Integrating mental health into primary care: Implementation outcomes and clinical impact of the Health Action for Psychiatric Problems In Nigeria including Epilepsy and SubstanceS (HAPPINESS) intervention

Abstract

Abstract Background Access to mental health care in low- and middle-income countries like Nigeria remains suboptimal. Integrating mental health care into primary care using a stepped-care, task-sharing approaches improves access. Research evidence on best model to scale up these approaches are needed. The Health Action for Psychiatric Problems In Nigeria including Epilepsy and SubstanceS (HAPPINESS) intervention is a multi-component, community-based, mobile technology-supported intervention developed to integrate mental health into primary health care centers in Nigeria using the World Health Organization's Mental Health Gap Action Programme-Intervention Guide (mhGAP-IG). This study evaluates the implementation outcomes and patient-level clinical impact of the HAPPINESS intervention. Methods Using a quasi-experimental design (single cohort with pre- and post- measures) and the Wilcoxon Signed Rank Test, Mann-Whitney U and Kruskal Wallis tests we assessed changes in psychiatric symptoms among patients treated for mental, neurological and substance use disorders through the HAPPINESS intervention using their scores on the Patient Health Questionnaire-9 and Brief Psychiatric Rating Scale at baseline and 6 months post-intervention. The implementation outcomes (feasibility, adoption, and fidelity) were assessed using Proctor’s implementation outcome framework. Results The HAPPINESS intervention implementation demonstrated high feasibility with robust site recruitment and 100% training completion rate. The adoption rate was high with 84% of the sites actively implementing the HAPPINESS intervention at 12 months. Fidelity to the intervention protocol (screening, assessment, treatment, follow up, referrals and consultation) was 81%. Patients’ retention rate in care at 6 months was 91% and at 12 months was 86%. The Wilcoxon Signed Rank Test showed a statistically significant reduction in PHQ-9 scores from baseline (Md = 9.5) to 6 months (Md = 3.0) post-intervention (z = 80.5, p < 0.001), with a large effect size (r = 0.8) and statistically significant reduction in BPRS scores from baseline (Md = 36.0) to 6 month (Md = 17.0) post-intervention (z = 128.5, p < 0.001), with a large effect size (r = 0.9). Conclusion This study adds to the growing evidence of the feasibility, effectiveness, role of mobile technology and potential for mhGAP-IG-based efforts to scale up mental health services through primary health care to increase access to evidence-based interventions in Nigeria.