A structured approach to integrating mental health services into primary care: development of the Mental Health Scale Up Nigeria intervention (mhSUN).

BACKGROUND: The treatment gap for mental illness in Nigeria, as in other sub-Saharan countries, is estimated to be around 85%. There is need to prioritise mental health care in low and middle income countries by providing a strong body of evidence for effective services, particularly with a view to increasing international and government confidence in investment in scaling up appropriate services. This paper lays out the processes by which a programme to integrate evidence-based mental health care into primary care services in Nigeria was designed, including a research framework to provide evidence from a robust evaluation. METHODS: This paper forms the first step in the overall process evaluation of the mhSUN intervention, where standard research practice indicates that the intervention, and its development, is clearly documented prior to subsequent evaluation. The report covers the period of programme development and evaluation design, and study site and design was chosen to allow generalisability and practical conclusions to be drawn for service development in Nigeria. In order to design an intervention that was informed by evidence and took into account local context and input of stakeholders, a structured process was followed, including: (1) Engagement of relevant stakeholders for information gathering and buy-in; (2) Literature review and gathering of pertinent evidence; (3) Situation analysis at a national and local level; (4) Model development (using Theory of Change); (5) Ongoing consultation, recognising the iterative nature of Theory of Change, and need for ongoing refinement of complex interventions. RESULTS: The different sections of the structured approach resulted in outputs that built the necessary components (literature review, situation analysis) for informing the Theory of Change. A Theory of Change map is presented, which includes transparent documentation of the assumptions and logic behind the activities to drive the desired change. In addition, it documents the indicators necessary to measure fidelity and draw conclusions as to hypothesised effects of different mechanisms of action in subsequent evaluation. CONCLUSION: In addition to the details of ensuring robust evaluation design, there are a number of considerations that are particular to the context that must be taken into account in programme development, including the relationships between ultimate beneficiaries, implementers, host government and institutions, donors, and programme evaluators. Structured methods from existing frameworks can be drawn upon to use and collate relevant information to maximise the local applicability of a generic evidence base. Theory of Change, with its documented assumptions can form the basis of subsequent evaluation and iterative programme refinement, contributing to a more scientifically valid means of developing mental health programmes for scale up.

Mental health care in Anglophone West Africa.

This column describes the current state of resources and practice in mental health care in the Anglophone countries of West Africa: the Gambia, Sierra Leone, Ghana, Nigeria, and Liberia. Information was systematically gathered from the five countries by using a standard framework for country situation analysis. Mental health services, which are in various stages of development, are characterized by inadequate human resources and long policy neglect. Despite the low numbers of specialists, the region has made important contributions to community service development and global mental health research. Challenges include manpower development, policy and legislation updates, and increased attention to policy and budget. Although mental health service is still grossly inadequate in the context of human and material constraints, there are slowly evolving signs of positive modernization and service development.

The Mental Health Leadership and Advocacy Program (mhLAP): a pioneering response to the neglect of mental health in Anglophone West Africa.

Developing countries in Africa and other regions share a similar profile of insufficient human resources for mental health, poor funding, a high unmet need for services and a low official prioritisation of mental health. This situation is worsened by misconceptions about the causes of mental disorders, stigma and discrimination that frequently result in harmful practices against persons with mental illness. Previous explorations of the required response to these challenges have identified the need for strong leadership and consistent advocacy as potential drivers of the desired change. The Mental Health Leadership and Advocacy Program (mhLAP) is a project that aims to provide and enhance the acquisition of skills in mental health leadership, service development, advocacy and policy planning and to build partnerships for action. Launched in 2010 to serve the Anglophone countries of The Gambia, Ghana, Liberia, Nigeria, Sierra Leone, this paper describes the components of the program, the experience gained since its initiation, and the achievements made during the three years of its implementation. These achievements include: 1) the annual training in mental health leadership and advocacy which has graduated 96 participants from 9 different African countries and 2) the establishment of a broad coalition of service user groups, non-governmental organizations, media practitioners and mental health professionals in each participating country to implement concerted mental health advocacy efforts that are focused on country-specific priorities.