One of the key issues we identified in the study of Grand Challenges in Global Mental Health was the need to integrate screening and core packages of services into routine primary health care; and to provide effective and affordable community-based care and rehabilitation. Linked to these challenges were research questions that included: How effective are brief screening tools for the detection of mental, neurological and substance abuse (MNS) disorders in routine care settings? and How effective are interventions for serious mental disorders delivered by lay health workers?
To answer this set of challenges and questions Grand Challenges Canada is funding a project in Kenya to identify at an early stage those children who have learning and communication disabilities, emotional problems and neuro-developmental conditions. The PIs are Professors David Ndetei of the African Mental Health Foundation and Kwame McKenzie of the University of Toronto. What they are trying to achieve is to promote mental wellbeing and prevent mental illness, to facilitate interventions for those children that need them, and thereby to reduce the huge treatment gap for children. The project is called KIDS, derived from The Kenya Integrated Intervention Model for Dialogue and Screening to Promote Children’s Mental Wellbeing.
There are very few screening programs of this kind in low- and middle-income countries (LMICs) and so it will be really important to evaluate not only the efficacy and feasibility of this program, but more importantly, its potential for scalability.
The team is already making substantial progress. They are engaging stakeholders (students, teachers, parents, health providers etc.) and have significant buy-in from the Ministry of Education. They have gained respectful and trusted entry into the communities where the pilot studies are being conducted. Normative data has been collected from 25 schools. A PhD student is assessing and describing language and communication in schoolchildren as a baseline for identifying deficiencies that will become part of the larger screening process.
These are quite early days for the study but at the Annual Grand Challenges meeting in Rio de Janeiro in October 2013 we learnt that so far 6000 children between the ages of 6 and 13 years have already been screened. The results are now being analyzed. I asked Professor Ndetei what are some of the issues they are facing. My interest here is to understand the ethical, legal and social issues arising from screening children for mental health conditions in LMICs. We ourselves at the University of Toronto have just launched a major Delphi study, led by our PhD student Fabio Salamanca-Buentello, to identify just such issues and so I was very keen to see what the KIDS team in the field was facing. Professor Ndetei told me that one of the issues they face is how to maintain confidentiality so as not to stigmatize the children who need interventions. One of my questions was about who in the system will provide the necessary interventions. What I learned was that the African Mental Health Foundation is actually training school counsellors and psychologists for these interventions, and working with specialized consultants to provide the children with life skills. But that is not all. The project does a few more things like setting up kids’ peer-to-peer clubs to help develop kids’ mental health. Students who run the clubs will be supported to help others get the help they need. Parent psycho-education and support groups will be set up. And there will be support and education for teachers to understand mental health problems and how they present. There will be direct links from the schools to the primary care workers who will specialize in mental health and offer pathways to care for those who are identified as having a need for treatment.
Professor McKenzie told me “We expect kids to get the help they need early, but we also expect that changing attitudes to mental health issues through this whole school activity will help kids who have difficulties that fall short of needing professional treatment, to get the support they need from their peers and also from their family.” He added “School mental health is vitally important if Africa is going to build its human resources and so its economies. The support of the ministry of education shows that they understand how important emotional intelligence and mental health are to the future of their children”
Poverty and ill health are cosy bedfellows. Poverty is a major social determinant of poor mental health. If you drive on the streets of Nairobi you would be forgiven in thinking that Kenya is now a middle income country, that there was very little poverty. But listening to Professor Ndetei a very different picture emerges. He said that working in the communities where the study is being undertaken has been a shocking experience for him and his colleagues. The poverty is so marked that some of the staff have been unable to cope psychologically and are considering resigning. We may think we know about poverty but there is a huge gap between understanding something in theory and being faced with it on the ground.