Evaluation of the community case detection tool in Northern and Western Uganda

INTERVENTION: The Community Case Detection Tool (CCDT) is a tool for trusted and respected community members to proactively identify children in need of mental healthcare and to encourage help‐seeking. The CCDT is made up of illustrated narratives depicting common examples of childhood psychological distress, such as social withdrawal, aggression, sleep problems, unexplained physical illness and injuries, and loss of hope. The tool is available in the most common languages spoken in the five settlements in Uganda, including Kiswahili, Kinyamwisha, Juba Arabic, Lugbara, Kakwa and Kuku. The CCDT will be integrated into routine practices and evaluated under these routine conditions, using data that are routinely collected. This study is led by a partnership between War Child Hollands (WCH) Research and Development Department, WCH Uganda and Transcultural Psychosocial Organisation (TPO) Uganda. Method of randomization The CCDT will be introduced and rolled out sequentially in five refugee settlements over the course of 9 months. The catchment area of a community gatekeeper using the CCDT (i.e., the area they serve) is equal to a zone. A zone is an administrative unit in a refugee settlement. Each settlement is divided into zones, and zones are divided into villages, clusters and blocks. Data is therefore collected per zone, instead of on the individual child, adolescent or caregiver level. Each zone in which War Child Holland and TPO Uganda are active will be considered a cluster in this study and randomization takes place at the zone level. Each zone will be randomized to a sequence and start timing for when the CCDT will be introduced there using a random number generator in Stata, Version 17. Randomization will be done CONDITION: Mental health conditions ; Mental and Behavioural Disorders SECONDARY OUTCOME: ; Secondary outcomes include the (1) acceptability and appropriateness of the CCDT according to trained community gatekeepers, (2) the feasibility of using the CCDT at scale, and (3) changes in attitudes towards individuals experiencing mental health problems among community gatekeepers:; ; 1. Acceptability and appropriateness of the CCDT according to trained community gatekeepers. defined as the satisfaction of community gatekeepers with various aspects of the CCDT tool and perceived fit and relevance of the CCDT tool, adapted to the local context in which it will be employed in the refuge settings. This will be assessed prior to implementation and will be assessed as part of WCH’s ongoing program activities. Where four community adaptation workshops were conducted with 20 community gatekeepers about the different emotional and behavioral problems related to mental health amongst children, these were subsequently used for the creation of the vignettes (one for emotional problems and one for behavioral problems). Furthermore, based on the problems that have been identified in the communities, the researchers have worked with a local artist to create context‐sensitive illustrations. A focus group discussion (FGD) was organized in the five settlements in selected zones with 25 community gatekeepers to assess: (a) the level of understanding of the illustrations and vignettes, (b) if they recall a child in their vicinity who experienced similar symptoms, (c) whether they were comfortable by the way the cases were presented in the vignettes and illustrations and (d) the extent to which the CCDT can be successfully used by gatekeepers during their daily routine tasks. The FGD was conducted in their local languages using the translated vignettes including Swahili, Kinyabwisha, Lugbara, Kakwa, Kuku, and Juba Arabic. Based on the FGD further adaptations to the tool were made.; ; 2. Feasibility of using the CCDT at scale, defined as the extent to which the CCDT can be successfully used at scale to detect children and adolescents in need of mental healthcare and promote help‐seeking. Qualitative data from gatekeepers will be gathered at two moments:; 2.1. During monthly supervision sessions: feedback will be gathered about their satisfaction, the actual fit and utility of the CCDT for everyday use and their motivation with regards to using the CCDT during their daily routine tasks. Questions will focus on the barriers and facilitators that gatekeepers face in using the CCDT.; 2.2. Post‐implementation FGDs (n = 2) and KIIs (n = 6). Questions will focus on the barriers and facilitators that gatekeepers faced in using the CCDT. This qualitative data will also be used to interpret the detection trends and supervision attendance per gatekeeper over time, using the gatekeeper logbooks.; ; 3. Attitudes among community gatekeepers towards mental health problems are measured through preferred social distance towards individuals experiencing mental health problems. This will be assessed at pre‐training, intermediate (i.e. after 6 months of using the CCDT) and at the end of the project. Social distance is defined as the degree to which people are willing to accept the individuals experiencing mental health conditions in regular social life. The Social Distance Scale (SDS) will be used for this. Explicit stigmatizing attitudes questionnaire widely used in mental health in global stigma comparisons; the Nepali version will be adapted for this and has 12 self‐report questions on a scale of 1 to 6. The tool will be translated to the six different languages (Swahili, Kinyabwisha, Lugbara, Kakwa, Kuku, and Juba Arabic), following a process for use in cross‐cultural research. Also, the researchers will be conducting cognitive interviews on all measures being used, in order to assess the understandability of the translated tools. The translated tools will be further adapted on the basis of these cognitive interviews.; INCLUSION CRITERIA: Two groups of participants are identified. The CCDT employs a gatekeeper model and is developed for trusted and respected community members (‘community gatekeepers’). Community gatekeepers use the CCDT to proactively detect children in need of mental healthcare to encourage help‐seeking. Community gatekeepers: Community gatekeepers will be selected from WCH’s and TPO’s existing networks and community‐based structures. They include: Village Health Teams (VHTs), teachers, group activity facilitators, child protection committee members, local community leaders and refugee committee leaders. They will be selected, based on the below criteria, by WCH’s and TPO’s Project Coordinators, responsible for ongoing programming with children and adolescents in each cluster. Specific inclusion criteria are: 1. At least 18 years of age 2. Trusted and respected memb PRIMARY OUTCOME: ; The primary outcome is the utilization of TPO’s mental healthcare services among children and adolescents detected by the CCDT. Utilization in this study will be defined as initial encounters with TPO’s mental healthcare among children and adolescents 6‐18 years old or their caregivers, or re‐entry into services for children and adolescents that have not been using TPO’s services for 6 months. This is measured in two ways:; ; 1. Service utilization data: the number of children and or adolescents aged 6‐18 years old that seek mental healthcare services from TPO, compared to utilization rates of practice‐as‐usual (i. e., during the pre‐CCDT period). TPO’s routinely collected monthly mental health service utilization data will be used for this. Following routine practices, upon intake, TPO’s clinical team completes a ‘case registration form’. Service utilization data will be collected monthly from each zone (i.e. cluster) the day before the next step. Furthermore, every cluster provides before and after utilization data, one month before the first step and one month after the final step of the SWT.; 2. The proportion of children and adolescents detected by the CCDT as in need of mental healthcare that seeks help at TPO. Two data sources will be used and compared for this:; 2.1. Detection data: number of detected cases per gatekeeper. Gatekeepers will be trained in keeping a log of the number of detected children while using the CCDT. Gatekeeper logbooks will be collected bi‐weekly by one of WCH’s facilitators attached to the zone and handed over to the project officers who will be trained in entering the data in a digital master sheet.; 2.2. Service utilization data: number of cases contacting TPO as a result of a community gatekeeper trained in the CCDT handing out a referral card. The same ‘monthly mental health service utilization data’ (see outcome 1 above) will be used for this. TPO’s clinical team will be trained to ask all new clients (children, adolescents or caregivers) an intake question regarding the reason for seeking help (including the community gatekeeper handing out the referral card as one of the options). This data is entered by the clinical psychologist in the ‘case registration form’ used upon entry.; ; The impact of the above outcome measures will be determined in three ways: (1) trends in monthly utilization data from TPO’s service points; (2) comparison of clusters where the CCDT has been implemented (experimental condition) with clusters where the CCDT has not yet been implemented (control condition); and; (3) proportion of CCDT cases detected that sought help at one of TPO’s service points. This data will be captured through routine reporting using the referral card, and intake questions.;