Combining mHealth and nurse-delivered care to improve the outcomes of people with seriousmental illness in West Africa

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PROJECT SUMMARY Worldwide, serious mental illnesses (SMI) such as schizophrenia or bipolar disorder are major causes of impairment and disability. In West Africa, the hardships of SMI are compounded by pervasive societal stigma, scarce treatment options, systematic exclusion, neglect, and abuse. People with SMI in West Africa describe the experience as akin to “receiving a death sentence.” West African mental healthcare systems have severely constrained resources that contribute to a large treatment gap. Most people with SMI receive services from traditional and faith healers who do not provide high quality care. Healers often use practices such as chaining, seclusion, and forced fasting that often worsen the negative impacts of SMI. Given the shortage of skilled mental health providers and the prevalence of healers, coupled with the established infrastructure healers have in place (e.g., referral networks, “prayer camps”, community ties) global health leaders have argued that healers and prayer camp settings may be leveraged as conduits for treatment, provided they receive appropriate training and support to provide higher quality care. Our multinational research team has developed M&M: a dual-pronged intervention package comprised of a mobile health program designed to train healers to deliver evidence-based psychosocial interventions while maintaining safety and patient dignity in practice (M- Healer) combined with pharmacotherapy delivered directly to the patients at their prayer camps via visiting nurse (Mobile Nurse). We have successfully completed usability, acceptability, feasibility and preliminary clinical testing of the modular elements of the intervention at prayer camps, with very promising results. We now propose to evaluate the effectiveness of the integrated M&M intervention in a fully-powered trial and share it widely through a new West African Digital Mental Health Alliance (WADMA), a mission centered network designed to jumpstart digital mental health research and cross institutional collaboration though grant funded studies, education, and integration of digital mental health tools in clinical practice. We aim to: 1. Evaluate the effectiveness of the M&M intervention using a stepped-wedge cluster randomized trial design; 2. Examine mediators and moderators of M&M intervention effects; and 3. Use qualitative methods to inform M&M intervention optimization and future implementation. Although focused on West Africa, the dual-pronged model we are testing to address quality of care needs, the outcomes we will measure, and the methodological lessons we will learn will all have translational implications for development and implementation of integrated technology-assisted treatment support packages for paraprofessionals caring for people with SMI in the United States.