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

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.

The background survey was conducted among PHC practitioners. It included questions related to mental health care services available at PHC level, education development needs and mental health literacy. University ethical clearance and permission was obtained from the Director of Free State Department of Health (FSDoH) and all the levels of management in FSDoH – provincial, district and sub-district level – prior to commencement. All clinics (n=16) and community health centres (n=2) in the Mangaung Municipality were included (total facilities n=18). Consent forms were signed by nurses who agreed to participate. All registered and enrolled nurses and nurse assistants who indicated that they screen for mental health were provided with questionnaires and requested to participate. A total of 98 nurses participated, of which the majority were professional nurses. Only 8 staff nurses and three nurse assistants participated. Some nurses were very excited to participate but others felt that they do not have time or did not want to participate. Data was captured by 8 November on site at the University of the Free State using SPSS. Data cleaning and analysis are underway.

The conference is regarded as an important event to share scientific evidence that can be used to develop health policies and best practices; and promote good quality care and access to the health services users. Collectively, the work presented at the Research Day reflects health-related research in the Province. The conference was attended by more than 200 health care workers and managers. The MEGA project enjoyed excellent exposure and those managers who attended the presentation showed enthusiasm towards the project, which contributes to buy-in at governmental and health service level.

See the presentation given by Ega Janse van Rensburg-Bonthuyzen here: https://tinyurl.com/data-collection-free-state

The three-day project meeting was organized at the University of the Free State in Bloemfontein, South Africa. TUAS, our European partners from Riga and Hamburg, and three project partners from South Africa and one from Zambia were present at the meeting. During the meeting, updates on the project status were shared, future activities planned and the division of work agreed on. In addition, an expert panel was conducted to validate the questionnaire for mapping mental health services. TUAS and RTU had a chance to become acquainted with a health centre in the suburbs. Nurses carry out excellent work with great professionalism while receiving around 200 patients a day, most of them children. According to the nurses, mental health issues are often completely ignored due to the sensitivity of the issues and lack of time.

Our Bloemfontein colleagues provided a great framework for the meeting. The university campus was functional and quite modern. Our journey went without any difficulties and we were delighted to notice that our project is moving forward, and the project partners are committed to accomplish a common goal.