Country Contextualization of the Mental Health Gap Action Programme Intervention Guide: A Case Study from Nigeria

The global burden of disease (GBD) study clearly brought to the fore the societal impact of mental health conditions, with the finding that neuropsychiatric conditions account for about 14% of the total disease burden [1]. The extent of this burden has been further emphasized by recent large-scale global surveys, which indicate that not only are mental disorders highly prevalent worldwide, but also that a huge treatment gap exists in both developed and developing countries [2],[3]. Furthermore, there is evidence to demonstrate that effective and affordable treatment for common mental disorders is feasible, even in low- and middle-income countries (LMICs) [4]. Several barriers and constraints in these countries have led to a situation where those with the greatest need for mental health services often lack access to these services [5]. It has therefore become imperative to seek innovative solutions to these global mental health challenges [6]–[8]. Current evidence favours innovative solutions that would result in overall health system strengthening, integrated provision of services [9], and improved access to evidence-based packages of care through task-shifting [10] As a way of confronting this global challenge, the World Health Organization (WHO) recently launched a programme of action to help countries implement activities aimed at narrowing the gap between need and available services for mental health care. This programme, the Mental Health Gap Action Programme (mhGAP), is designed to assist LMICs in their efforts to scale up the coverage of mental health services for their citizens [11]. An important component of the programme is the development of the mhGAP-Intervention Guide (mhGAP-IG), a manual designed to facilitate the recognition and management of a set of priority mental, neurological, and substance use (MNS) disorders in non-specialist settings. The manual is the product of a rigorous international expert consensus on the most burdensome MNS conditions, and describes approaches to their recognition and the provision of evidence-based interventions, both pharmacological and non-pharmacological, for alleviating these conditions. The priority conditions covered by the mhGAP-IG are depression, psychosis, dementia, bipolar disorder, epilepsy, behavioural disorders, developmental disorders, alcohol use disorders, drug use disorders, and suicide and self harm. The guide provides information on the diagnosis of each condition and the common interventions that can be offered to sufferers by non-specialists. Particular emphasis is placed on the use of commonly available non-pharmacological interventions wherever evidence exists for their efficacy. Referrals to the next level of care are suggested when such are indicated. The process of developing this tool was based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to generate an evidence-based, intervention package [12],[13]. Furthermore, the mhGAP-IG is not a stand-alone tool, but comes with a range of supporting technical tools, which includes a facilitator's guide for each module, a contextualization questionnaire, and tools for monitoring and evaluating its use. There is wide variability in local circumstances among countries, both in regard to the organization of their health systems and the availability of resources to deliver the recommended interventions. Furthermore, differences also exist in the composition and training of health care personnel, loosely referred to as "non-specialists." For example, in some countries these may be highly skilled doctors with postgraduate training in family medicine or general practice while in some others, especially in low resource settings, such providers may be community health workers with minimal training. For these reasons, it is recommended that a process of contextualization of the generic version of the mhGAP-IG be implemented in each country setting in order to produce a fully adapted version that meets with the needs of the extant health system in which it is to be used. This paper describes the process of adaptation and contextualization of the manual for the Nigerian health system, a system with broad similarities with those of many sub-Saharan African countries.