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PRIDE Hub Project Summary


DR. DOS SANTOS: My name is Palmira Santos. I am a psychologist and co-investigator in the PRIDE hub. I recently obtained my PhD at Federal University of San Paolo, took a Fogarty D43 grant in Mozambique with Drs. Weinberg and Oquendo as multiple principal investigators. Today, with Milton and Tony, I will have the pleasure to start telling you about our PRIDE sub-Saharan Africa hub in Mozambique.

Let me start with the acknowledgments. So many amazing people to thank. I'm so proud of our Mozambique team. What an amazing, dedicated, and fun group to work with and lead public mental health with science, with almost no resources.
We are together.

I will start by summarizing our amazing accomplishments. We validated measures for several mental disorders and suicide risk, developed Digital Fica Bem! or Mental Wellness Tool. Developed digital apps for three evidence-based treatments, developed a severe disorders diagnostic algorithm and psychotropics recommendations. Trained local trainers, psychiatric technicians, primary care providers, community health workers are being trained right now, conducted mixed methods evaluation, received an R01 and submitted another, received collaborative small grants or K awards, published multiple articles, received COVID-19 supplement to bring work to New York City. We are planning scaling up PRIDE in New York State.

Before we describe our scaleup study, let me tell a little of my Mozambique. We are 30 million inhabitants, with about 70 percent living in rural areas. We are the fourth poorest country in the world, with 20 psychiatrists, 140 psychologists, 350 psychiatric technicians. Psychiatric technicians are a task-shifting strategy, started by the Ministry of Health in 1993 with almost no resources. They are charged with psychiatric care for epilepsy and mental disorders in urban mental health clinics at district level. Unfortunately, the rural areas don't have access to mental health care. This is a reality that PRIDE in partnership with Ministry of Health is changing. Separately, our collaboration is also changing our local expertise by graduating PhDs in mental health.

DR. WAINBERG: Hi, everyone. I'm Milton Wainberg. Together with Maria Oquendo I'm a multiple PI of our wonderful PRIDE hub. Let's talk about the scaleup component. The main aim is to determine the most effective delivery pathway in terms of implementation outcomes, service level outcomes, and patient level outcomes. We are running a cluster randomized trial. The first 12 months is implementation, where we provide the training and certification of all the staff participating in each of the pathways, and the following 12 months, it's for competency and sustainability of the pathway delivery. We also are conducting a rigorous process evaluation mixed methods through the study to identify barriers and facilitators to implementation and gather feedback and next steps from multiple stakeholders.

Unfortunately, two cyclones in 2019 and the COVID-19 pandemic in 2020 have stopped for one period of time our study and about to conduct the following 12 months competency and sustainability pathway delivery.

So what is the research question? Who or which pathway can adopt and provide the necessary patient outcomes while increasing access, implementation outcomes? The three pathways are to determine the following goal, right? Determine best strategy to expand comprehensive for all disorders mental health care, including medications and evidence-based interventions. As you can see, the sample is a very large one. We are working in the province of Nampula where there are about 6 million adults, and we are thinking that we would get 10 to 15 of those screened.

Pathway 1 is usual care at the district level, where psychiatric technicians in urban areas provide care. Pathway 2 is clinic level care in community settings where community health workers screen, refer, people to the clinics where the primary care providers and medicine technicians provide both evidence-based treatments and psychotropics, and arm 3, which is the community and clinic level care. The treatment is split between community health workers who provide evidence-based treatments, and the medication management is done by clinic providers.

The ratio is 1, 2, and 2. We have three districts with clinics, and five districts with clinics in the different pathways, 2 and 3, and the number of families that each community health worker visits per year is the numbers that you see on the right.
So community health workers have to visit at least one time a year every family, and they tend to work by having an informant who they talk to about things and what's happening in the family. Pregnancy, who is having diarrhea, HIV care, TB and malaria, they do it all. Because of that, we met with the director of the community health workers from the country to ask them, ask him, how many questions can the community health workers ask to ascertain mental health disorders? And remember, we're doing all mental disorders.

Well, the answer was three to five. I have to tell you that we managed. We were able to get, with three questions about each household member to the informant, determine who would have any mental disorder, with 73 percent sensitivity. We called that identification by proxy. Then the community health worker meets with that individual, repeats the same three questions, and we have 94 percent sensitivity for any mental disorder, and with nine more questions in step three, we can ascertain if there's acute care need or we can provide evidence-based treatments for suicide risk, severe disorders, alcohol and substance use disorders, and common mental disorders.

All of these both assessments and evidence-based treatments are digitized to guide the providers in doing their work.

Our outcomes include patient, service, and implementation outcomes, and the beauty of using our digital tool is that almost all the outcomes can be ascertained just by using the tool except cost, because it doesn't count the dollars or the (inaudible), but with the effort we can calculate the cost. Interestingly, if we do population-based studies, we will be able to determine the time, incidence, and prevalence.

MR. SULEMAN: I'm Antonio Suleman, co-investigator and coordinator of the scale-up study, and about to present my dissertation to obtain my PhD in San Paolo. This is our tablet. Providers according to their role and arm in the study can use the mental wellness tool, the three evidence-based treatment apps, and/or the medication algorithm. I will now show you the look of just a few frames of the three evidence-based treatment apps.

This is some frames of the SBIRT app. It guides the provider to assess a typical day of drinking and drug use. Then, according to the assessment, guides the provider with next steps and provides education about the potential harms. It then will move to guide the therapist to provide motivational interviewing.

These are again just a few frames of IPC app. After defining the sick role and interpersonal inventory, will allow us to determine the people in the patient's life and how close they are. After, end with a series of questions, one of the interpersonal problem areas becomes the focus of the work.

Finally, here is SPI with psychoeducation about the temporality of the suicidal thoughts and feelings, and the features of the safety plan.

DR. WAINBERG: Now let me tell you the innovations that we have been able to put together. We focus the work always thinking of sustainability. We accomplish that by leveraging existing resources, the research funds only pay for training, not for clinical care. Training of a local cadre of trainers and supervisors that can continue with the work, and the technology that will also stay. This is the first study to provide comprehensive mental health care. We developed the Fica Bem!, the mental wellness tool, this novel, brief, efficient, and valid method of identifying and triaging those in need of care to provide them evidence-based treatments that are all digitized, and which by doing that we enhance fidelity to the evidence-based treatment. We can provide real-time supervision and quality control and creates also a digital clinical chart and electronic medical record.

It's 100 percent task-shifting/sharing and stepped care. It's coordinated by mental health specialists, however. Providers are community health workers and medicine technicians, and the supervisors are psychiatric technicians.

I'm going to move to talk about our work in capacity-building with the PRIDE Seed Teams, where we work with Botswana, Malawi, South Africa, and Zambia. The seed teams are committed to working together and included in each country junior researchers, policymakers, trainer-of-trainers, and senior- and mid-level faculty. The mentors were from diverse institutions working in the different countries. Each designed and is implementing a mental health implementation science pilot project in their country, evaluating screening and linkage to care in diverse settings.

In 2018 and 2019, we had a yearly in-person training where we did evidence-based treatment, implementation science courses, and also gathered the teams to provide, to figure out developing their pilot work and to work in between them to help each other in improving those pilot designs. We also had a one-day conference.
Unfortunately, the COVID-19 pandemic did not allow us to continue with this last element, and for a while interrupted the implementation that now is getting finished in all the countries.

Thank you so much. Obrigado.