Combining mHealth Technology and Pharmacotherapy to Improve Mental Health Outcomes and Reduce Human Rights Abuses in West Africa: Intervention Field Trial

Background: In West Africa, healers greatly outnumber trained mental health professionals. People with serious mental illness (SMI) are often seen by healers in “prayer camps” where they may also experience human rights abuses. We developed M&M, an 8-week long dual-pronged intervention involving a) a smartphone-delivered toolkit designed to expose healers to brief psychosocial interventions and to encourage them to preserve human rights (M-Healer app), and b) a visiting nurse who provides medications to their patients (Mobile Nurse). Objective: To examine the feasibility, acceptability, safety, and preliminary effectiveness of the M&M intervention in real-world prayer camp settings. Methods: We conducted a single-arm field trial of M&M with people with SMI and healers in a prayer camp in Ghana. Healers were provided with smartphones with M-Healer installed and were trained by practice facilitators to use the digital toolkit. In parallel, a study nurse visited their prayer camp to administer medications to their patients. Clinical assessors administered study measures to participants with SMI at pre-treatment (baseline), mid-treatment (4 weeks) and post-treatment (8 weeks). Results: Seventeen participants were enrolled in the study and most (n=15, 88.3%) were retained. Participants had an average age of 44.3 (SD: 13.9) and 59% (n=10) were male. Fourteen participants (82%) had a diagnosis of schizophrenia and two participants (18%) were diagnosed with bipolar disorder. Four healers were trained to use M-Healer. On average, they self-initiated app use 31.9 (SD: 28.9) times per week. Healers watched an average of 19.1 videos (SD: 21.2), responded to 1.5 prompts (SD: 2.4), and used the app for 5.3 days (SD: 2.7) weekly. Pre/post analyses found a statistically significant and clinically meaningful reduction in psychiatric symptom severity (Brief Psychiatric Rating Scale: 52.3 to 30.9; Brief Symptom Inventory: 76.4 to 27.9), psychological distress (Talbieh Brief Distress Inventory: 37.7 to 16.9) shame (Other as Shamer Scale: 41.9 to 28.5), and stigma (Brief Internalized Stigma of Mental Illness Scale: 11.8 to 10.3). We recorded a significant reduction in days chained (1.6 to 0.5) and a promising trend for reduction in days of forced fasting (2.6 to 0.0, p = 0.059). We did not identify significant pre/post changes in patient-reported working alliance with healers (Working Alliance Inventory), depressive symptom severity (Patient Health Questionnaire-9), quality of life (Lehman Quality of Life Interview for the Mentally Ill), beliefs about medication (Beliefs about Medications Questionnaire – General Harm sub-scale) or other human rights abuses. No major side effects, health and safety violations, or serious adverse events occurred over the course of the trial. Conclusions: The M&M intervention proved to be feasible, acceptable, safe, and clinically promising. Preliminary findings suggest the M-Healer toolkit may have shifted healer behaviors at the prayer camp so that they commit fewer human rights abuses.