Implementation of the Mental Health Gap Action Programme (mhGAP) in Kosrae State in the Federated States of Micronesia

Introduction

Improving access to mental health care is a global health priority, particularly for low- and middle-income countries. One strategy is World Health Organization’s (WHO) Mental Health Gap Action Programme (mhGAP), which provides evidence-based guidance for managing mental, neurological, and substance abuse conditions. mhGAP has been implemented in more than 90 countries including several Pacific Island countries.^1,2 Despite this widespread training, many Pacific Island countries have few health care workers trained and mhGAP implementation remains low. Access to mental health across Micronesia is limited as the region is composed of small remote islands with a limited mental health workforce. The estimated mental health treatment gap in Micronesia is over 90%. ³ We describe the implementation of mhGAP training in Kosrae state, Federated States of Micronesia (FSM). We incorporated 2 modifications to traditional mhGAP training: (1) combination of in-person and online training and (2) longitudinal posttraining support.

Methods

mhGAP training was conducted in collaboration between Kosrae Community Health Center (KCHC) and the University of Hawai’i Department of Psychiatry (UH). Two UH psychiatrists trained 18 KCHC members including doctors, nurses, and community health workers. 25% of the content was covered online and 75% during a 1-week in-person training. All mhGAP units were covered except Epilepsy. After training, the KCHC mental health team (2 nurses and 1 physician) and UH psychiatrists met weekly online for longitudinal support.

This study did not require institutional review board approval as it was deemed professional development/quality improvement and not human subjects research by the University of Hawai’i Research Compliance Department.

Results

Initial feedback to mhGAP training was positive. Participants reported that mhGAP was clinically useful, materials were appropriate, and saw behavioral health training as a priority. However, providers were most comfortable doing group work with peers (eg, nurses with nurses). In interdisciplinary groups, latent hierarchies often emerged with the physician as leader, leaving many participants less engaged. We recommend grouping peer providers initially to build skills and then transitioning to interdisciplinary groups to facilitate a shared approach to behavioral health.

All participants strongly preferred in-person sessions to online training. Communication was easier, and trainers could better “read the room” in person. However, 1 week was not sufficient to cover all mhGAP modules; online sessions allowed additional training time and enabled valuable longitudinal support post-training. A reliable internet connection and computer system were critical.

One primary concern was how to apply mhGAP in Kosrae, and there were several suggestions. First, it would be helpful to practice applying mhGAP to de-identified KCHC patients. Second, more practice is needed during and after training to promote comfortable use of mhGAP Intervention Guide in everyday clinical care. Finally, we suggested after each mhGAP module, the team could brainstorm how to improve current KCHC practices using mhGAP.

Following mhGAP training, the KCHC mental health team and UH psychiatrists video-conferenced weekly for longitudinal support including case consultation, behavioral health education, and applying the mhGAP Intervention Guide to specific cases. An example of posttraining support is as follows: we discussed the case of a patient with recurrent panic attacks, followed the mhGAP protocol “Other Significant Mental Health Complaints” to discuss workup, reviewed the module’s management strategies including “Relaxation Training,” and discussed psychoeducation on panic attacks. We have used this strategy to assess multiple patients with different psychiatric complaints, most often mania and psychosis. We continue to work on integrating mhGAP protocols into KCHC’s routine clinical care. Based on our experience, we feel that completing mhGAP training without longitudinal support would be insufficient to promote significant change in clinical practice.

Discussion

In this article, we describe mhGAP training in Kosrae, FSM. Given the significant mental health treatment gap across Micronesia, this represents an important step in expanding mental health training to local providers. Our training model included two important modifications: (1) combination of in-person and online training and (2) longitudinal posttraining support.

Although in-person training is preferable when possible, online training offers less costly mhGAP training to remote regions and enables critical posttraining support. This can be particularly helpful in the Pacific as much of the population lives in small island developing states (SIDS) with few available mental health providers.^1,2 Given the significant impact of COVID-19 on mental health, expanding online mental health training is especially compelling. Before beginning an online training program, it is important to invest in building relationships between trainer/trainees, conduct stakeholder interviews to determine training priorities, assess the impact of local culture on perceptions of mental health, and ensure adequate technology. Based on our experience, a useful strategy is to begin training in person followed by online sessions for ongoing training and longitudinal support.

The longitudinal posttraining support was considered one of the most useful program components by participants, as even after mhGAP training, they wanted ongoing supervision to help apply mhGAP to their daily clinical work. The lack of routine posttraining support has been identified as a barrier to successful implementation of mhGAP. ¹

One primary limitation of our study was limited local adaptation of mhGAP specifically to Kosrae. KCHC members recommended that training would have been more helpful were it tailored to Kosraen culture, local patients, and KCHC clinical workflow.

Conclusion

Expanding WHO mhGAP training within Pacific Island Countries is an important strategy to improve access to mental health care. We describe implementation of mhGAP training in Kosrae, FSM. Our training model included two helpful modifications: (1) using online sessions, which enables delivery of mhGAP to remote areas; and (2) longitudinal support posttraining, which has been identified as an important factor in successful implementation of mhGAP.