Empowering East Africa: Duke Nursing Mental Health Initiative

Funding travel for East African scholars partnering with Duke and each other to improve mental health care in the region, the Duke Global Health Institute (DGHI) has awarded a grant to Duke University School of Nursing Assistant Professor and DGHI Assistant Research Professor Brandon Knettel, PhD. The year-long grant will allow scholars from the University of Global Health Equity (UGHE) in Rwanda; Kilimanjaro Christian Medical Center (KCMC) in Tanzania; Moi University in Kenya; and Makerere University in Uganda to attend workshops at each of those institutions to learn about focused areas of expertise. The two-day workshops will include a combination of didactic training, visits to research and clinical sites to learn about existing services, collaborative planning for capacity building and funding opportunities, and professional networking.

“We are actively planning for our first partner-led workshop, which will take place from June 24-26,” Dr. Knettel said. “Our colleague Dr. Florence Jaguga will lead the workshop, focused on community-engaged approaches for mental health treatment.”

Rwanda lost as many as one million people to genocide during the conflicts of the 1990s, including many of the nation’s medically trained professionals. And in Tanzania, as recently as 2018, there were no psychiatrists or psychologists at KCMC, one of the largest hospitals in the country. “Historically, mental health just hasn’t been a part of the health system and hasn’t been prioritized,” said Knettel, who has worked in Tanzania since 2009. But that is changing. The East African community has seen improvement in quality of life and fewer preventable deaths from things like malaria and HIV/AIDS, said Knettel, so now, mental health is the logical next step. But it needs support. The scholars from Africa and Duke, who have begun collaborating with help from NIH grants, will work together not just to train new mental health care workers, but also to change how the care is delivered. The travel grant will facilitate that collaboration.

Inspired by the work of the late Paul Farmer, a Duke alumni and founder of UGHE in Rwanda, Knettel said these collaborative efforts among the four partner sites will build capacity in the region and address health inequities and social injustice. “With a brand-new mental health system, we have the opportunity to reinvent the way health access works,” Knettel says. “It may be a lofty thing to say, but that’s really where we are.” Historically in other settings around the world, when introducing a new service, the people with the most resources get it first, Knettel said. “Here, we’re taking a different approach, where the people who need it most get it first.”

One such program, led by Knettel and funded by the National Institute of Mental Health, focused on suicide prevention in Tanzania using a nurse-led strategy where three questions are added to a nurse’s patient inquiry. If patients’ responses to these mental health screening questions indicate they need further assessment, they can be seen immediately by a mental health provider via telehealth. If the patient agrees, they can then be directly connected to a mental health provider for treatment. Building the care into the existing system is not only cost-effective, it provides access to patients who might not ever seek help for serious mental distress. But catching more patients means more providers will be needed; supporting the local institutions in their training efforts is imperative to increasing capacity, a main goal of the partnership. “The need is so great that these providers, as soon as they come out of their training, they are just overwhelmed by the need already,” Knettel said.

He’s taken that concern to heart when also thinking about the long-term viability of the whole program. “With regard to sustainability [of the program], we’re implementing a task-shifted approach, where the few psychiatrists, psychologists, and mental health nurses are supervising larger cohorts of health workers such as diploma-trained nurses and community members trained to deliver brief interventions,” Knettel explained.

“The well-being of our task-shifted counselors is really critical,” he continued, “and it begins with appropriate supervision, support, and compensation for their work. Counseling is challenging work under any circumstances, and especially when you’re concerned about meeting your family’s basic needs at home. We also think it’s crucial to offer opportunities for educational and professional advancement for our partners who are interested in obtaining more training.”