick Lund, Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
Graham Thornicroft, Centre for Global Mental Health and Centre for Implementation Science, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
Kamal Gautam, Transcultural Psychosocial Organization Nepal (TPO Nepal), Kathmandu, Nepal.
Mark J. Jordans, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, Center for Global Mental Health, King's College London, London, UK.

Document Type

Journal Article

Publication Date

6-16-2022

Journal

Implementation science : IS

Volume

17

Issue

1

DOI

10.1186/s13012-022-01202-x

Keywords

Cost-effectiveness; Depression; Developing countries; Primary care; Randomized controlled trial; Stigma; Training

Abstract

BACKGROUND: There are increasing efforts for the integration of mental health services into primary care settings in low- and middle-income countries. However, commonly used approaches to train primary care providers (PCPs) may not achieve the expected outcomes for improved service delivery, as evidenced by low detection rates of mental illnesses after training. One contributor to this shortcoming is the stigma among PCPs. Implementation strategies for training PCPs that reduce stigma have the potential to improve the quality of services. DESIGN: In Nepal, a type 3 hybrid implementation-effectiveness cluster randomized controlled trial will evaluate the implementation-as-usual training for PCPs compared to an alternative implementation strategy to train PCPs, entitled Reducing Stigma among Healthcare Providers (RESHAPE). In implementation-as-usual, PCPs are trained on the World Health Organization Mental Health Gap Action Program Intervention Guide (mhGAP-IG) with trainings conducted by mental health specialists. In RESHAPE, mhGAP-IG training includes the added component of facilitation by people with lived experience of mental illness (PWLE) and their caregivers using PhotoVoice, as well as aspirational figures. The duration of PCP training is the same in both arms. Co-primary outcomes of the study are stigma among PCPs, as measured with the Social Distance Scale at 6 months post-training, and reach, a domain from the RE-AIM implementation science framework. Reach is operationalized as the accuracy of detection of mental illness in primary care facilities and will be determined by psychiatrists at 3 months after PCPs diagnose the patients. Stigma will be evaluated as a mediator of reach. Cost-effectiveness and other RE-AIM outcomes will be assessed. Twenty-four municipalities, the unit of clustering, will be randomized to either mhGAP-IG implementation-as-usual or RESHAPE arms, with approximately 76 health facilities and 216 PCPs divided equally between arms. An estimated 1100 patients will be enrolled for the evaluation of accurate diagnosis of depression, generalized anxiety disorder, psychosis, or alcohol use disorder. Masking will include PCPs, patients, and psychiatrists. DISCUSSION: This study will advance the knowledge of stigma reduction for training PCPs in partnership with PWLE. This collaborative approach to training has the potential to improve diagnostic competencies. If successful, this implementation strategy could be scaled up throughout low-resource settings to reduce the global treatment gap for mental illness. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04282915 . Date of registration: February 25, 2020.

Department

Psychiatry and Behavioral Sciences

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