SHARP Hub Project Summary
DR. PENCE: Hello and welcome. My name is Brian Pence, and I'm co-principal investigator of the Sub-Saharan Africa Regional Partnership for Mental Health Capacity Building, or the SHARP project, funded by NIMH's Center for Global Mental Health Research. Our team is very pleased to present today an overview of the SHARP design and activities, including presentation of our aims, the SHARP randomized trial component, the capacity-building component, and a discussion of the interaction of SHARP with the policy environment, before concluding with a summary.
To present an overview of our objectives, I am pleased to hand off to Dr. Jones Masiye, Deputy Director for Noncommunicable Diseases and Mental Health in the Malawi Ministry of Health and SHARP co-principal investigator. Thank you, Jones.
DR. MASIYE: Thank you very much, Brian Pence. So the overall SHARP objective in both Malawi and Tanzania is to make sure that we conduct high-quality research and capacity building activities with the aim that we strengthen the evidence-based mental health implementation schemes, among researchers policymakers, providers. In so doing, we are improving the mental health care and also enhancing the mental health research capacity as well as inform our mental health policy in Malawi.
Let me hand off to Dr. Kazione Kulisewa, who is a SHARP clinical director, and chair of the Department of Psychiatry and Kamuzu University of Health Sciences. Dr. Kulisewa will present the SHARP randomized trial study design. Over to you.
DR. KULISEWA: Thank you, Jones. The study was conducted 10 recruited these clinics that primarily treat hypertension and diabetes. These clinics are based at district or secondary-level hospitals across all three regions of Malawi.
The study aimed to ensure universal depression screening with the Patient Health Questionnaire-9 in all clinic attendees, conduct and manage safety risks, especially social risk assessment, ensure that all patients with moderate to severe depression are treated appropriately with antidepressants, fluoxetine and amitriptyline, using algorithm guided management. Finally, in patients with mild depression, to be treated with a type of psychosocial therapy developed in sub-Saharan Africa known as a friendship bench.
Through one-to-one constrained randomization, the ten clinics were assigned to two implementation strategies. Five clinics received the basic implementation package. This consisted of a local champion who is a clinical provider who received intensive training in depression management and subsequently coordinated trial activities at their facility. Five clinics received enhanced implementation package, which in addition to the local champion had an external supervision team which would visit the clinic, inspect and audit healthcare records, and observe service provision each quarter.
The supervision team subsequently discussed strengths and challenges of the facility with the hospital co-management team and submit a report to the facility for recommendations.
The primary outcomes of interest were the proportion of patients who were screened appropriately for depression and attending the clinic and the proportion of patients who haven't been identified as having depression were initiated and subsequently managed with appropriate treatment or intervention as per protocol at each visit.
The clinical outcomes of interest were the improvement in mental health of participants, as measured by the remission of depressive symptoms. This was objectively measured through the reduction of Patient Health Questionnaire-9 scores, and the improvement in physical health, which is measured by the number of patients whose blood pressures were well controlled.
And now I'll hand over to Chifundo Zimba, the SHARP project director, who will present further details about the unfolding of the SHARP trial.
DR. ZIMBA: Thank you. SHARP started its activities in January 2019 by identifying the champions in all facilities and the counselors that have been working in the trial, and then those champions, they trained their fellow clinicians, then launched the trial midway in 2019, and for two years, we have been providing clinical services, enrolled patient cohort, and collected data in all the facilities. In addition to that, the clinicians received refresher trainings and, as said by my colleague, we also provided external supervision, and throughout the study, we have been conducting qualitative studies starting with the formative phase, early January, and then mid-evaluation, and now we are conducting the end of the trial evaluation.
Just to sum up with all the activities that we have been doing, we have so far trained 30 champions, 493 clinicians, 65 counselors, and the clinicians and the counselors have seen over 90,000 patient visits. We have also provided 35 external supervisions and in the patient cohort, we have enrolled 960, of which we have managed to retain over 90 percent at the 3, 6, and 12 months follow-up. So data analysis by fall 2022.
And now I hand over to Steven Mphonda who is our Malawi Friendship Bench master trainer, the Friendship Bench counseling in Malawi. Over to you, Steve.
MR. MPHONDA: Thanks, Chifundo. For Friendship Bench, we opted for train the trainers model, which enabled us to have a pool of trainers who were always available to do trainings, and supervision across all sites. So the advantages of using peer counselors, counselors were always available. It is cost-effective, and most importantly, the counselors share the same cultural values with clients. So it was easy for them to understand the problems of their clients. However, peer counselors require a lot of attention and ongoing supervision to achieve quality counseling.
COVID-19 affected our Friendship Bench operations. So counselors were asked to stay home. We conducted a series of trainings in how they can do the counseling via phone. So the advantages of phone counseling were that the counseling was done at the client's convenient time, but it also eased the pattern of space as most of the facilities complained that they did not have proper space for counseling. But also some patients comfortable talking on the phone rather than face-to-face.
Looking at the disadvantages, some patients did not have phones. So they missed out on receiving counseling. But also for those with phones, in Malawi especially in the north areas, we have electric issues. So it was difficult to connect to these patients. But also, for the counselors to conduct the sessions, they needed to have airtime. So sometimes there was a bit of delay from the central office to process airtime for the counselors.
And now, I will hand off to Chris Akiba, SHARP project coordinator, who will discuss one of the key findings from our qualitative research. Chris?
MR. AKIBA: Thank you, Steve. We wanted to briefly describe the impact of site leadership on implementation of the trial strategies. So to first describe what we mean by leadership, we're referencing two individuals within each district hospital. They are the district's health officer or DHO. That's the person most responsible for hospital operations. The DHO oversees the district medical officer, or DMO, who is more focused on day-to-day clinic operations.
A mixed methods analysis of one-on-one interviews with clinic staff as well as quantitative indicators from clinical process data revealed leadership engagement impacted fidelity to the trial's strategies. More engaged leaders were able to name all or most of the champion strategy components, tended to be present at the NCD clinic, described equal prioritization of depression and NCD service provision, shared an awareness of implementation barriers, and facilitated efforts to overcome them.
Less engaged leaders tended to lack these qualities, which resulted in NCD clinic environments that were less able to overcome implementation barriers. Those barriers unattended resulted in champions mostly shouldering the burden of depression integration alone and ultimately lowering fidelity to the implementation strategies.
So in terms of capacity building, SHARP aimed to do three things. One, to build implementation science skills and expertise among Malawian and Tanzanian researchers and policymakers in the area of mental health. Two, to ensure policymakers and researchers could effectively apply research findings on evidence-based mental health programs through routine practice, and three, strengthen dialogue between researchers and policymakers, ultimately facilitating efficient and sustainable scaleup of mental health services in Malawi and Tanzania.
SHARP comprises several capacity building components listed on the slide here to work towards those ends, including embedded research experiences, pilot grants focused on providing small amounts of funding to researcher policymaker pairs to carry out implementation studies, training in implementation research grant writing and effective mentorship, as well as didactic short courses, and webinars and journal clubs focused on the intersection of implementation science and mental health.
You can see on the slide here a few indicators related to each of the capacity-building components. Since the start of the study, 50 individuals have completed the implementation science and mental health short courses, another 12 and 8 completed additional coursework more focused on mentorship and grant writing respectively.
Eleven pilot grants have been awarded to researcher policymaker pairs, from which 10 manuscripts have either been published or currently in progress. One of those pilot grantees has gone on to be awarded a Fogarty fellowship. Two other individuals have been awarded diversity supplements; two dissertations have also stemmed from the study. There have also been multiple embedded research opportunities for SHARP team members.
So I will now hand back off to Dr. Jones Masiye, co-PI and director of noncommunicable diseases and mental health services at the Ministry of Health in Malawi.
DR. MASIYE: Thank you very much, Chris. When I was presenting on the overall objective of SHARP, that is to conduct the high-quality research and capacity building activities to inform mental health policy, I'm happy to report that as a country we manage to revise our Mental Health Action Plan in 2020.
When it comes to visibility of mental health in this country, I tell you that it has now increased, but if you compare some five years ago, people are now able to talk about mental health issues, the Ministry, facility, and even at provider levels. Even members of parliament, who are currently sitting, they have been talking about mental health issues, all because of SHARP project.
There's also, if you look at what is happening in the Ministry of Health, mental health issues were not necessarily like a priority. But I'm happy that as Ministry of Health now, we are putting mental health issues in our essential health package. That is being revised in our health (?)(0:11:00) strategic plan 3. In coordination with the technical working groups on mental health, we are now able to coordinate very well with our teams. Plans are under way that we should expand the Friendship Bench counselor and psychosocial counselor cadres.
We have managed to secure some resources that we should do now in develop the suicide prevention strategy. All this because we are now being able to -- the visibility is there, people are able to understand what mental health is all about in this country.
Let me hand over back to Brian Pence, who is the co-principal investigator. Back to you, Brian. Thank you.
DR. PENCE: Thank you very much, Jones and team. Just as a quick summary, the SHARP trial is providing information about the relative value of different implementation strategies for achieving integration of depression services into standard clinical care. Our capacity-building activities have substantially expanded and enhanced the pool of mental health researchers in Malawi and Tanzania, and there has been significant interaction between SHARP and the policy environment, in particular with Malawi's health policy now explicitly including a strategy to integrate mental health care into the management of chronic diseases.
So we'd like to conclude by thanking the many partners in this work and in particular, of course, our funders at the National Institute of Mental Health Center for Global Mental Health Research.
Thank you very much.