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Evaluating process and clinical outcomes of a primary care mental health integration project in rural Rwanda: a prospective mixed-methods protocol
  1. Stephanie L Smith1,2,3,
  2. Claire Nancy Misago4,
  3. Robyn A Osrow5,
  4. Molly F Franke1,
  5. Jean Damascene Iyamuremye4,
  6. Jeanne D'Arc Dusabeyezu4,
  7. Achour A Mohand4,
  8. Manzi Anatole2,
  9. Yvonne Kayiteshonga4,
  10. Giuseppe J Raviola1,2
  1. 1Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
  2. 2Partners in Health, Boston, Massachusetts, USA
  3. 3Division of Medical Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
  4. 4Mental Health Division, Rwanda Biomedical Center, Kigali, Rwanda
  5. 5Doctors without Borders, Nairobi, Kenya
  1. Correspondence to Dr Stephanie Smith; stephanie_smith{at}


Introduction 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.

Methods and analysis 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.

Ethics and dissemination 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.


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  • Contributors SLS developed the proposal concept, drafted the proposal and is a coprincipal investigator of the study. CNM is a coprincipal investigator of the study and provided critical revisions to the manuscript. RAO was a technical advisor for the IMB MH programme and revised critically for content. MFF provided statistical analysis support and revised critically for content. JDI, JDD and AAM manage different aspects of the national mental health programme in Rwanda, and revised the manuscript critically for content. MA provided contextual inputs and critical revisions. YK leads the national mental health programme in Rwanda and revised critically for content. GJR supported the initial development and strategic focus of the IMB mental health programme leading to the current intervention, leads the PIH mental health programme, mentored and supervised SLS as the principal investigator, advised the IMB mental health team, advised the proposal creation and provided critical revisions to the manuscript.

  • Funding This work is generously supported by Dr Rick and Nancy Moskovitz, and by Dr Stephen Kahn and the Abundance Foundation.

  • Competing interests None declared.

  • Ethics approval Rwanda National Ethics Committee (RNEC).

  • Provenance and peer review Not commissioned; externally peer reviewed.

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