Six mental health care projects in developing countries demonstrate effective, affordable options
- 100,000+ people reached by Grand Challenges Canada's mental health program, 10,000+ treated
- Pakistan 'Family Networks for Kids' project shifts tasks from health workers to relatives, neighbours; creates strong network of new recruits to care for youths with behavioral difficulties
- Kenya's traditional healers, faith healers and community health workers refer 1,600 to clinics, 500 diagnoses result
- Zimbabwe's low-cost 'Friendship Bench' demonstrates powerful impact in reducing depression
Toronto — Based on a successful pilot project in which traditional Kenyan healers and community workers helped identify almost 500 cases of mental illness, Grand Challenges Canada, which is funded by the Government of Canada, today announced a major scale up investment to be matched by partners.
The Kenya initiative is one of six innovations in Africa, Asia and Haiti earning scale-up investments, their pilot projects having proven effective at addressing mental health problems in low-resource countries.
The two other Africa-based projects, in Uganda and Zimbabwe, for the first time integrate treatment of depression into HIV patients' care.
Meanwhile, two Asia-based projects, in Pakistan and Vietnam, will create care for children and youths as well as adults.
And a project in Haiti is providing cost-effective mental health treatment in a land where badly neglected bipolar and other neuropsychiatric disorders constitute 10% of the health burden.
Grants of CDN $4.1 million through Grand Challenges Canada will be more than doubled by the contributions of partners in the six projects, creating a total investment of $8.7 million.
"The Government is proud to support initiatives such as this that will benefit the most vulnerable. By investing in innovation to improve the effectiveness of mental health services in developing countries, Canada is helping to accelerate positive change and find solutions to global development challenges. I strongly believe Canadians can play an important role in making Canada a leader in development innovation," said Canada's Minister of International Development and La Francophonie, the Honourable Marie-Claude Bibeau.
Says Dr. Peter A. Singer, Chief Executive Officer of Grand Challenges Canada: "People with mental illness in the developing world are too often simply ignored or hidden in a bleak darkness rather than helped. It has been a privilege to support these groundbreaking projects since their inception, to see the convincing evidence of their positive impact, and now to help scale up the success of six bold ideas which will improve the health of tens of thousands of people."
Mental health disorders constitute 14% of global disease worldwide. But almost three quarters of this burden occurs in low- and middle-income countries, where a shortage of trained personnel and other resources leave enormous populations with little or no access to mental illness treatment.
Through its Global Mental Health portfolio, Grand Challenges Canada, funded by the Government of Canada, has invested over $39 million to date to develop the Mental Health Innovation Network and funded 70 projects in 26 countries, including 15 large "transition-to-scale" investments. To date, the portfolio of innovations has reached over 100,000 people, and over 10,000 people have accessed treatment. Given the early stage of the innovations, the true impact will occur in the coming years as the most promising of these innovations transition to scale.
"Canada is among the world's leading funders of global mental health innovation," said Dr. Shekhar Saxena, Director of Mental Health and Substance Abuse at the World Health Organization. "Its leadership is helping to turn the tide in the global mental health challenge, with substantial impact in low and middle income countries."
The funding announcement coincides with Bell Let's Talk, a Canadian initiative promoting mental health with national awareness and anti-stigma campaigns.
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Six Scale-Up Global Mental Health Projects
Enlisting African traditional healers, faith healers, and community health workers to help detect mental illness – Africa Mental Health Foundation (Implementation: Kenya)
Innovative model enlists traditional African healers, faith healers, community workers to help detect mental illness; in pilot project, about 1,600 people are referred to clinics; 500 are diagnosed with mental illness
Mental health care model enlists African traditional healers, faith healers and community health workers to help detect mental illness. In pilot, about 1600 people were referred to clinics, 500 were diagnosed with mental illness.
A major new investment will enable the Africa Mental Health Foundation (AMHF) to build its referral networks and expand its integration of mental health into existing public and community health services by training formal (nurses, clinical officers) and informal (traditional healers, faith healers) healthcare providers.
In Kenya, with a high prevalence of mental disorders among its 40 million citizens, there are only about 500 practicing psychiatrists and psychologists. This shortage of professionals, combined with limited drug supplies, government funding and stigma, leaves most of those living with mental illness unable to access much needed diagnosis and treatment.
The AMHF approach breaks down barriers between the formal and informal sectors, encouraging dialogue and training to increase synergy and communication.
Viability of the model was demonstrated in a proof of concept project, funded by Canada's International Development Research Centre, during which the referrals of people suspected of having mental illness rose from nil to 1,593, of which almost one-third (494, or 31%) were clinically diagnosed with a mental health disorder by trained healthcare staff.
The new funding will help AMHF scale up from two to 20 facilities in Makueni County, located between Nairobi and Mombasa. It will engage and educate more than 160 community health workers, traditional and faith healers and anticipates identifying 6,000 more suspected cases of mental illness. If the same rate of success prevails as in the pilot program, almost 2,000 people will be diagnosed within the year.
Project goals also include building awareness and combating the stigma of mental illness within rural communities and, long-term, a community mental health care model that can be scaled up and implemented throughout Kenya.
Scale-up funding includes CDN$660,000 from the Government of Makueni County – a rare commitment from an African government body to a mental health program. The effort is also supported by New York-based Columbia University's Global Mental Health Program.
Dr. Victoria Mutiso, [email protected]
The Friendship Bench – Zimbabwe AIDS Prevention Project, University of Zimbabwe (Implementation: Zimbabwe)
Low-cost 'Friendship Bench' therapy proves effective in pilots at alleviating mental illness symptoms, will extend to 14,000 patients
Friendship Bench lay health workers, known as "Grandmothers."
Low-cost therapy proves effective at alleviating depression, other mental illness symptoms; scale-up funding will extend to reach 14,000 patients
A technique developed and demonstrated in Zimbabwe to be an inexpensive, effective way to alleviate depression and other mental illness symptoms among HIV-AIDS and other patients will expand to reach 14,000 additional people in 2016 thanks to today's new international investment.
In a 2012 study funded by Grand Challenges Canada, the Zimbabwe AIDS Prevention Project assessed the effectiveness of the Friendship Bench in a randomized controlled trial conducted with over 500 individuals with depression enrolled at 24 clinics in the capital city, Harare.
Lay health workers, known as community 'Grandmothers,' deliver cognitive behavioural therapy in a safe, comfortable environment on wooden benches outside on the clinic grounds.
Patients, referred to the benches by clinicians, receive up to six 45-minute counselling sessions, including one home visit and, in some cases, referral to other health or social services or to income-generating activities. Specialist support is available via mobile phones and tablets.
Assessed after 6 months, the prevalence of depression was less than 10% among roughly 250 Friendship Bench participants versus roughly one-third in a control group of similar size. The full study is expected to be published later this year.
A Cloud-based platform developed by the project team serves to integrate training, screening patient referrals and follow-up.
In addition, over 70% of beneficiaries in the recent trial participated in the creation and sale of large, colourful shoulder bags (known as "zee bags"), an activity that plays an important role in rebuilding confidence and an opportunity to earn an income.
Zimbabwe, with 15 million citizens, has just 10 practicing psychiatrists and 15 clinical psychologists.
With help from scaling partners, the low-cost, innovative Friendship Bench program will be introduced at 60 primary health care clinics in Harare and two neighbouring cities.
Based on further results due next year and Zimbabwean Government support, the Friendship Bench program could be made available in every primary care facility nationwide.
Ruth Verhey / Ronald Munjoma +263-4-703-565, [email protected]
Dixon Chibanda, [email protected]
Social, emotional and economic empowerment through Group Support Psychotherapy – Makerere University (Implementation: Uganda)
Training community health workers engaged in HIV/AIDS care to reach and assist the highest number of mental health patients
In Sub-Saharan Africa, one in three HIV patients experience significant depression symptoms, known to interfere with motivation to take anti-retroviral medications.
In Uganda, important gains in improving access to HIV/AIDS care but little has been done to address the mental health needs of persons living with HIV. As well, depression among such patients is compounded by other factors such as war, poverty and low levels of education, especially in post-conflict settings.
To help address the lack of services, Dr. Etheldreda Nakimuli-Mpungu and colleagues developed an intervention that treats depression through social support, which includes teaching positive coping skills and creating income-generating abilities.
With Grand Challenges Canada seed funding, the "Group Support Psychotherapy" approach was evaluated in a trial, the results published in the journal Lancet HIV last April. The group reported that six months after the end of treatment, 85% of GSP participants had recovered from depression, compared to 50% who took part in a control group intervention. Further, Group Support Psychotherapy participants had greater increase in function levels, social support and self-esteem.
With scale-up funding, the team will train 90 professional health workers and 180 lay health workers engaged in HIV/AIDS care in rural areas of three northern Uganda districts to also recognize and deliver Group Support Psychotherapy for depression. This will improve access to a first line treatment for depression and make its delivery more sustainable.
The following outcomes are expected over the year ahead: 70% of targeted depressed individuals will experience improvements in depression symptoms, increased self-esteem, social support and function levels; 50% will be economically productive with increased livelihood assets and fewer disability days; and 20% will experience measurably less poverty.
Scaled up throughout the north and other areas of Uganda with high HIV prevalence, up to 325,000 people could experience Group Support Psychotherapy care and over 65,000 could experience significant improvements in depression and functioning by 2030.
The core project team is comprised of leading academics and researchers from the universities of Makerere and Ottawa, as well as Dr. Sheila Ndyanabangi, the key mental health policy maker at the Ministry of Health in Uganda.
Partner funding of $450,000 will be provided by UK-based charity MQ: Transforming Mental Health, which promotes research to improve the impact of mental health treatment, illuminate causes of mental illnesses, and support the best and most innovative researchers and thought leaders of the future. Dr. Etheldreda Nakimuli-Mpungu is a recent winner of MQ's Fellows Award, one of 11 recipients in the past three years and the first from a low- or middle-income country.
Etheldreda Nakimuli-Mpungu, [email protected]
Neil Balmer, [email protected]
"Frugal Innovations" for promoting mental health among adults and children – Centre for Applied Research in Mental Health and Addictions / Simon Fraser University (Implementation: Vietnam)
Making the most of scarce resources through "frugal innovations": Training community health workers to treat anxiety and depression and providing telephone-based coaching and support to families of children with behavioural difficulties
Making the most of scarce resources: Simon Fraser University-led project trains community health workers to help patients cope with anxiety and depression, and provides telephone-based coaching and support to families of children with behavioural difficulties
Mental health disorders, of which alcohol abuse, depression and anxiety are the most prevalent, constitute one-sixth (16%) of the disease burden in Vietnam, exceeding the global average. The availability of trained mental health professionals, however, falls far below that of other countries.
In a 2011 study, Vietnam ranked last among 144 low- and middle-income countries on the availability of mental health care, with 1.7 psychiatrists and 11.5 psychosocial care providers per 100,000 population.
A project led by the Centre for Applied Research in Mental Health and Addictions (CARMHA) at Simon Fraser University's Faculty of Health Sciences project helps to fill this service gap in two low-cost ways: Training community health workers to treat adults suffering from anxiety and depression, and providing telephone-based coaching and support to families of children with behavioral difficulties.
A two-year pilot study in two provinces of Vietnam successfully demonstrated the approach, screening almost 1,300 people, of which 127 now receive treatment for depression – more than three times the number anticipated – and pre/post treatment evaluations show statistically-significant decreases in symptoms.
Building on that success, the adult depression program will be scaled up and rolled out in 32 communities across nine provinces in Vietnam. It is expected that roughly 4,250 people with depression will access services, of which 1,280 will experience improvements in the next year.
Whereas the pilot project focused solely on adult depression, the scaled-up project will include a child and family-focused component. Materials for a distance coaching model called "Strongest Families" have been adapted and translated for Vietnamese use, and a 25 family pilot study is underway.
The team will evaluate the Strongest Families model in nine provinces, with five coaches providing support to an estimated 740 children and parents over three years.
Elliot Goldner, [email protected]
Centre for Applied Research in Mental Health and Addictions / Simon Fraser University
Creating Family Networks (FaNs) for children with developmental disorders – Human Development Research Foundation (Implementation: Pakistan)
Task-shifting from health workers to relatives, neighbours: Family Networks for Kids (FaNs) creates a powerful network of new recruits to care for youths with developmental disorders
Task-shifting from health workers to relatives, neighbours: In Pakistan, the Family Networks for Kids (FaNs) project creates a powerful web of new recruits to care for youths with developmental disorders
In Pakistan, developmental disorders including intellectual disabilities and autism affect over 7% of children – 13.2 million in total – almost all of them untreated due to discrimination, poor awareness of the medical need among family members and front line health-providers, and the lack of specialist services especially outside of urban centres.
The Human Development Research Foundation (HDRF), one of Pakistan's most active development and health organizations, designed the Family Networks for Kids (FaNs) to help parents recognize and help their children cope with mental illness challenges.
The programs organizes and trains family volunteers – called "champions" – to provide help to their own children and to those within their network of five to seven families.
Champions provide training and care via a tablet-based, Avatar-assisted Cascade Training (ACT) system that contains interactive, intuitive modules with story-telling avatars based on the World Health Organization's (WHO) mental health Gap Action Plan (mhGAP).
Wireless phone-based technology supports the program in many other ways as well. Initially, family members dial into an Interactive Voice Response (IVR) system to answer questions that help identify a child likely to have a developmental disorder, reducing the need to travel to a doctor or to wait for a health worker's visit.
With a CDN$768,000 Grand Challenges Canada grant in 2012, a study of FaNs within a rural population of 30,000 people successfully developed technology-assisted identification, training and intervention-delivery solutions, trained 17 family champions, screened over 2,500 children and identified 70 affected families.
A study, published in the journal Pediatrics, compared the phone system with a house-to-house survey using the same questions and found it successfully identified 92 out of 109 (84.4%) children under 10 years old with developmental disorders. The cost of screening per child: US $7.00 door-to-door vs. $0.07 using the phone system.
After the interventions, the study showed clinically meaningful improvements in participating child global disability scores, understanding and communication, getting around/mobility, self-care, engagement in school and non-school activities, participation in society, and less stigma.
With its transition-to-scale funding, HDRF will roll out the program to train 300 champions and screen more than 27,000 families for developmental disorders, with expectations that 3,000 children and adolescents will be treated and helped to improve functioning with fewer emotional and behavioural problems.
An HDRF partner, Autism Speaks, shares with the World Health Organization an interest in the roll-out of this task-shifting model – training parents and family members rather than lay health workers. HDRF is also collaborating with World Vision Pakistan (WVP) and Pakistan's Federal Ministry of National Health Services (MOH), which will closely follow outcomes to assess the model's feasibility for wider adoption.
Usman Hamdani, [email protected]
Andy Shih, [email protected]
Promoting a community-based mental health model in rural Haiti and building a national scale-up plan – Zanmi Lasante (Implementation: Haiti)
Novel model helps reach those most in need while team helps develop, fund a national mental health plan in Haiti
An epilepsy patient in Haiti with her local healthcare worker. Novel project helps reach those most in need while working to help Haiti develop a national mental health care plan Neuropsychiatric disorders, such as bipolar disorders constitute 10% of the overall disease burden in Haiti but largely go undiagnosed or untreated.
The mental health infrastructure in Haiti consists of a single psychiatric hospital and health centre in Port au Prince – capital of a country with 10.3 million citizens.
Building on experience using community-based approaches to treat diseases such as HIV and tuberculosis, Zanmi Lasante – one of Haiti's largest non-governmental health care providers – developed the "5×5 Model" to help people suffering depression, bipolar disorder, psychosis, epilepsy, as well as child and adolescent disorders.
Mental health services are delivered by professional and lay workers in the existing public health system trained and supervised across four mental health care pathways. The model is being integrated into the services provided at 11 public primary care facilities serving 1.3 million people and co-managed by Zanmi Lasante in collaboration with the Ministère de la Santé Publique et de la Population and the Ministry of Health.
In a three-year proof of concept project, roughly 10,000 individuals received mental health treatment at 11 sites – 1,935 with depression, 1,360 with epilepsy and 1,004 with suicidal thoughts. Of these, an estimated one third have already experienced improved clinical outcomes as a result of positive diagnosis and treatment.
During its 15-month transition-to-scale, Zanmi Lasante will refine and strengthen its model, provide refresher mental health care training to 100 staff, and improve monitoring and evaluation and supervision systems. The organization anticipates treating another 3,500 patients.
Another fundamental goal: development of a national mental health plan for Haiti based on the model, assisted by collaborators, including the Pan-American Health Organization.
Eddy Eustache, [email protected]
Giuseppe Raviola, [email protected]
Alexandra Rose, [email protected]
About Grand Challenges Canada
Grand Challenges Canada is dedicated to supporting Bold Ideas with Big Impact in global health. We are funded by the Government of Canada and we support innovators in low- and middle-income countries and Canada. The bold ideas we support integrate science and technology, social and business innovation to find sustainable solutions to health challenges – we call this Integrated Innovation. Grand Challenges Canada focuses on innovator-defined challenges through its Stars in Global Health program and on targeted challenges in its Saving Lives at Birth, Saving Brains and Global Mental Health programs. Grand Challenges Canada works closely with Canada's International Development Research Centre (IDRC), the Canadian Institutes of Health Research (CIHR) andGlobal Affairs Canada to catalyze scale, sustainability and impact. We have a determined focus on results, and on saving and improving lives. http://www.grandchallenges.ca