NIHR SSCR: Evaluation of the Connecting People Intervention: A Pilot Study

To address the evidence gap in low and middle-income countries (LMIC) we assessed knowledge translation of social interventions for adults with mental health problems across economic boundaries using a systematic review of peer-reviewed literature. Our findings provide evidence for the successful translation of locally adapted social interventions to LMIC, though the specific knowledge translation mechanisms varied greatly. With only 23 studies meeting inclusion criteria for this review, further investigation is needed to ascertain the conditions surrounding knowledge translation of social interventions globally.

In July 2013 University of York Research Fellow, Meredith Fendt-Newlin, visited Sierra Leone to gain an understanding of existing mental health service needs and to evaluate the acceptability and feasibility of adapting a UK psychosocial intervention model to meet those needs. Strong local partnerships were established between the research institutions (UofY, KCL) and gatekeepers most familiar with the local mental health services in and around Sierra Leone’s three main cities (Freetown, Bo, Makeni).

Qualitative data were collected from interviews, focus groups and observations across a diverse range of actors involved in mental health care. Stakeholders strongly advocated for reform of mental health legislation, though it remains low on the policy agenda and laws are out-dated. Mental health services on the whole were extremely under-resourced, and the limited resources were typically concentrated in psychiatric hospitals; thus in practice there is weak integration of mental health into primary health care.

In Sierra Leone, the mental health treatment gap exceeds 95%, with one trained psychiatrist and one psychiatric hospital for a population over six million. Although training was completed for 21 mental health nurses, focus was placed on the medical model, which is problematic in a country with poor access to medications. Upon graduating in 2013, the nurses were allocated to district hospitals across the country with referral pathways reaching into the rural communities. Efforts to enhance the mental health services have been growing, however, evidence-based, socially robust care that is integrated with the existing health system is greatly needed.

Findings from the feasibility study indicate enthusiasm for the potential of social interventions to promote meaningful involvement for adults with mental health problems, aiding in their recovery and enhancing social inclusion. People with mental health problems represent one of the most stigmatised and vulnerable groups in the country. Therefore, advocacy was seen as a necessary component to models of care including enhancing public awareness of mental illness to reduce stigma.

Data points to a significant need for training in low-cost psychosocial approaches to mental health care at both the district and community levels. A joint approach of both individual care and community support is vital. For example, mental health nurses who support individuals to deepen links within their communities, especially with families, were viewed as necessary for recovery. Communities in Sierra Leone play an integral role in facilitating social interaction and inclusion in meaningful activities; enhancement of such links may conceivably improve wellbeing for adults with mental health problems.

FINDINGS/RESULTS
Results from the feasibility study were used to develop the Sababu Intervention Model and Training Programme, a locally adapted version of the CPI which has been found to be an acceptable and feasible approach to meet the needs of people with mental health problems in Sierra Leone. In Krio, ‘sababu’ means connections with other people, in particular, benefiting from connections with other people. Suggested as a suitable name for the training programme by members of the MHC, Sababu relates to the notion of social capital which describes the connections among people and the shared value that arises from such connections. Sababu offers techniques for training mental health workers within a social intervention framework. We have contextualised language, activities and theory to ensure the bespoke training materials are culturally sensitive, thus enhancing retention and sustainability. Sababu has now been piloted in Sierra Leone with the group of (20) mental health nurses and three month follow-up data is being analysed to determine its effectiveness.

COLLABORATIONS
Research collaborations have been strengthened with King’s Centre for Global Health- King’s Sierra Leone Partnership, and set-up collaborations with Enabling Access to Mental Health in Sierra Leone, The University of Makeni, the Mental Health Coalition, and the World Health Organisation in Sierra Leone.


STAFF
This research has been conducted by the project investigators and no staff have
been employed specifically to undertake it.

COMMERCIALISATION/TRANSLATION
Throughout this study
strong partnerships have been established across a number of sectors in Sierra
Leone including: 1) community members, including religious leaders and lay people; 2)
local and international NGOs working in health and mental health service
development; 3) mental health professionals, including specialist psychiatric nurses and managers/supervisors; 4) policy makers in the Ministry of Health and Sanitation, and Ministry of Social Welfare; and 5) institutions involved in training future leaders in mental health and social work, including University of Makeni and Fourah Bay College.

In light of the Ebola outbreak, which reached Sierra Leone in May 2014, iterations to the Sababu Intervention were made to address the changing needs of the local during a humanitarian crisis. The training programme we developed and piloted in 2015 has been picked-up by local and international organisations, aspects of it have been used to train community health officers (CHOs) by the World Health Organisation as part of the Ebola Response Initiative.

APPLICATIONS SUBMITTED
We have taken a staged approach to the project, applying for smaller grants to support each stage of the project (feasibility, stakeholder development and training programme facilitation, evaluation of the training programme, and eventually the larger pilot and taking the adapted model to other low and middle income countries). This allows us to ensure a collaborative approach to the research with Sierra Leonean partners to meet the local needs.

Awarded, PI: Martin Webber, August 2013, Connecting People in Sierra Leone Filming, Wellcome Trust/C2D2, £1680.
Shortly after the first visit to Sierra Leone in July 2013 we were awarded a second grant from C2D2 Outreach Fund to create a short promotional video of the feasibility study in Sierra Leone. The film was launched at the C2D2 Conference at University of York in September 2013 and can be viewed here: https://youtu.be/XIXSQMNldF8

Awarded, PI: Martin Webber, September 2013, Translating social theory and mental health interventions in Sierra Leone, Maudsley Charity, £14437.
In 2013 we applied and were awarded £14,437 from the Maudsley Charity to continue the project after the feasibility study funded by C2D2. This funded two subsequent vists to Sierra Leone. The first, in May 2014 was to obtain ethics and Ministry of Health and Sanitation approval for the intervention pilot study and to run creative sessions with stakeholders to further develop the practice model and training programme. The second visit in April 2015 was to pilot the training with a group of 20 mental health nurses.

Awarded, PI: Martin Webber, April 2015, Teaching and learning filming project, Rapid Response Fund, University of York Teaching Committee, £1680.
In April 2015 we were awarded £1680 to develop high-quality and accessible learning materials to train students in how to adapt evidence-based social interventions for use with service users from diverse cultural backgrounds, such as black and minority ethnic (BME) groups, and migrant populations. Using Sierra Leone as an exemplar, the learning and teaching materials will be used to teach students how models can be adapted and used effectively in their own practice, offering a research-enriched teaching and learning opportunity.

Awarded, Meredith Newlin, April 2015, Dissertation Fellowship, American Association for University Women (AAUW), $20000USD.
Researcher Meredith Fendt-Newlin was also awarded a Dissertation Fellowship for $20,000 USD from the American Association for University Women (AAUW) to write her PhD dissertation fulltime in 2015-2016, reporting on findings from the project in Sierra Leone.