Spagnolo J, Champagne F, Leduc N, et al. A program to further integrate mental health into primary care: lessons learned from a pilot trial in . Journal of Global Health Reports. 2019;3:e2019022. doi:10.29392/joghr.3.e2019022

Research Articles A program to further integrate mental health into primary care: lessons learned from a pilot trial in Tunisia † ‡ †† ‡‡ Jessica Spagnolo*, François Champagne , Nicole Leduc , Wahid Melki**, Nesrine Bram , Imen Guesmi , Michèle ††† ‡‡‡ †††† ‡‡‡‡ Rivard***, Saida Bannour , Leila Bouabid , Sana Ben Hadj Hassine Ganzoui****, Ben Mhenni Mongi , Ali Riahi , ††††† ‡‡‡‡‡ †††††† Zeineb Saoud*****, Elhem Zine , Myra Piat , Marc Laporta******, Fatma Charfi Keywords: global health https://doi.org/10.29392/joghr.3.e2019022

Journal of Global Health Reports Vol. 3, 2019

Background Tunisia is a lower-middle-income country located in North Africa. Since the 2010-2011 Revolution, a campaign of civil resistance to protest high levels of youth unemployment, difficult living onditions,c and government corruption, a rise in mental health problems, substance use disorders, and suicide attempts/deaths has been recorded. To address untreated mental health symptoms, a mental health training program was offered to primary care physicians (PCPs) working in the Greater area of Tunisia, a collaboration between members of the Tunisian Ministry of Health, the School of Public Health at the Université de Montréal (Québec, Canada), the World Health Organization (WHO) office in Tunisia, and the Montréal WHO-PAHO Collaborating Center (CC) for Research and Training in Mental Health (Québec, Canada). Program description The training was based on the Mental Health Gap Action Programme (mhGAP) Intervention Guide (IG), a program developed by the WHO to help further develop the mental health competencies of non-specialists working in non-specialized settings. Our team adapted the mhGAP-IG training to the primary care realities of the Greater Tunis area, offered the training program to PCPs between February and April 2016, and evaluated the program using a randomized controlled trial and implementation analysis. Discussion The adaptation, implementation, and evaluation of the training program equipped our team with important lessons learned, supported by evidence in the field of Global Mental Health. First, developing partnerships helped create a feasible program that met the practical and research needs of the country. Second, benefitting from political commitment to mental health facilitated the development of partnerships, the implementation of the training program, and the training’s accompanying evaluation. Third, piloting the program helped identify challenges attributed to the training program and its implementation, the mental health care system, and the research tools, information that may be used to “build back better.” Last, sharing research findings collaboratively helped ensure their validity and encouraged greater knowledge uptake.

* School of Public Health, Institut de recherche en santé publique de l’Université de Montréal (IRSPUM), Québec, Canada † School of Public Health, Institut de recherche en santé publique de l’Université de Montréal (IRSPUM), Québec, Canada ‡ School of Public Health, Université de Montréal, Québec, Canada ** Hôpital Razi, Service de Psychiatrie "D", , Tunisia †† Université de Tunis El-Manar, Tunis, Tunisia ‡‡ Centre médico-scolaire et universitaire de Manouba, Tunisia *** School of Public Health, Université de Montréal, Québec, Canada ††† Centre de soins de base , Manouba, Tunisia ‡‡‡ L’observatoire national des maladies nouvelles et émergentes, Tunis, Tunisia **** URR Ariana, Tunisia †††† Dispensaire Den Den, Manouba, Tunisia ‡‡‡‡ Centre de soins de base Ettadhamen, Ariana, Tunisia ***** Centre de soins de base Boumhel, Direction Régionale de la Santé de , Tunisia ††††† Direction régionale de la santé de Tunis, Centre de soins de base Taib Mhiri, Tunisia ‡‡‡‡‡ Douglas Mental Health University Institute, Montréal, Québec, Canada ****** McGill University, Montréal, Québec, Canada †††††† Université de Tunis El-Manar, Tunis, Tunisia A program to further integrate mental health into primary care: lessons learned from a pilot trial in Tunisia

Conclusion We hope that sharing such lessons learned will aid other countries with similar profiles to develop and/or adapt, implement, and evaluate programs that target untreated mental health symptoms in primary and community-based settings and hence address priorities in Global Mental Health.

Tunisia is a lower-middle-income country 1 located in Center (CC) for Research and Training in Mental Health North Africa. Since the 2010-2011 Revolution, a campaign (Québec, Canada). of civil resistance to protest high levels of youth unem- The mhGAP-IG is a training included under the mhGAP ployment, political repression, government corruption, and umbrella, an evidence-based program that aims to help difficult livingonditions c 2, a rise in mental health prob- build system capacity in LMICs by further developing and lems, substance use disorders, and suicide attempts/deaths integrating mental health into primary care and communi- has been recorded. 3-4 Through “the societal dialogue,” a ty-based settings. 18, 19 The mhGAP-IG training, currently participatory process that aimed to understand the health in its second version 20, is used to help train non-special- concerns of Tunisian citizens and create possible health re- ists working in non-specialized settings in effective men- form tracks that would aid decision-makers in improving tal health care for what the WHO considers priority mental, the health of all, accessing mental health care was recog- neurological, and substance use disorders in LMICs. These nized as a key challenge. 5 Commitment to improving ac- include: depression, psychosis, epilepsy/seizures, develop- cess to needed mental health services was endorsed by the mental disorders, behavioural disorders, dementia, alcohol Tunisian Ministry of Health, particularly by the develop- use disorders, drug use disorders, and self-harm/suicide. 17, ment of the 2013 Tunisian National Strategy for the Promo- 20 The guide is unique. First, the mhGAP-IG was developed tion of Mental Health 6 and the creation of the Committee through a rigorous process. A systematic review of evidence for Mental Health Promotion in 2015. Underlining the ur- available in mental health (e.g. detection, treatment, and gency of this commitment is also Tunisia’s location within management) was conducted, extracting data on interven- the Eastern Mediterranean Region (EMR), one of the World tions that have been proven effective. 21 The mhGAP-IG Health Organization (WHO) regions with the least number presents these interventions (i.e. “what to do”) using easy- of countries to have produced a mental health plan or strat- to-follow diagrams. 17, 20 Second, the mhGAP-IG was devel- egy 7 and with one of the highest rates of mental disorder oped through international participatory processes. Specif- burden compared to the global average. 8 ically, the guide was developed by including expert opinions Despite the Ministry’s commitment to further the transi- from researchers, decision-makers, and healthcare profes- tion from institutional to community-based mental health sionals. 21, 22 Third, the guide is updated every couple of care 6, challenges to mental health care offered in primary years to include the latest evidence on mental health care care settings continue to abound. First, personnel trained in delivery in LMICs specifically, as well as extensive feedback effective mental health care are lacking in number: 1) there from experts who have used its previous versions. 20, 22 are not enough mental health nurses and psychosocial care Last, the mhGAP-IG is accompanied by training and evalua- providers to meet current need 9; and 2) while primary care tion tools to facilitate implementation and research. These physicians (PCPs) see patients consulting for mental health include: facilitator guides, trainee guides, PowerPoint pre- problems in primary care, studies highlight their limited sentations, a contextualization guide to help adapt the competencies in detecting, treating, and managing mental training material and content to local healthcare realities, illness. 6, 10-11 Second, while the Ministry has adopted the knowledge questionnaires, and supervision sheets. 22 2013 Tunisian National Strategy for the Promotion of Men- Since its launch in 2010, the mhGAP-IG training has tal Health, some barriers continue to challenge the treat- been utilized in over a hundred countries. 23, 24 Given that it ment and management of mental health conditions in pri- is a standard training program, the WHO suggests its adap- mary and community-based settings: 1) substance use dis- tation before implementation. The next section of the paper orders are heavily stigmatized in Tunisia 6, 12, 13; 2) restric- gives a brief overview of the training program’s adaptation tions placed upon PCPs related to the prescription of psy- to and implementation in the Greater Tunis area of Tunisia. chotropic medications 14; and 3) the continued allocation of most of the funding for mental health (and, therefore, re- PROGRAM DESCRIPTION sources) to specialized care. 6, 12, 13 Feasible and scalable ways to address the rise of un- Members of the Tunisian Ministry of Health (WM and FC) treated mental health symptoms in primary care settings is chose specific mhGAP-IG training modules 17 considered therefore a priority in Tunisia and in other low- and mid- priorities in the country. These included: general principles dle-income countries (LMICs) facing similar issues. 15-16 of care, depression, psychosis, suicide/self-harm, and sub- Given the involvement of PCPs in mental health care in stance use disorders (i.e. alcohol and drug use). Using the Tunisia, albeit with limited competencies 6, 10-11, a mental mhGAP-IG’s accompanying Adaptation Guide, these mod- health training program was offered to these non-special- ules were adapted to meet the Greater Tunis area’s local ists. Specifically, a training program based on the Mental primary healthcare realities in consultation with members Health Gap Action Programme (mhGAP) Intervention of the Tunisian Ministry of Health, three Tunisian psychia- Guide (IG) (version 1.0) 17, developed by the WHO, was of- trists (“trainers”), and seven physicians responsible for con- fered to PCPs working in the Greater Tunis area of Tunisia tinuing medical education in the Greater Tunis area (“tu- between February and April 2016, and evaluated between tors”). 12 Tutors, well-versed in mental health detection, January 2016 and September 2017. The training program’s treatment, and management, were assigned to help trainees implementation and evaluation were part of a pilot project during and after training. They also assisted trainers during undertaken collaboratively between members of the Min- training sessions. istry of Health in Tunisia, the School of Public Health at The training was conducted over six weeks for a total the Université de Montréal (Québec, Canada), the WHO of- of 19 hours. The first efiv weeks consisted of general lec- fice in Tunisia, and the Montréal WHO-PAHO Collaborating tures, role plays, and group discussions on the chosen mod-

Journal of Global Health Reports 2 A program to further integrate mental health into primary care: lessons learned from a pilot trial in Tunisia ules, totaling 17 hours. The last training session consisted of a two-hour support session animated by trainer-psychia- trists. This session allowed trainees to present challenging mental health cases and perform further role plays. Figure 1 highlights components of the training’s adaptation and im- plementation in the Greater Tunis area of Tunisia. The training program was evaluated in two ways. First, using a randomized controlled trial, our team assessed the training program’s impact on PCPs’ mental health knowl- edge, attitudes, self-efficacy, and self-reported practice (i.e. the importance allocated to mental health care per week and the number of referrals to specialized services done per week). These competencies and practice characteristics are listed as “outputs” in Figure 1. Second, using imple- mentation analysis, our team explored how contextual fac- tors might influence the program’s implementation (i.e. through the adaptation of the training program to local pri- mary healthcare realities of the Greater Tunis area 12) and Figure 1 might interact with the program to influence its expected outcomes. 14 mhGAP-IG implementation model for the Greater Tunis area of Tunisia.

OBJECTIVE ological aspects of research are developed to ensure their In this paper, we share the lessons learned from our pro- feasibility within local contexts. 30 gram that focused on further integrating mental health into Input from members of the Ministry of Health guided primary care in Tunisia by adapting, implementing, and our program. Based on their involvement in the develop- evaluating a training program based on the mhGAP-IG (ver- ment and launch of the 2013 Tunisian National Strategy for sion 1.0) 17 in the Greater Tunis area. Such lessons are sup- the Promotion of Mental Health 6, they highlighted practi- ported by relevant literature in the field of Global Mental cal and research needs to be addressed in collaboration with Health.We hope that our experiences may be useful to oth- our research team, using each stakeholder group’s strengths er LMICs in their quest to address untreated mental health and skills. For example, while mental health training pro- symptoms with similar programs in primary or community- grams have been offered to PCPs in Tunisia, these were not based settings. offered as part of a systematic national program, such as under the leadership of the Committee for Mental Health DISCUSSION Promotion. They were offered, however, under the leader- LESSON 1: DEVELOPING PARTNERSHIPS ship of individual governorate directors. Therefore, it was of interest to include a mental health training program as part Partnerships are relationships between stakeholder groups of a national entity’s responsibilities. 6, 31 The Director of with different skills and expertise but collaboratively work- the Montréal WHO-PAHO CC for Research and Training in ing together to accomplish a goal. 25 In the case of our pro- Mental Health suggested the use of the mhGAP-IG training gram, relationships with the following partners were devel- due to his familiarity with the program, his knowledge of its oped: a research institution (the School of Public Health wide implementation in LMICs 23, 24, and its novel train- at the Université de Montréal), the political realm (the ing aspects, such as role plays, videos, and tools (i.e. guides Tunisian Ministry of Health), the medical field (members of and evaluation components). 22 Besides meeting practical the Tunisian Ministry of Health who closely collaborated, needs in the country, the implementation of the mhGAP-IG through their affiliation with Hôpital Razi and Hôpital Mon- in Tunisia would also serve to expand the program’s limit- gi-Slim, with three Tunisian psychiatrists and seven PCPs in ed evidence in French-speaking nations 32:Tunisia, to our charge of continuing medical education in the Greater Tu- knowledge, is one of the first French-speaking nations to nis area), and international organizations (the WHO office implement and evaluate a mental health training based on in Tunisia and the Montréal WHO-PAHO CC for Training the mhGAP-IG. 23, 33 and Research in Mental Health). Of note, these partnerships In addition, members of the Ministry of Health informed also constitute ties between a high-income country (HIC) our team of the country’s research gaps in the field of men- (i.e. Canada) and an LMIC (i.e. Tunisia). tal health. These included: a portrait of PCPs’ mental health A priority in Global Mental Health is to create partner- competencies in the Greater Tunis area, to help inform ships in order to generate information that establishes “the training material and aspects of health policy; an under- health needs in a given setting, to propose culturally apt standing of contextual barriers preventing the attainment and cost-effective individual and collective interventions, of desired mental health training results, never explored be- to investigate their implementation, and to explore the ob- fore in Tunisia; and a short- and long-term assessment of stacles that prevent recommended strategies from being the impact of an implemented mental health training pro- implemented”. 26 However, the traditional position of re- gram on PCPs’ competencies, also never before assessed. search institutions in HICs—that is, as producers and gate- Our research team sought to address these gaps by devel- keepers of knowledge, following their own research agendas oping specific research objectives with accompanying independently of those of key stakeholders where research methodologies that were deemed feasible by members of is to be conducted 27—fails to address this priority in the the Ministry of Health, all the while building local research field of Global Mental Health. 28 Instead, partnerships must capacity. 6, 29 A randomized controlled trial (RCT) was thus ensure that needs are adequately identified, articulated, suggested by members of the Ministry of Health and the and addressed, specificallyy b stakeholders with vested in- WHO office in Tunisia. It was also supported by the di- terest in them. 29 Partnerships must also ensure method- rectors of the governorates of the Greater Tunis area. This

Journal of Global Health Reports 3 A program to further integrate mental health into primary care: lessons learned from a pilot trial in Tunisia methodology allowed us to invite public-sector PCPs work- ing in the Greater Tunis area to the mental health training and randomize participants into two groups: Group 1 (n=52) and Group 2 (n=60). Both groups participated in the mental health training program at different times, ensuring: 1) that all those interested would receive the training; 2) that the training’s short-term impact on PCPs’ mental health com- petencies would be assessed in comparison to a control measure; and 3) that the training’s long-term impact would be assessed by pooling both groups, increasing statistical power. Offering the training to both groups but at different times also encouraged the interviewing of PCPs who com- pleted the first round of training in orderxplore toe how contextual factors interacted with the implemented pro- Figure 2 gram to influence its expected outcomes. Of the 45 PCPs as- Evaluation of the mhGAP-IG training in the Greater Tunis area of Tunisia. signed to Group 1 who completed the training, 18 partici- pated in individual or group interviews between March and April 2016. 14 In addition, the RCT’s pre-training question- LESSON 2: BENEFITTING FROM POLITICAL COMMITMENT TO MENTAL HEALTH naires, administered to consenting PCPs prior to random- ization (n=112), helped us to paint a portrait of their men- Tunisia is a country politically invested in improving its tal health clinical practice and competencies. 31 Figure 2 il- mental health capacity, specificallyy b furthering the transi- lustrates the adopted methodology to evaluate the training tion from institutional to community-based care. This vest- program in the Greater Tunis area of Tunisia. ed interest has not only been seen in the drafting and adop- The research objectives and methods discussed and de- tion of the 2013 National Strategy for the Promotion of veloped in partnership are not only of interest to Tunisia Mental Health 6 but in important developments around this but fit globally into the larger initiative of building research strategy. First, the Ministry of Health created the Commit- capacity in Global Mental Health. First, conducting an RCT tee for Mental Health Promotion to lead activities related to where the intervention is offered to both groups of partici- the strategy’s implementation. Interestingly, the Ministry pants at different times responds to ethical questions raised appointed Dr.Wahid Melki as its Director, a chief psychia- around offering an intervention to one group over anoth- trist at Hôpital Razi, the only operating mental health hos- er despite the limited mental health resources in LMICs. 29 pital in the country 6, 12, 13, but also a PCP by training. Second, to evaluate a mental health intervention such as His early career as a PCP allowed him to truly grasp the a training program, RCTs and implementation analyses as challenges behind, and the necessity of, offering effective complementary methodologies are encouraged to help gen- mental health care in primary care settings. Therefore, his erate practical (but local) knowledge for health systems. 30 vested interest has been to work on building PCPs’ mental This practical and local evidence may influence important health competencies in primary care settings and to en- decisions regarding the intervention’s scale-up within spe- courage the organizations in which they work to support cificonte c xts. 34, 35 Third, results respond to the deficits in this endeavor. Second, the Ministry of Health revamped the mental health evidence from LMICs. 29 Specifically, while university curricula by drafting and passing a decree for the 90% of the global population live in LMICs, only between inclusion of a mandatory two-month mental health intern- 3% and 6% of the mental health research published in high- ship in post-graduate medical school that had previously impact journals comes from such countries. 26 been optional for future family physicians. 41 The first grad- Some grants support partnerships for the development uating class under the new curricula is planned for 2019. of research capacity, specificallyor f those partnerships The drafting of the mental health strategy and Tunisia’s within the field of Global Mental Health and with a vested interest in further developing PCPs’ mental health com- interest in developing collaborations between income petencies were not independent of contextual events but groups. 29, 36 These targeted opportunities are important aligned with a process to involve Tunisian citizens in iden- considering the limited global health funding allocated tifying potential tracks for country-wide health system re- specifically to Global Mental Health research, especially form. 5 Such a process was locally known as le dialogue within LMICs. 7, 26, 29, 37 However, for this program, fund- sociétal [“the societal dialogue”], where Tunisian citizens ing was obtained through organizations that support such participated in focus groups to identify health care system partnerships more generally in the field of health: 1) Mitacs challenges. 5 After verbatim analysis, eight reform tracks Globalink 38, an organization funded in part by the Govern- were established, one of which was to strengthen health ment of Canada to create partnerships between academic system capacity by creating proximity health services. 5 institutions in order to better train students in global health This reorganization aimed to: 1) promote the use of multi- research; and 2) the New Initiatives Funding of l’Institut disciplinary teams in primary care settings; 2) valorize gen- de recherche en santé publique de l’Université de Montréal eral medical practice; and 3) further equip PCPs in effective (IRSPUM) 39, which supports new collaborations in order to patient management. This reform track was also discussed develop research on topics currently under-represented at extensively as a way of meeting the untreated mental health the School of Public Health at Université de Montréal. By needs in Tunisia [6], specificallyy b developing an already applying to funding from initiatives beyond those centered existent resource engaged in mental health care but with solely on Global Mental Health research development, our apparent deficits (i.e. CPP s). 6, 10-11 aim was to increase the visibility of our project and our new Our program worked amidst this political enthusiasm, or collaboration, as well as the visibility of mental health in what the field of Global Mental Health calls “political com- general, an under-represented discipline in global health. 40 mitment to mental health system development” (ie, “the organized intentions and actions of key decision-makers in a society, especially political leaders, to respond effectively

Journal of Global Health Reports 4 A program to further integrate mental health into primary care: lessons learned from a pilot trial in Tunisia to the mental health needs of the population” 42). “Special trainees was similarly highlighted as a major strength dur- attention” to mental health capacity-building in the coun- ing one of the first mhGAP-IG training demonstrations on try thus offered a unique way to forge and foster partner- clinical utility in Nigeria. 46 It is worth noting, however, that ships with a communal goal: the training of already grad- our team had limited contact with “tutors” post-training. uated PCPs in effective mental health care using the mh- Therefore, despite their role as “tutors” to trained PCPs, it GAP-IG 17 and the program’s evaluation. Given this mo- is difficult to wkno how they explicitly conducted their as- mentum and the mental health champions among our part- signed tasks post-training and to what extent they had an ners (ie, members of the Ministry of Health), funding for influence on the training program’s expected outcomes. the implementation of the mhGAP-IG training was covered Second, the adapted training program was assessed using by the WHO office in Tunisia, fostering local ownership of an RCT. Pilot results suggest that the adapted program can its implementation. In addition, findings show that benefit- increase mental health knowledge and self-efficacy, while ting from this political commitment to mental health could decreasing referrals and negative mental health attitudes increase the use of research in policy by creating “a recep- among PCPs in the Greater Tunis area of Tunisia. However, tive policy environment [for] the ‘right research at the right our findings vre eal no impact on the importance PCPs allo- time’”. 43 cate to mental health practice. While the goal of our pilot trial was not to generalize results to all PCPs working in LESSON 3: PILOTING THE PROGRAM TO “BUILD BACK BETTER” Tunisia, but rather to see whether the training program worked in the Greater Tunis area, these results do hint at “Building back better” is a term used by the WHO for mental possible outcomes should the training program be offered health care after emergencies. 44 In this paper, we use the to public sector PCPs working in other areas of Tunisia who term to refer to suggested improvements after piloting an would agree to participate in a mental health training. Re- intervention. gardless, an RCT design is unable to provide a plausible Given widespread untreated mental health symptoms in explanation for these findings. Hence, qualitative methods LMICs, the Global Mental Health movement aims to scale become necessary to better understand the context in which up evidence-based mental health interventions, particular- the intervention was implemented. 21, 47-48 Implementa- ly those that are feasible and effective at promoting the in- tion analysis is thus a priority in the Global Mental Health tegration of mental health within primary and community- field, since it helps identify practical challenges that deci- based settings. 15-16 Scaling up is defined as “efforts to in- sion-makers could address to further encourage the imple- crease the impact of innovations successfully tested in pilot mentation of programs that support the use of non-special- or experimental projects so as to benefit more people and to ists such as PCPs in mental health care and that promote foster policy and programme development on a lasting ba- the integration of mental health into primary care settings. sis”. 45 At the heart of this definition is the tingpilo of in- 15-16, 21, 47-48 terventions within contexts that are considering innovation Eighteen Tunisian trainees interviewed identified vse eral scale-up to better understand if they are feasible, effective, barriers when describing contextual factors influencing the and sustainable. mhGAP-IG training’s expected outcomes. 14 These include: Several steps were taken to pilot the mhGAP-IG in 1) structural factors (e.g. restrictions that challenge PCPs’ Tunisia. First, given that the WHO encourages the adapta- prescription of certain medications, stigma against sub- tion of the mhGAP-IG training to local contexts before im- stance use and misuse, the political favoritism of physical plementation 17, 20, our team allocated four months (i.e. illnesses, and the non-systematic implementation of con- September 2015 to January 2016) to its adaptation to the lo- tinuing mental health training for PCPs); 2) organizational cal primary healthcare reality of the Greater Tunis area. Our factors (e.g. logistical issues for the provision of care, such team published the adaptation details 12, which filled a gap as the lack and uneven distribution of certain medications, in the Global Mental Health literature 23, to facilitate repli- and the difficulty of collaborating with medical personnel cation and/or help other LMICs undergo such a process. In untrained in mental health care); 3) provider factors (e.g. brief, the adaptation process ensured that: 1) training mod- PCPs’ limited mental health experience and their need to ules from the mhGAP-IG were chosen to meet pressing local be self-motivated to provide care to patients consulting for needs and contextually adapted; 2) a training schedule was mental health issues); 4) patient factors (e.g. patients’ often tailored to the availability of PCPs to encourage their par- negative beliefs about the health system and healthcare ticipation; 3) a support network of “tutors” was developed professionals, as well as their limited motivation to seek (ie, PCPs well-versed in mental health care and in charge care); and 5) innovation factors (e.g. limits to the clinical of continuing medical education in the Greater Tunis area) utility of the training curriculum and issues with schedul- to help trainees during and after training, which was espe- ing, potentially explaining drop-out). Interestingly, some of cially important given specialists’ heavy time constraints; the contextual factors highlighted by trainees also mirror 4) role plays were translated into Tunisian Arabic to mirror the gaps identified during the tationadap process. 12 These real-world consultations; and 5) gaps in mental health ser- include: lack and uneven distribution of psychotropic med- vices within primary and community-based settings were ications across healthcare clinics in the Greater Tunis area, identified. 12 stigma against substance use and substance misuse, as well Our team believes that a strength of the adaptation as deficits in ontinuingc mental health training for PCPs. 12 process during this pilot phase was the creation of a support Besides potentially affecting the integration of mental network for trainees, using an already existing yet available health into primary and community-based settings and in- resource (ie, “tutors”) in primary care settings. Given the fluencingCP P s’ involvement in the field of mental health, WHO’s emphasis on ongoing supervision when offering the such contextual barriers are important to consider for two mhGAP-IG training 17, 20, but also Tunisia’s inability to mo- additional reasons. First, they may potentially reproduce bilize mental health personnel to provide such support, our or perpetuate, over the long-term, certain gaps uncovered team developed a realistic way of supporting trainees that prior to training in PCPs’ mental health knowledge (i.e. could be piloted and easily reproduced on an ongoing basis lower scores on content related to substance use disorders should the program be scaled up. Of note, mobilizing an al- and suicide/self-harm), attitudes (i.e. beliefs about the dan- ready existing yet available resource to provide support to

Journal of Global Health Reports 5 A program to further integrate mental health into primary care: lessons learned from a pilot trial in Tunisia gerousness of people with mental health issues), and self- were explained by a complementary methodology: trainees efficacy (i.e.w lo er scores on confidence in capabilities to acknowledged that while the Tunisian Ministry of Health detect, treat, and manage what PCPs deem more complex has been encouraging PCPs to record mental health sta- mental health conditions, such as substance use disorders, tistics per primary healthcare clinic, they also experienced suicide/self-harm, and psychosis). 31 Second, contextual limited follow-up by administrators, which has consequent- factors, identifiedy b 18 interviewed PCPs, might challenge ly jeopardized the institutionalization of proper record- the training program’s scale-up to other regions of Tunisia. keeping. 14 Information from trainees on such a challenging Our sample of interviewed PCPs consisted of those working part of the methodology helped us gain a clear understand- in the public sector from one area of Tunisia. However, ing of why it proved problematic. In addition, administering we believe that our findings are usefulor f informing pro- questionnaires allowed us to provide some measure of relia- gram scale-up. Specifically,PCPs working in the public sec- bility for these scales, based on our sample from the Greater tor of the Greater Tunis area experience similar barriers to Tunis area. Interestingly, while the attitudes questionnaire effective mental health care as in other Tunisian regions. used in our trial (i.e. the Mental Illness: Clinicians’ Atti- Nonetheless, while considering scaling up such a training tudes (MICA) Scale (version 4.0) 31, 50, 51) had acceptable program, it would be useful to develop and implement ini- internal consistency in a previous study [56], it did not show tiatives to tackle contextual factors that may challenge the results that were as promising in our sample. 31 attainment of its expected results. Our pilot results, generated by diverse and complemen- Another promising feat of piloting an intervention is the tary methodologies 47, 52, may thus be used to “build back ability to test the feasibility of implementing its specific better” should the program be scaled up. Insight from our modules, research methodology, and tools. First, when pilot program may be used to improve: 1) the training pro- preparatory work was in progress prior to the implementa- gram itself, by rendering it more clinically useful and rele- tion of the mhGAP-based training in the Greater Tunis area, vant; 2) the implementation of the training program, by en- some of the program’s crucial elements were unavailable to suring that material accompanying certain modules is avail- the research team. For example, while rates of anxiety dis- able; 2) the research program, by brainstorming on the tools orders have increased since the 2010-2011 Tunisian Revo- best suited to collect data; 3) the mental health system, by lution and remain a concern, at the time of adaptation and addressing gaps in available resources and organizational pilot implementation, the accompanying training material barriers to effective mental health care and collaboration; (i.e. PowerPoints, facilitator guides, and participant guides) and 4) mental health policies, by addressing restrictions on for the module on conditions related specifically to stress 49 PCPs’ prescription abilities and stigma against substance was not available in the language in which medical training use and misuse. is provided. This unavailability was an implementation bar- rier to a much-needed module. 12 LESSON 4: SHARING RESEARCH FINDINGS Second, by tailoring the standard training content and Priority for the sharing of results has traditionally been program to local primary care realities of the Greater Tunis through peer-reviewed publications, written reports, and area of Tunisia, systemic gaps were uncovered in resources conference presentations. 53, 54 Such mediums are impor- for mental health treatment suggested by the mhGAP-IG. tant for the sharing of findings in the field of Global Mental 17 These include deficits inommunit c y-based mental health Health, especially given evidence of the limited representa- services for people living with mental illness, such as little tion of mental health at international global health confer- investment in subsidized housing and the unavailability of ences 55 and in the global health literature. 26, 29 supported housing and supported employment initiatives. To share findings from this program, our team aimed to: 12 In addition, while many standard modules of the mh- 1) produce several publications in both English and French, GAP-IG include therapeutic interventions as part of the the medical language in Tunisia; 2) participate in various management skills to be developed by trainees (i.e. behav- research conferences; and 3) further develop individual re- ioural activation, interpersonal therapy, cognitive-behav- search capacities by encouraging the involvement of local ioural therapy, contingency management therapy, family collaborators in the writing and publication process. 28 For counselling/therapy, interpersonal psychotherapy, and mo- example, many of our Tunisian collaborators contributed to tivational enhancement therapy), trainings in such thera- literature reviews, especially sections pertaining to infor- pies in Tunisia are reserved for psychosocial care providers, mation about the Tunisian healthcare system, the results such as psychologists or psychiatrists. 12 As a result, psy- and discussion sections, and manuscript revisions, all to chotherapy is very rarely conducted by PCPs in Tunisia. ensure that information adequately represented contextual These uncovered deficits may be addressedy b the promo- realities. Such involvement also aimed to build research ca- tion of treatments that use resources currently available pacity in the country [6] and, more generally, in the EMR, in Tunisia (albeit distributed unevenly across the country), the WHO region in which Tunisia is represented. Records namely psychotropic medications. This reality in Tunisia 6, show that research initiatives in the EMR are disproportion- 12 and in other LMICs 7 might challenge the WHO’s vision ately low in comparison to the mental health burden. 8, 56, of the mhGAP-IG’s self-sufficiency as a packageering off a 57 diverse set of complementary and necessary interventions Despite the sharing of research findings through more for mental illness. 17, 18, 20 traditional mediums, knowledge-to-action gaps in the Last, one of the most surprising discoveries made during Global Mental Health fieldontinue c to persist. 58 Therefore, the pilot testing of the mhGAP-IG in the Greater Tunis area discussions of strategies for ensuring greater knowledge up- was the number of challenges PCPs had when asked to re- take to improve mental health practices, services, and poli- port their mental health statistics. PCPs reported these by cies beyond traditional mediums are of international focus. filling out a mental healthtic prac e questionnaire based on 59, 60 Findings reveal that knowledge translation (KT) the Mental, Neurological and Substance Use Patient Vis- strategies, which aim to move beyond the diffusion of find- it Summary developed by the WHO to accompany the mh- ings uniquely towards the promotion of exchanges on such GAP-IG training and included in the original research pro- findings withe k y stakeholder groups 52, 54, have been tocol. 33 Interestingly, these mental health statistical issues shown to be effective in improving mental health practices

Journal of Global Health Reports 6 A program to further integrate mental health into primary care: lessons learned from a pilot trial in Tunisia and policies. 59 Our team attempted to uphold the prin- mary care. Both endeavors are priorities in Global Mental ciples of KT by relying on a feasible strategy: the organi- Health. zation of a dissemination session in Tunisia. The session regrouped PCPs who participated in the training program and accompanying research, trainer-psychiatrists, PCPs in charge of continuing medical education in the Greater Tu- ACKNOWLEDGEMENTS nis area (ie, “tutors”), members of the Ministry of Health, members of the WHO office in Tunisia, and directors of the The authors wish to acknowledge: 1) Dr. Guido Sabatinelli, governorates of the Greater Tunis area, in order to provide former WHO representative in Tunisia, and Ann-Lise Guis- opportunities for exchange on preliminary findings from set, PhD, for their support in the development of this pro- the program. Besides feedback on findings, this session re- gram and technical support while JS was in Tunisia; 2) Dr. sulted in the creation of key recommendations on ways to Sonda Trabelsi, trainer-psychiatrist, for her dedication to further PCPs’ involvement in mental health care, some of the program; and 3) the WHO office in Tunisia, for their ad- which were identifiedy b the research, while others moved ministrative support while JS was in Tunisia. JS would like beyond it. Recommendations were regrouped into a report to personally thank Matthew Rettino for his editing ser- and sent to all trainees for additional comments prior to be- vices. ing used as a reference by the mental health champions in Ethics: Research approval was obtained from the Univer- our team during discussions with the Ministry of Health on sité de Montréal (Québec, Canada) (#15-117-CERES-D) and future mental health priorities for the country. Razi Hospital (Manouba, Tunisia). Interestingly, when discussing the dissemination ses- Disclaimer: The views expressed in the submitted article sion, one of our Tunisian partners shared: “In my years in- are the authors’ and not an official position of the authors’ volved in mental health research, this is the first tempat t institutions or research funders. to regroup study participants and share with them the pre- Funding: Jessica Spagnolo is funded by Fonds de liminary findings they helped produce.” This statement was recherche du Québec – Santé (FRQS, project #33774). Data shocking to many of our Canadian collaborators, seeing as collection was funded by Mitacs Globalink (research fel- KT “has been adopted in Canada because translation of re- lowship, #IT06835). The overall program in which this pa- search is embedded in the mandate of the Canadian Insti- per is inscribed is funded by Institut de recherche en santé tutes of Health Research (the federal agency for the funding publique de l’Université de Montréal (IRSPUM) – New Ini- of health research)”. 54 Therefore, encouraging and facili- tiatives Grants. tating a culture of KT in Global Mental Health research is Competing interests: Dr. Marc Laporta works for the of utmost importance. Such development may be facilitated Montréal World Health Organization (WHO)-Pan American through targeted grants—for example, the one our research Health Organization (PAHO) Collaborating Center for Re- team received to disseminate results in the country in which search and Training in Mental Health (Douglas Mental the findingsere w collected 61—or by making KT strategies Health University Institute). All other authors declare no mandatory upon the receipt of grants that fund Global Men- conflicts of interests. The authors completed the Unified tal Health research. Competing Interest form at http://www.icmje.org/coi_dis- closure.pdf (available upon request from the corresponding CONCLUSION author), and declare no further conflicts of interest. Correspondence to: The adaptation, implementation, and evaluation of a pro- 17 Jessica Spagnolo gram based on the mhGAP-IG (version 1.0) in the Greater School of Public Health, Institut de recherche en santé Tunis area of Tunisia generated important lessons learned, publique de l’Université de Montréal (IRSPUM) supported by evidence in the field of Global Mental Health. 7101 Park Ave, Montreal Our hope is that such experiential knowledge may be of use Québec to other countries interested in addressing untreated men- Canada, H3N 1X9 tal health symptoms by developing/adapting, implement- [email protected] ing, and evaluating programs that aim to build: 1) non-spe- cialists’ mental health competencies; and 2) the capacity of health systems to further integrate mental health into pri-

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Journal of Global Health Reports 7 A program to further integrate mental health into primary care: lessons learned from a pilot trial in Tunisia

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