Trimbos in India en Moldavië
Trimbos is known as a research institute focusing on mental health and addiction. Perhaps less well-known are the activities of Trimbos in supporting local governments in low and middle-income countries, as well as countries in transition, in the development and implementation of interventions that aim to strengthen their mental health care system. To illustrate our work, we provide two examples of implementation efforts in India and Moldova.
The Atmiyata Project in India
Approximately 6% of India’s population of 1.2 billion people have a common mental disorder (depression or anxiety). Even with ambitious plans for training future generations of mental health specialists, there will not be sufficient numbers of specialists to address population needs. In addition, there is a stark difference between the availability of mental health professionals in rural areas, as much of the mental health workforce is concreted in urban areas.
In an effort to reduce this shortage of support options in rural areas, we (the Centre for Mental Health Law and Policy, Indian Law Society, with Trimbos Institute as the lead collaborator) developed the Atmiyata intervention in 2013 and implemented it in a rural district of the state of Maharashtra. The Atmiyata intervention is a community led innovation using informal care providers for the identification, support and referral for persons with common and severe mental disorders. Informal care providers consist of community-based volunteers (Atmiyata Champions and Mitras – meaning friend) that have a desire to contribute to the overall wellbeing in their villages.
The Atmiyata Champions and Mitras are supported in delivering support through a phone-based app which contains locally developed films that can be shown to community members on commonly experienced problems that cause distress. These films encourage community members to identify their own stressors and develop together with the Champion strategies to address issues. In addition, to tackle the financial strife that many community members face, Champions facilitate the steps necessary to secure financial benefits from state or national-level social welfare schemes. Proof-of-concept for these community volunteers was demonstrated, particularly in reducing depressive symptoms and increasing access to social welfare benefits. We subsequently started the scale-up of this model in the state of Gujarat, in close collaboration with the Ministry of Health and Family Welfare of the Government of Gujarat in 2016, with an ambitious goal to reach 1 million people in 3 years.
In addition to the development and the implementation of the intervention, our work addresses important implementation research questions such as how effective community-led interventions are when provided within larger public health systems, at scale, and 2) why such interventions are or aren’t effective. To evaluate the implementation strategy of this intervention, we are using the RE-AIM (Reach, Effectiveness, Adoption, Implementation and Maintenance) as a guiding implementation research framework. The effectiveness element of the framework is assessed through a stepped wedge cluster randomised trial. To look at other domains of implementation, we are carrying out a process evaluation to assess uptake of the intervention among Atmiyata Champions. In addition, a health economic evaluation is being carried out to understand program components that are crucial for decision-makers and health planners to consider for sustaining the intervention in the district, as well as for replication to other parts of the state.
The MENSANA Project in Moldova
Moldova is a low and middle-income country nestled between Ukraine and Romania, where historically mental health was largely institutionalized, with psychiatric hospitals being the main providers of care. The MENSANA project was initialised in 2014 and aims to support the Ministry of Health, Labour, and Social Protection in the implementation of their national mental health program which reforms the entire mental health system.
Over the past few years, the project has supported the creation of a more conducive policy and legislative framework that lends itself to a more progressive, responsive, and rights-based mental health system. It has also set up 4 functional community mental health centres, supported by a set of services (primary care, specialised inpatient care) that all work together in a care pathway for people with mental health problems to get the support they need from health professionals at different levels of the health system. All psychologists and psychiatrists working in hospital and community-based settings have been trained through the project. Importantly, admissions to psychiatric hospitals have decreased from the 4 pilot districts, and home treatment provided to prevent acute crises has increased. Work practices have changed, in that mental health professionals and family doctors operating at the primary care level work more collaboratively. Community members, local opinion makers, and regional and national decision-makers are more aware of the reform and aware of the need for stronger and continued cooperation between the health and social sector.
To evaluate the results achieved, a process evaluation assesses facilitating and challenging factors for change in the service delivery model in the country from different stakeholder perspectives. This is complemented by a cost-effectiveness analysis of the new model of care as well as a policy analysis. Preliminary results show a number of system-level challenges to implementation the community-based model of care, such as the shortage in the mental health workforce (particularly in rural areas and migration), social determinants of health that adversely affect mental health outcomes (poverty, social isolation, unemployment), and stigma and discrimination. For more information about MENSANA, please visit www.trimbos.md.
Our implementation journey will continue in India and Moldova, in distilling lessons learned from the implementation process and using them in instigating plans to continue to improve population-level mental health. Interested in our other international activities? Please visit www.trimbos.org.
Laura Shields-Zeeman & Marjonneke de Vetten
For more information please contact: [email protected]