After numerous video calls among the project consortium, it was clear that each partner country is sliding into national lockdown. These lockdowns were limiting domestic and international mobility, causing the consortium to make a decision to postpone the planned project meetings in South Africa until the situation stabilizes. Unfortunately, it is still unclear whether the project consortium will be able to implement any of the remaining face-to-face meetings.

What kind of actions has MEGA taken to tackle the damaged caused by COVID-19?

As a consortium that mainly represents the healthcare field, MEGA was in an advantaged position to understand the impending pandemic. Therefore, the MEGA consortium was prepared to implement some rapid changes in order to soften any possible damage caused by COVID-19. The first step was to ensure the safety of project participants and partners. This is why the MEGA consortium decided to cancel all physical meetings in Europe and Africa, transferring all the remaining project meetings to online platforms. Implementation of activities which were intended for the general public (e.g. seminars, trainings) was tackled by establishing tailor-made materials, which would replace the initially planned physical meetings and seminars.

The situation with piloting the MEGA mobile application was a bit more complicated, due to limited interaction with project stakeholders caused by the pandemic. As the MEGA app had to be tested in real-life settings by project stakeholders (nurses, clinical officers, etc.), the consortium could not use any digital tools or online platforms to replace the face-to-face testing period. However, the MEGA consortium strongly believes that the health of the primary healthcare specialist is more important than the overall project results. Fortunately, nurses in several South African and Zambian clinics were able to use the MEGA app while fulfilling their daily duties and, thus, the project was able to collect the necessary data.

What can MEGA and other KA2-projects/EU learn from the pandemic?

The pandemic period has been an excellent learning curve for both the funder and the beneficiaries. Communication during the lockdown period has shown that almost all partners have access to a solid internet connection and online tools. However, we have observed that consortiums (not only MEGA) are not advancing these tools as often as they could. Therefore while planning new projects, e-toolkits should be more commonly used.

As it is still quite difficult to predict when the current pandemic will end, consortiums need to advance the lessons learned and work on implementation strategies that are more reliant on different e-solutions. Fortunately, the MEGA consortium has already taken many necessary steps to become more virtual. Thus, project funder could collect these case studies and develop guidelines on how to develop a virtual working environment and how to shift work online.

The risk assessment will be more closely reviewed while preparing new projects. The future project consortiums have to practice out of the box thinking and be prepared for situations, which might not even happen. Therefore, also the funder should put more emphasis on risk assessment plans and closely review how the future projects are estimating possible risks. Project consortiums have to be ready to tackle unexpected issues.

Students in the Faculty of Health Sciences are trained by 600 academic staff members located in four schools, namely Dentistry, Healthcare Sciences, Health Systems and Public Health and Medicine. Training is in partnership with the Gauteng Health Department in Steve Biko, Kalafong and Weskoppies Hospitals and Mpumalanga’s Witbank Hospital and its community.

From left to right:

Dr Gerhard P Grobler, the principal psychiatrist and head of the clinical unit Psychiatry at Steve Biko Academic Hospital, in partnership with the Department of Psychiatry. He is the co-investigator and national lead in South Africa, as well as a lead researcher & project manager for the MEGA project.

Tumisang Chiloane is a research assistant at the University of Pretoria and has also been involved in the MEGA project as a trainer for participating clinics at the UP site.

In the MEGA project, the UP team is responsible for the implementation and evaluation of the mobile application, which involves establishing contact with the relevant political and health care authorities at the selected health care districts in South Africa and Zambia.

The healthcare workers at participating sites in Pretoria have been trained and are equipped to initiate the implementation of the MEGA mobile application. The post-evaluation of the training suggests that the primary healthcare workers are comfortable with incorporating the MEGA app into their daily practice. They will require some technical support and regular visits to troubleshoot any issues pertaining to the use of the app.

Against all the odds, Free State continued with the implementation of the mobile application screening tool throughout the lockdown. Even though patient numbers declined drastically, hope springs eternal. All our trained nurses are positive about the new tool and problems with the use thereof have been few and far between. Nurses report finding the mobile application especially useful as it raised new awareness of mental health problems in their teenage patients, and because it made them realise that mental health screening has been neglected.

It has further been reported by one of the Free State MEGA nurses that she believes that her use of the mobile tool already saved more than one life as she detected severe mental health problems and suicidal tendencies in some of her young patients. Another reported that she now realises that mental health problems often stem from the difficult circumstances teenagers are faced with every day, including poverty, violence and substance use, and that they themselves often employ substance abuse to numb emotional pain and despair.

Importantly, the use of the mobile tool called attention to a myriad of gaps in the functioning of the mental health care system, to the degree that, at times, it seems to be ill-equipped to meet demands for particularly secondary and tertiary mental health care. The Free State will continue to implement the mobile tool still for some months and the team is looking forward to conducting focus group discussions at the end of the pilot.

Screening a young mother

The six-hour workshops covered two main topics, firstly training on a variety of mental health-related themes as contained in the MEGA training handbook developed by Hamburg and Turku Universities of Applied Science partners; and secondly how to use the MEGA mobile application (app), developed by our partners at the Riga Technical University, for the purpose of assessing for mental health problem onset in youth. Collectively, the eight Free State nurses trained, work in a variety of primary health care (PHC) facility departments, including HIV&AIDS/antiretroviral treatment (ART); tuberculosis (TB); integrated management of childhood illnesses (IMCI); maternal and child health; antenatal care; family planning;  and the chronic and the acute conditions departments. Ten to 19-year olds visiting facilities for a wide variety of purposes will, therefore, be screened with the app. Our nurses expressed excitement to be part of the research. The Free State team experienced difficulty recruiting participants to implement the app in PHC facilities, due to severe understaffing. As a result, the pilot group in the Free State is quite small. However, despite these challenges, the MEGA team here is determined to make a great success of the pilot project over the next six months.

Free State MEGA team training of nurses, 31 January 2020

Throughout the lengthy preparation phase for the training, there was a growing awareness that the MEGA training needs to offer learning opportunities for a heterogeneous group of trainees with diverse educational and cultural backgrounds. We, therefore, tried to produce compact learning material consisting of sound information about youth mental health issues in a way that opens up a space for discussion and reflection, Most of all we want to equip practitioners with a new skill – how to use the MEGA app.  The MEGA curriculum is split up in modules and trainers follow a manual in the form of a powerpoint presentation, which guides them step-by-step through a 6-hour training course. In order to guarantee a level of standardization, trainers should orientate towards the notes and follow the curriculum as much as possible. However, if there is a lack of time, the principle “less is more” applies. If the group of trainees is fairly advanced, the (online) material offers a variety of further readings.

The results of a short evaluation questionnaire all participants filled out after the training day show that the MEGA “Training the Trainer” course in Cape Town proved to be a success. Trainees enjoyed the mix of presentation, large and small group discussion and the hands-on practice session using the app in a role-play setting. They gave valuable feedback for the final revision of the MEGA app, which was appreciated by our partners from Riga who are launching the final version of the app. The MEGA trainers are ready to rumble and the MEGA team is excited to roll out the MEGA training in February 2020!

From right to left:

Prof. Dan Stein, Professor and Head of the Department of Psychiatry & Mental Health. He is a clinician-scientist, educator-mentor, and advocate-leader in the fields of neuroscience and mental health.  His specific focus for more than two decades has been on anxiety disorders, obsessive-compulsive and related disorders, and trauma- and stress-related disorders (i.e., anxiety and related conditions). He has contributed to the field via collaboration, mentorship, and publication.

Dr. Adele Pretorius, Senior Programme Manager in the Department of Psychiatry and Mental Health. She is a Clinical Psychologist and holds a PhD in Biosystems Engineering. She has been managing large multi-site research studies in the Department since 2014. Previously, she has managed multi-national projects related to human performance and safety in the private sector in South Africa.

Deborah Jonker, Project Manager and PhD student in the Department of Psychiatry and Mental Health. She is a research psychologist with an interest in integrative transdisciplinary approaches to neuroscience and public mental health. Her PhD focuses on the complications arising from prenatal substance exposure and maternal mental health risk factors on children in early life.

Weslin Charles, Research Assistant in the Department of Psychiatry & Mental Health. She has been involved in various mental health research projects for the past 10 years with a specific focus on the impacts of substance use on children in the South African context.

The UCT team is enthusiastic to be a collaborator in this partnership that will aim to integrate both good practice and science to design a mobile health application to screen for common child and adolescent mental health problems in primary health care (PHC) settings.

The University has a student population of about 26,000 students at both undergraduate and postgraduate levels with approximately 300 academic staff members and support staff. The University offers more than 157 programmes at both undergraduate and postgraduate levels. The school of Nursing Sciences is one of the 13 Schools of the University of Zambia. The School offers both undergraduate and postgraduate degrees in Clinical Nursing, Maternal and Child Health, Community and Global Health, and Psychiatry and Mental Health Nursing. The School runs both onsite and distance programmes for undergraduates. The Erasmus+ MEGA Project is hosted within the Mental Health Department of the School. The Project is run by a team of five staff members who are responsible for the dissemination related activities which is Work Package 8 of the MEGA Project. In addition, team members participate and contribute to all the other work packages of the project.

The Profile for each team Members is given below:

1. Mwape Lonia is a Senior Lecturer at the University of Zambia. She is the Vice-President of the General Nursing Council of Zambia and is a Vice-Chair of the National Research Ethics Board. She leads the MEGA project for UNZA.
2. Katowa-Mukwato is a Senior Lecturer at the University. She has specialized in teaching and learning of clinical skills, simulation & knowledge translation. She is a project manager and controller in the MEGA project.
3. Ms Wahila Ruth is a Head of Department of Basic and Clinical Nursing Sciences at the University. She is also a lecturer and PhD Candidate. She fulfils the role of the researcher in the project.
4. Chapima Fabian is a lecturer at the University of Zambia and a PhD fellow. He is a Researcher role in the MEGA project.
5. Mumbuluma Peterson is a member of the Zambia Institute of Chartered Accountants and a fellow of ACCA. His role in the MEGA project is to ensure that accounting and financing issues in the project at UNZA goes smoothly and within the approved budget.

In preparation, the trainer of the UFS team put together a book with the relevant training materials and supplements supplied by the MEGA project as well as an additionally sourced video on depression, a contextually appropriate article on depression conducted among Sesotho speaking respondents in the Mangaung Metro area, where the UFS team focuses their MEGA project activities. The Free State team further included a cultural competency test in the materials.

Despite meticulous planning and preparation, the UFS team faced some challenges. An unannounced taxi strike occurred on the day the training was scheduled for. As a result, several nurses working in the facility were absent, and the nurse who was earmarked to be trained could not be spared because the clinic was severely short-staffed. Only the social worker was released for the training.

The training commenced at 09:00. After an hour of training, the trainee informed the team that she is unable to stay much longer as she must attend to patients at a special clinic on a Wednesday (which was the training day). The team was not informed about this situation beforehand. The team requested the trainee to at least complete the Personal Reflection checkbox sheet and to go through the app questions and get her impressions on that and the training she was able to undergo. Completing the checkbox sheet took up 10 minutes and going through the evaluation took up 30 minutes.

The trainee expressed her gratitude for the training and the book with training materials and supplementary information on mental health and mental health care, and expressed that she would like to be part of the rest of the training, provided it is spread over two-hour sessions and several days – on days and times that suit all the trainees identified for the training.

It is clear from the pilot experience that it may prove challenging to recruit nurses for the eventual formal training, and to get their buy-in. Furthermore, the UFS MEGA team will have to customize the training per the needs of clinics. The team will have to work very hard to get buy-in from the Free State Department of Health, facility managers and the identified trainees for the training to take place successfully.

It should also be noted that mental health care is a lower priority part of the public health care system in the Free State, and presumably elsewhere in South Africa. In general,  mental healthcare receives less time, attention and resources in comparison to other health care programmes. For this reason, it may be difficult to recruit nurses for training.

A short evaluation of the training that did take place on the day was conducted. The trainee was asked to name mental health/illness topics she would like to see included in the eight-hour training course on mental health and mental health care. She indicated that she would like to see information on depression and stress and the differences between the two. These two concepts are contextually not often separated by the patients and some nurses. The same is true for PTSD and anxiety. It is important to include clear guidelines for nurses to distinguish between stress, depression, PTSD and anxiety.”

She also suggested information for nurses and social workers pertaining to referral to a psychiatric unit or a psychologist/ psychiatrist. Clear guidelines should be provided about when a patient can be treated in a clinic and when a patient should be referred for a higher level of care.

The trainee was also asked her opinion about the scheduling of the training. She indicated that a whole day is too long to take personnel out of their duty, as clinics are short-staffed. It will, therefore, be better to break up the training into two hours over several days.

From left to right:

Prof Soraya Seedat is Distinguished Professor and Executive Head of Department of Psychiatry at Stellenbosch University. She is the Principal Investigator for the Stellenbosch site.

Dr Sharain Suliman is a research psychologist and postdoctoral researcher in psychiatry. She is the project co-ordinator.

Dr Leigh van den Heuvel is a psychiatrist and PhD student who is acting as project manager for the Stellenbosch team.

Sr Irene Mbanga is a Mental Health Nurse with a Nursing Admin Diploma. She has been involved in various mental health research projects for the past 20 years and is the trainer for SU site.

We are hopeful that the project will lead to improved access to mental health services and enhanced mental health care for youth in South Africa and Zambia.