Reducing stigma among healthcare providers to improve mental health services (RESHAPE): protocol for a pilot cluster randomized controlled trial of a stigma reduction intervention for training primary healthcare workers in Nepal.


Background: Non-specialist healthcare providers, including primary and community healthcare workers, in low- and middle-income countries can effectively treat mental illness. However, scaling-up mental health services within existing health systems has been limited by barriers such as stigma against people with mental illness. Therefore, interventions are needed to address attitudes and behaviors among non-specialists. Aimed at addressing this gap,REducingStigma amongHealthcAreProviders to ImprovEmental health services (RESHAPE) is an intervention in which social contact with mental health service users is added to training for non-specialist healthcare workers integrating mental health services into primary healthcare. Methods: This protocol describes a mixed methods pilot and feasibility study in primary care centers in Chitwan, Nepal. The qualitative component will include key informant interviews and focus group discussions. The quantitative component consists of a pilot cluster randomized controlled trial (c-RCT), which will establish parameters for a future effectiveness study of RESHAPE compared to training as usual (TAU). Primary healthcare facilities (the cluster unit,k = 34) will be randomized to TAU or RESHAPE. The direct beneficiaries of the intervention are the primary healthcare workers in the facilities (n = 150); indirect beneficiaries are their patients (n = 100). The TAU condition is existing mental health training and supervision for primary healthcare workers delivered through the Programme for Improving Mental healthcarE (PRIME) implementing the mental health Gap Action Programme (mhGAP). The primary objective is to evaluate acceptability and feasibility through qualitative interviews with primary healthcare workers, trainers, and mental health service users. The secondary objective is to collect quantitative information on health worker outcomes including mental health stigma (Social Distance Scale), clinical knowledge (mhGAP), clinical competency (ENhancing Assessment of Common Therapeutic factors, ENACT), and implicit attitudes (Implicit Association Test, IAT), and patient outcomes including stigma-related barriers to care, daily functioning, and symptoms. Discussion: The pilot and feasibility study will contribute to refining recommendations for implementation of mhGAP and other mental health services in primary healthcare settings in low-resource health systems. The pilot c-RCT findings will inform an effectiveness trial of RESHAPE to advance the evidence-base for optimal approaches to training and supervision for non-specialist providers. Trial registration: identifier, NCT02793271.





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Publication Info

Kohrt, Brandon A, Mark JD Jordans, Elizabeth L Turner, Kathleen J Sikkema, Nagendra P Luitel, Sauharda Rai, Daisy R Singla, Jagannath Lamichhane, et al. (2018). Reducing stigma among healthcare providers to improve mental health services (RESHAPE): protocol for a pilot cluster randomized controlled trial of a stigma reduction intervention for training primary healthcare workers in Nepal. Pilot Feasibility Stud, 4. p. 36. 10.1186/s40814-018-0234-3 Retrieved from

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Brandon A. Kohrt

Adjunct Associate Professor in the Department of Psychiatry and Behavioral Sciences

Brandon Kohrt is a medical anthropologist and psychiatrist who completed his MD-PhD at Emory University in 2009. He is currently Assistant Professor of Psychiatry, Global Health, and Cultural Anthropology at Duke University. Dr. Kohrt has worked in Nepal since 1996 researching and aiding victims of war including child soldiers. Since 2006 has worked with Transcultural Psychosocial Organization (TPO) Nepal. Dr. Kohrt has been a consultant to The Carter Center Mental Health Program Liberia Initiative since 2010. Dr. Kohrt is the component lead for the Grand Challenges Canada funded Mental Health Beyond Facilities (mhBeF) program in Nepal, Liberia, and Uganda. Dr. Kohrt has published scientific articles and book chapters about mental health among conflict- and disaster-affected populations in Nepal, Liberia, and Haiti. Dr. Kohrt has collaborated on numerous documentary films about human rights and global health including Returned: Child Soldiers of Nepal’s Maoist Army.  


Elizabeth Louise Turner

Associate Professor of Biostatistics & Bioinformatics

Dr. Turner is Associate Professor of Biostatistics and Global Health and serves as Director of the Research Design and Analysis Core of the Duke Global Health Institute. Her primary methodological focus is on the design and analysis of randomized controlled trials, particularly those that involve clustering such as cluster randomized trials (CRTs), stepped wedge CRTs and individually-randomized group treatment trials. She is expert in the implementation of trials in low resource settings, with a substantive focus on malaria, mental health and cardiovascular disease.

Dr. Turner joined the Department of Biostatistics & Bioinformatics and Duke Global Health Institute in March 2012 following four years as Research Fellow in the Department of Medical Statistics at the London School of Hygiene and Tropical Medicine (LSHTM). Since then, she has continued to hold a joint position with Duke's Global Health Institute (DGHI) where she serves as faculty statistician and collaborates with faculty and affiliates. Dr. Turner earned her undergraduate honors degree in Mathematics from the University of Warwick, UK, during which she spent an intercalated year at the Universite of Pierre et Marie Curie, Paris, France. She then earned her MSc and PhD in Statistics from McGill University, Canada, with her doctoral studies funded by the prestigious Commonwealth Scholarship.

Thanks to her participation in multi-disciplinary projects, Dr. turner has a great appreciation for the importance of good study design and data collection and is well aware that no fancy statistical analyses can save researchers from the scourge of bad data. Through those experiences and her teaching in different settings, including the UK, Canada, France and Tanzania, she is aware that statisticians and their collaborators sometimes “speak a different language”. As a result, her approach is very much one of translation, pragmatism and collaboration.

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