Scaling up care for perinatal depression for improved maternal and infant health (SPECTRA): protocol of a hybrid implementation study of the impact of a cascade training of primary maternal care providers in Nigeria

(2021) 15:73 Gureje et al. Int J Ment Health Syst https://doi.org/10.1186/s13033-021-00496-6 International Journal of Mental Health Systems Open Access STUDY PROTOCOL Scaling up care for perinatal depression for improved maternal and infant health (SPECTRA): protocol of a hybrid implementation study of the impact of a cascade training of primary maternal care providers in Nigeria Oye Gureje1*, Bibilola Oladeji1, Olatunde Olayinka Ayinde1, Lola Kola1, Jibril Abdulmalik1, Waheed Akinola Lanre Abass2, Neda Faregh3 and Phyllis Zelkowitz4,5 Abstract Background: The large treatment gap for mental disorders in low- and middle-income countries (LMIC) necessitates task-sharing approaches in scaling up care for mental disorders. Previous work have shown that primary health care workers (PHCW) can be trained to recognize and respond to common mental disorders but there are lingering questions around sustainable implementation and scale-up in real world settings. Method: This project is a hybrid implementation-effectiveness study guided by the Replicating Effective Programmes Framework. It will be conducted in four overlapping phases in maternal care clinics (MCC) in 11 local government areas in and around Ibadan metropolis, Nigeria. In Phase I, engagement meetings with relevant stake holders will be held. In phase II, the organizational and clinical profiles of MCC to deliver chronic depression care will be assessed, using interviews and a standardized assessment tool administered to staff and managers of the clinics. To ascertain the current level of care, 167 consecutive women presenting for antenatal care for the first time and who screened positive for depression will be recruited and followed up till 12 months post-partum. In phase III, we will design and implement a cascade training programme for PHCW, to equip them to identify and treat perinatal depression. In phase IV, a second cohort of 334 antenatal women will be recruited and followed up as in Phase I, to ascertain post-training level of care. The primary implementation outcome is change in the identification and treatment of perinatal depression by the PHCW while the primary effectiveness outcome is recovery from depression among the women at 6 months post-partum. A range of mixed-method approaches will be used to explore secondary implementation outcomes, including fidelity and acceptability. Secondary effectiveness outcomes are measures of disability and of infant outcomes. Discussion: This study represents an attempt to systematically assess and document an implementation strategy that could inform the scaling up of evidence based interventions for perinatal depression using the WHO mhGAP-IG in LMIC. Trial registration This study was registered on 03 December, 2019. https://doi.org/10.1186/ISRCTN94230307. *Correspondence: 1 Department of Psychiatry, University of Ibadan, Ibadan, Nigeria Full list of author information is available at the end of the article © The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Gureje et al. Int J Ment Health Syst (2021) 15:73 Page 2 of 15 Keywords: Perinatal depression, Primary care, Implementation study, MhGAP-IG Background It is now commonly accepted that the mental health treatment gap in low- and middle-income countries (LMIC) requires a shift in policy and health planning in which focused attention is given to the horizontal integration of mental health into primary and maternal health care. This is because not only is mental health care an integral component of holistic, person-centred maternal care, there are also inherent benefits to perinatal women when mental health is embedded within routine maternal care. Some of these benefits include early and increased detection of mental health conditions, improved accessibility to mental health care, reduced stigma, as well as an intimate link of mental health to the maternal care needs of perinatal women [1]. The case for the integration of mental health into routine maternal care is further strengthened by the fact that the material and human resources necessary to respond to the burden of mental disorders, including perinatal depression, are grossly inadequate in most LMIC. For example, Nigeria has about 250 practicing psychiatrists for a population of over 200 million people [2]. The situation is worse for other mental health specialists such as clinical psychologists and social workers. The few available specialists are mostly based in urban areas and are therefore inaccessible to the majority of the population who resides in rural settings. The integration of mental health into primary care requires that the providers at that level of care are empowered with the skills necessary for them to offer basic but essential service for common mental health problems. A recent situation analysis of maternal mental health in primary care in five LMIC (India, Nepal, Uganda, South Africa and Ethiopia) [3] found that while most of the countries had a national mental health policy that included maternal mental health, almost all of them did not have a national plan that included dedicated maternal mental health services. In all of the LMIC, perinatal women could only access mental health services through referral to mental health specialists at district or specialist centres, some of which were several kilometres away. Perinatal depression occurs in up to 10% of women prenatally and 13% postnatally in high-income countries [4]. There is evidence suggesting higher rates in LMIC. In a recent systematic review, the weighted mean prevalence for common perinatal mental disorders was 16% in the antenatal period and 20% postnatally in LMIC [5]. Perinatal depression is associated with long-term adverse consequences for maternal wellbeing and infant development. Perinatal depression is associated with suffering and loss of productivity [6], and is an important risk factor for maternal suicide [7]. Child adverse consequences (...truncated)