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Building the Capacity for the Integration of Mental Health in Primary Care in Tunisia

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Building the Capacity for the Integration of Mental Health in Primary Care in Tunisia Université de Montréal Global mental health: Building the capacity for the integration of mental health in primary care in Tunisia Par Jessica Maria-Violanda Spagnolo Département de gestion, d’évaluation et politique de santé École de santé publique Thèse présentée en vue de l’obtention du grade de Philosophiae Doctor (PhD) en santé publique, option Organisation des soins de santé Décembre 2018 © Jessica Maria-Violanda Spagnolo, 2018 RÉSUMÉ ET MOTS CLÉS Contexte Dans les pays à faible et moyen revenu, s’attaquer au fardeau causé par les troubles mentaux, les troubles liés à la consommation de drogues et alcool, et l’automutilation/suicide est rendu plus difficile par le nombre limité ou la répartition inégale de professionnels formés en santé mentale. L’intégration de la santé mentale dans les soins de santé primaires par l’offre d’une formation en santé mentale pour les non-spécialistes, tels les médecins généralistes (MG), est une des solutions mises de l’avant un peu partout dans le monde pour faire face à ce problème. Afin de faciliter cette intégration, l’Organisation mondiale de la santé (OMS) a développé le Programme d’action : Combler les lacunes en santé mentale (mhGAP), et un guide d’intervention (IG) qui regroupent des interventions basées sur des données probantes visant les problèmes de santé mentale que l’OMS considère comme prioritaires. Cette thèse présente la mise en œuvre et l’évaluation d’une formation basée sur le programme mhGAP, offerte à des MG travaillant dans la région du Grand Tunis, en Tunisie, un pays à revenu intermédiaire de la tranche inférieur situé en Afrique du Nord. Méthodes L'évaluation du programme de formation a été faite en employant des méthodes mixtes. Premièrement, l’évaluation de l’efficacité de la formation a été réalisée à l’aide d’un essai randomisé contrôlé. Nous avons évalué l'impact de la formation sur les connaissances et les attitudes envers la santé mentale, le sentiment d'auto-efficacité pour la détection, le traitement et la gestion des troubles de santé mentale et les pratiques cliniques en santé mentale rapportées par les MG à court terme (six semaines après la formation) et à long terme (18 mois après la i formation). Deuxièmement, une étude de cas a été utilisée pour explorer comment les facteurs contextuels ont contribué à influencer les résultats obtenus. Résultats La formation a eu un impact significatif à court terme sur les connaissances, les attitudes et l’auto- efficacité, mais pas sur les pratiques cliniques en santé mentale rapportées. Ces changements ont été maintenus à 18 mois post-formation. De plus, les MG ont rapporté, à 18 mois, avoir réduit le nombre de références en services spécialisés comparativement à celles faites avant la formation. Toutefois, les MG ont identifié plus d’obstacles que d’éléments facilitateurs en décrivant les facteurs contextuels ayant influencé les résultats de la formation. Les méthodes qualitatives ont alors permis d’identifier des pistes de solutions que les décideurs pourraient employer pour encourager davantage la participation des MG en santé mentale. Conclusion L’utilisation de méthodes mixtes pour évaluer le programme de formation mhGAP dans la région du Grand Tunis, en Tunisie, a permis d’en arriver à une compréhension fine des enjeux liés à son implantation et de ses effets. Les résultats de cette thèse peuvent aussi s’avérer utiles dans d’autres contextes similaires où l’on vise à mieux cibler les symptômes de santé mentale non-traités en renforçant les capacités de prise en charge au niveau des soins primaires. Mots-clés Santé mentale, évaluation de programme, soins primaires, médecins généralistes, mhGAP, méthodes mixtes, Tunisie ii ABSTRACT AND KEYWORDS Background In low- and middle-income countries (LMICs), addressing the burden caused by mental health conditions, substance use disorders, and self-harm/suicide may be challenged by the limited number and/or unequal distribution of mental health personnel. Integrating mental health into primary care settings through the training of non-specialists such as primary care physicians (PCPs) is an internationally acclaimed solution to address such challenges. To facilitate this integration, the World Health Organization (WHO) developed the Mental Health Gap Action Programme (mhGAP) Intervention Guide (IG), regrouping evidence-based interventions for what the WHO considers priority mental health conditions. This dissertation presents the implementation and evaluation of an mhGAP-based training offered to PCPs working in the Greater Tunis area of Tunisia, a lower middle-income country located in North Africa. Methods Evaluation of the training program employed a mixed-methods approach. First, evaluation for effectiveness was conducted using a randomized controlled trial (RCT). We assessed the short- term (six weeks post-training) and long-term (18 months post-training) impact of the training on PCPs’ mental health knowledge, attitudes, self-efficacy, and self-reported practice. Second, a case study design was used to explore how contextual factors interacted with the implemented training program to influence its expected outcomes. iii Results The training had a statistically significant short-term impact on mental health knowledge, attitudes, and self-efficacy, but not on self-reported practice. When comparing pre-training results and results 18 months after training, these changes were maintained. In addition, PCPs reported a decrease in referrals to specialized services 18 months after training in comparison to pre-training. However, PCPs identified more barriers than facilitators when describing contextual factors influencing the training program’s outcomes. Hence, qualitative methods helped identify practical challenges that decision-makers could address to further promote PCPs’ involvement in mental health care in primary care settings and thus impact the health of people with mental health problems. Conclusion A mixed-methods approach helped create a comprehensive understanding of the implementation and evaluation of the mhGAP-based training in the Greater Tunis area of Tunisia. Findings may also be useful in other settings with similar profiles that aim to target untreated mental health symptoms by building individual and system-level capacity. Keywords Mental health, program evaluation, primary care, physicians, mhGAP, mixed-methods, Tunisia iv TABLE OF CONTENTS RÉSUMÉ ET MOTS CLÉS ......................................................................................................................... i ABSTRACT AND KEYWORDS .............................................................................................................. iii TABLE OF CONTENTS ............................................................................................................................ v LIST OF TABLES ................................................................................................................................... viii LIST OF FIGURES ..................................................................................................................................... x LIST OF SUPPLEMENTARY FILES ....................................................................................................... xi LIST OF ACRONYMS ............................................................................................................................. xii DEDICATION ........................................................................................................................... xiii ACKNOWLEDGEMENTS ..................................................................................................................... xiv CHAPTER 1: GENERAL INTRODUCTION ............................................................................................ 1 1.1. Background to the dissertation ......................................................................................................... 2 1.1.1. The mental health treatment gap ............................................................................................... 2 1.1.2. Global Mental Health: definition and political involvement .................................................... 2 1.2. Problem statement ............................................................................................................................ 4 1.2.1. Challenges in Global Mental Health ......................................................................................... 4 1.2.2. Potential opportunities in Global Mental Health ...................................................................... 8 1.2.3. Tunisia and Global Mental Health .......................................................................................... 10 1.3. Study pertinence and research questions ........................................................................................ 11 1.4. Dissertation structure ...................................................................................................................... 14 CHAPTER 2: REVIEW OF THE LITERATURE .................................................................................... 17 2.1. Synopsis ......................................................................................................................................... 18 2.2. Exploring mental illness ................................................................................................................. 19 2.2.1. Defining mental illness ...........................................................................................................
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