title: Evaluating process and clinical outcomes of a primary care mental health integration project in rural Rwanda: a prospective mixed-methods protocol.
abstract: Integrating mental healthcare into primary care can reduce the global burden of mental disorders. Yet data on the effective implementation of real-world task-shared mental health programmes are limited. In 2012, the Rwandan Ministry of Health and the international healthcare organisation Partners in Health collaboratively adapted the Mentoring and Enhanced Supervision at Health Centers (MESH) programme, a successful programme of supported supervision based on task-sharing for HIV/AIDS care, to include care of neuropsychiatric disorders within primary care settings (MESH Mental Health). We propose 1 of the first studies in a rural low-income country to assess the implementation and clinical outcomes of a programme integrating neuropsychiatric care into a public primary care system.
  
  
  
  A mixed-methods evaluation will be conducted. First, we will conduct a quantitative outcomes evaluation using a pretest and post-test design at 4 purposively selected MESH MH participating health centres. At least 112 consecutive adults with schizophrenia, bipolar disorder, depression or epilepsy will be enrolled. Primary outcomes are symptoms and functioning measured at baseline, 8 weeks and 6 months using clinician-administered scales: the General Health Questionnaire and the brief WHO Disability Assessment Scale. We hypothesise that service users will experience at least a 25% improvement in symptoms and functioning from baseline after MESH MH programme participation. To understand any outcome improvements under the intervention, we will evaluate programme processes using (1) quantitative analyses of routine service utilisation data and supervision checklist data and (2) qualitative semistructured interviews with primary care nurses, service users and family members.
  
  
  
  This evaluation was approved by the Rwanda National Ethics Committee (Protocol #736/RNEC/2016) and deemed exempt by the Harvard University Institutional Review Board. Results will be submitted for peer-reviewed journal publication, presented at conferences and disseminated to communities served by the programme.
authors.affiliation: Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.|Partners in Health, Boston, Massachusetts, USA.|Division of Medical Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA.
authors.forename: Stephanie L
authors.initials: SL
authors.lastname: Smith
authors.affiliation: Mental Health Division, Rwanda Biomedical Center, Kigali, Rwanda.
authors.forename: Claire Nancy
authors.initials: CN
authors.lastname: Misago
authors.affiliation: Doctors without Borders, Nairobi, Kenya.
authors.forename: Robyn A
authors.initials: RA
authors.lastname: Osrow
authors.affiliation: Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Molly F
authors.initials: MF
authors.lastname: Franke
authors.affiliation: Mental Health Division, Rwanda Biomedical Center, Kigali, Rwanda.
authors.forename: Jean Damascene
authors.initials: JD
authors.lastname: Iyamuremye
authors.affiliation: Mental Health Division, Rwanda Biomedical Center, Kigali, Rwanda.
authors.forename: Jeanne D'Arc
authors.initials: JD
authors.lastname: Dusabeyezu
authors.affiliation: Mental Health Division, Rwanda Biomedical Center, Kigali, Rwanda.
authors.forename: Achour A
authors.initials: AA
authors.lastname: Mohand
authors.affiliation: Partners in Health, Boston, Massachusetts, USA.
authors.forename: Manzi
authors.initials: M
authors.lastname: Anatole
authors.affiliation: Mental Health Division, Rwanda Biomedical Center, Kigali, Rwanda.
authors.forename: Yvonne
authors.initials: Y
authors.lastname: Kayiteshonga
authors.affiliation: Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.|Partners in Health, Boston, Massachusetts, USA.
authors.forename: Giuseppe J
authors.initials: GJ
authors.lastname: Raviola
mesh_terms: D003150:Community Health Workers / Q000193:education*; D019033:Delivery of Health Care, Integrated / Q000379:methods / Q000592:standards*; D006801:Humans; D001523:Mental Disorders / Q000628:therapy; D008605:Mental Health Services; D010043:Outcome and Process Assessment, Health Care; D011320:Primary Health Care; D011446:Prospective Studies; D012107:Research Design; D012424:Rural Population; D012432:Rwanda; D011795:Surveys and Questionnaires
keywords: MENTAL HEALTH; PUBLIC HEALTH