in2mentalhealth

What will be the most easy and most effective way to reach and train health workers in the field about mental health treatments? Now we have the WHO mhGAP Intervention Guide, but how to get this guide implemented in all the corners of the world? Printed on paper? Via the internet? Smartphones? SMS and voice platforms? Here’s an overview of what is possible and seems necessary.

Introduction:
Approximately every four out of five people in low- and middle-income countries (LMIC) who need services for mental health conditions do not receive them. Even when available, the interventions often are neither evidence-based nor of high quality. The World Health Organization (WHO) launched the Mental Health Gap Action Program (mhGAP) for LMIC with the objective of scaling up care. The WHO mhGAP Intervention Guide (mhGAP-IG) has been developed to facilitate this scaling up in non-specialized health-care settings. The mhGAP-IG is issued in 2010 and now available in English, French and Spanish for $24,- (reduced prices for developing countries), with Arabic, Chinese, Russian and other languages to follow.
The mhGAP-IG is brief, 89 pages. It describes in detail what to do but does not go into descriptions of how to do. According to the WHO it is important that the non-specialist health-care providers are trained and then supervised and supported in using the guide.
The guide consists of decision trees for mental conditions including: depression, psychosis, bipolar disorders, epilepsy, developmental and behavioral disorders in children and adolescents, dementia, alcohol use disorders, drug use disorders, self-harm/suicide and ‘other significant emotional or medically unexplained complaints’. The guide starts with ‘general principles of care’, and ends with ‘advanced psychosocial interventions’.
The WHO, together with more then 100 experts from around the world, is developing mhGAP-IG training packages. These packages have been piloted in Ethiopia, Jordan, Lebanon, Libya, Nigeria, Honduras and Panama (June 2012 mhGAP newsletter). The training packages are divided in a Base Course (35 hours) and a Standard Course (more intensive training). The WHO invites and encourages experts and organizations from around the world to field test these courses.
The WHO has the intention to develop elearning and mlearning training packages for the mhGAP-IG as well, but at the end of 2012 this are still plans, the main focus seems yet on face2face trainings.

1. Use of printed versions:
For reading: The purchase costs of a printed book, as well as the additional shipping and transport costs, and the unreliability of the postal services, can be a hurdle in the distribution of the printed version in LMIC (see for instance a Tanzanian report on distance learning). Alternatively, the guide could be downloaded (free) from the WHO website, however downloading an 89 page book is not ideal and incurs the high costs of (desktop, colour) printing and subsequent photocopies.

Another disadvantage with the book format is the promised update in 5 years. By the time the guide has arrived in all corners of the world, the newer version (with relevant new insights into evidence based practices) is new in stock. For example the Hesperian’s success ‘Where There Is No Doctor’ has been updated this year for the 26th time since it’s original publication in the seventies.
For training: In February 2011 the first training workshop on the mhGAP-IG was held in Jordan. This 5-day training consisted of 24 nurses and doctors, using the print version of the guide along with explanatory flowcharts, quiz games, self assessment tests and role plays. It depends on the creativity of the trainer to what extent the book or a printed version of the guide is workable as a training tool.
This kind of face2face trainings seem the most ideal option for the implementation of the mhGAP-IG. But the in most LMIC there is a shortage of health tutors and facilities. And a face2face training necessitates the movement of the health worker away from the field, which interrupts the delivery of services and is expensive due to travel and accommodation fees.

2. With the internet/desktop/laptop/CD-rom/USB stick:
For reading: Documents, such as this guide, are often conveyed, via the internet, in PDF (Portable Document Formats). People can download the document via the internet and read online (during internet access) on their laptop or desktop computer screen. A PDF document that is published on a CD ROM (a CD with a read only memory that disallows any changes to be made to the material stored) or DVD, or copied to a computer storage stick (USB stick) or simply onto the hard drive of a computer, can then be accessed off line (without an internet connection), repeatedly.
Online reading of the guide is cheap and reduces shipping and transport costs. It offers a couple of extra advantages, like access to the latest updated issue of the guide and the possibilities of nice, user friendly programs and interfaces. For example decision tree software with go-to tabs, notes storage, information charts and a find-utility, can make the reading and use of the guide more attractive and richer.
Learning can be enhanced by adding electronic libraries of resources on a particular health topic. A good online example in this field is the K4Health eToolkit program, now with nearly 50 health eToolkits, topics ranging from family planning, communicative diseases, to leadership and management. The mhGAP-IG would fit very well within such a series. K4Health distributes the toolkits on CD-rom for ‘no internet’ areas, and offers a free easy-to-use eToolkit Application software program for other organizations
A good off line example is the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings, 2007. This guide, as well as the related resource materials, is distributed worldwide on CD-roms and in a PDF online.
The main disadvantages of internet/computer based distribution is the constant need of a computer nearby and standby. Beside the problems of severe electricity shortages and interruptions, field workers often have no or very poor computer access (e.g. one computer in a whole health centre or only access via internet cafes) and very expensive internet access (e.g. 9 African countries have no fibre-optic internet yet and rely for 100% on satellite bandwidth with prices up to 25 times the average USA price and even $5000,- a month). And most services are still very, very slow.
With the little cyber experience workers can have such limited computer skills, that additional training and support in this area will be needed as well.
For training: Learning via the internet or on a computer is called e-learning. As well as the benefits of not having to travel, and therefore no interruption to daily work, e-learning also gives health workers the opportunity to study at their own pace, and preferred time of the day or week.
But internet-learning (or via CD) offers another advantage above an ‘once only’ face2face training elsewhere: repetition of the content. Information that is presented and repeated over spaced intervals is learned and retained more effectively. Additionally, working with internet programs allows insertions of a variety of extra interfaces, such as videos, tests, chat services between students and tutors, quizzes, multimedia, etc. There are also free open source (available for anyone online) systems to aid learning, such as Learning Management Systems (LMS) and Virtual Learning Environment (VLE) packages. One example of this sort of package is Moodle. Moodle is a widely adopted system (more than 5 million courses with more than 57 million users) with features like assignment submission, discussion forums, file downloads, grading of work, instant messages, online calendar, online news and announcements, online quizzes, and wiki’s.
One example of this kind of comprehensive program is the ICATT (IMCI Computerized Adaptation and Training Tool, and IMCI stands for Integrated Management of Childhood Illness). This ICATT tool has an attractive design with several modules all with a Read, See, Practice and Test component. Another is the Spaced Education. A good SpacedEd course consists of thoughtfully framed questions with multiple options as potential answers, delivered via e-mail, RSS feeds, or directly on the SpacedEd website. Once the participant answers a question, the website delivers a brief passage that explains the correct and wrong answer.

3. With mobile apps on smartphones:
For reading: A smartphone, like an Apple iPhone or a Blackberry, is a modern handheld device with a telephone function and a connection with a wireless internet platform. The first smartphones were devices that mainly combined the functions of a personal digital assistant (PDA) and a mobile phone and/or camera. The newer, high tech smart phones can also include high-resolution touch screens, and high-speed data access via WiFi (wireless internet from an access point or hotspot) and mobile broadband (like 3G, GPRS; wide-area wireless internet networks). Smartphone prizes drop, and especially those using the Android operating system are growing in popularity. For example the lower-cost model Ideos from Huawei costs $80,- in Kenya. This smartphone has found its way into the hands of 350,000+ Kenyans, an impressive sales number in a country where 40% of the population lives on less than two dollars a day. Thus the future seems to look bright for smartphones and smartphone apps.
The newest mobile devices, which are conquering the market, are the tablet computers. A tablet computer looks like a smartphone, but it’s larger. It’s a flat computer integrated into a flat touch screen and primarily operated by touching the screen rather than using a physical keyboard.
Apps are software applications, usually designed to run on smartphones and tablet computers. They are available (to download) through application distribution platforms that are operated by the owner of the mobile operating system, such as the Apple App Store, the Android app Market, and BlackBerry App World. Some apps are free, while others have a fee for use, or a one-time cost. There are many apps available, such as for email, calendar, personal contact or chat, news, games, banking, location based services, commercial goals, information access, social media, etc. Any organization or person can build an app and offer it to the public via the app stores.
Apps for mobile phones can have a high added value for previously unconnected people. Users in a lot of LMIC are skipping the personal computer/land line experience altogether and accessing parts of the internet for the first time through their mobile device. There are entire app stores dedicated to serve the needs of developing country users, like the Reliance app store in India and Safaricom app store in Kenya. Actually, a lot of new apps are developed in LMIC.
Jorge Martinez from the BebeMama mobile app project gives a checklist for a mHealth app for LMIC: App runs on the basic handsets (e.g. on a small screen), app is friendly to illiterate users, app is in local language/dialect, app minimizes bandwidth usage and costs, and app makes business sense for the sponsor. The Hesparian Foundation was running a money raise campaign for creating Mobile Apps to Save Lives and to get the book ‘Where There is No Doctor’ on a smartphone app.
For training: Education via a smartphone apps offers the same benefits as the internet learning software like nice attractive tools and designs. The extra advantages are the pocket format; easy taking it with you, the availability of the device in LMIC (in the future) and the integration of the program in the already existing private situation of most health workers; they own an use the mobile device already on a daily base.
An example of mobile learning via smartphones is the Training System for Health Care Workers in Peru. They worked with the iPhone and the Nokia N95, used the mobile Moodle software as the learning platform, and incorporated use of Skype mobile and Facebook mobile to enable peer-to-peer contact and the development of a Community of best Practice.

4. With mobile phones without wireless internet:
For reading: Although smart phone use is growing rapidly worldwide, for the foreseeable future however, a low tech mobile phone without internet access (called GSM, cell or cellular phone) will probably remain the core means of connectivity in a lot of LMIC.
More than three-quarters of the world’s 5.3 billion mobile phones are located in the developing world, and penetration is up to nearly 70% in developing countries. Products and service in those countries still rely heavily on text messaging and voice and these unique challenges fostered highly creative solutions like the M-pesa banking system, Text to Change, Mobile 4 Good, and a Nokia 1100 mobile phone which costs under $20. A couple of app stores, like the Indian Aircel PocketApps store, offer even SMS-apps for people who don’t own a smartphone and the Indian Idea Cellular offers apps and services provided by voice.
The whole mhGAP-IG reading on a SMS app seems not feasible. But using open source platforms like FrontlineSMS (which enables instantaneous two-way communication on a large scale among other features), or profcasts (short audio clips that users download on their phone) one can convey parts of the guide piece by piece, or certain parts on request. With the FrontlineSMS platform you can even run your own text-based information service (decision tree) via an automated SMS reply manager and the Idea Cellular company has an automatic voice reply system as well.
For training: Conducting a training in the mhGAP-IG solely by mobile phones is possible, but a mix with face2face sessions or other channels is off course more effective (often called blended learning). But suppose you can’t reach your health worker via another channel then via the ‘everywhere available’ phone net?
FrontlineSMS has been building a special module for education and training: FrontlineSMSLearn, built on the core FrontlineSMS platform. Moodle developed a Mobile Learning Engine, the MLE Moodle. The MLE is integrated in the Moodle eLearning system at one’s desktop/laptop, but with the MLE-Moodle one can access the Moodle installation everywhere on the phone and do the standard Moodle activities like a quiz, a survey, lessons, assignments, use directories etc.
In the My.Coop Mobile Learning Toolkit one can find 15 methods of learning all of which are designed to be carried out in combination with one or more face2face sessions. This open source, step by step guide is divided in 4 categories: deliver content, assign tasks, gather feedback and provide support, and is an inspiring document for anyone who needs easy applicable examples in this field.
In Kenya the AMREF’s Virtual Nursing School (AVNS) trained hundreds of nurses with a mobile support network as an important component. Using the FrontlineSMS platform tutors sent messages to all students on exams, relevant medical documents etc, and nurses where able to send questions which were answered by the tutors.
The nongovernmental organisation D-tree International has developed an electronic version of the aforementioned Integrated Management of Childhood Illness programme (IMCI), the e-IMCI, for use on cell phones and other mobile devices. This program guides health workers step-by-step through the IMCI assessment, classification and treatment plan. This has been piloted in rural Tanzania, and initial results indicate that clinicians more closely adhere to the IMCI protocol when using e-IMCI than without it, and were enthusiastic about its use with patients.

Conclusions and recommendations:
Not one of the 4 distribution channels mentioned above seems to be the one and only most promising in conveying the mhGAP-IG. I would suggest to create reading and training materials in all 4 distribution channels and to concert these efforts international. Then look for the local/national circumstances and options and implement what is most suitable there. In a national mhGAP policy project off course; just scattering guidelines over a country will not be very helpful.

-I want to stress not to forget the last channel. Although thinking about SMS and voice based services seems a step backwards for people in the North, for a vast amount of people in rural and underserved communities this is for the years ahead the first and only way to connect to information and education.

-A lot of apps and mobile platforms are currently breed in LMIC and connecting and cooperating with these innovators will prevent inventing the wheel again or missing the most suitable, simple and low-tech solutions which are needed in low resource settings.

-The distribution of the mhGAP-IG and the additional necessary trainings will trespass national LMIC (mental) health budgets easily. North-South alliances and involvement of NGOs and/or other funding resources may be essential for covering the costs of the startup of programs, but also for the ongoing print, telephone and internet costs for the users. An early involvement of telecom providers, or other sponsors, can decrease these costs as well (toll free numbers and donations of free network time).

-It’s sad that the mental health field is and was no priority in many countries and international campaigns. But the gain now is that we can learn, lend and copy from other health fields, which are a long way ahead in eLearning and other innovations. A few examples above show that ‘the road is already paved’. A great resource in this context is the Preparing the next generation of community health workers: The power of technology for training Produced by Dalberg Global Development Advisors, May 2012.

Roos Korste, psychologist, trainer, blogger and founder of in2mentalhealth