Evaluating process and clinical outcomes of a primary care mental health integration project in rural Rwanda: a prospective mixed-methods protocol

Introduction: Integrating mental healthcare into primary care can reduce the global burden of mental disorders. Yet data on the effective implementation of real-world task-shared mental health programmes are limited. In 2012, the Rwandan Ministry of Health and the international healthcare organisation Partners in Health collaboratively adapted the Mentoring and Enhanced Supervision at Health Centers (MESH) programme, a successful programme of supported supervision based on task-sharing for HIV/AIDS care, to include care of neuropsychiatric disorders within primary care settings (MESH Mental Health). We propose 1 of the first studies in a rural low-income country to assess the implementation and clinical outcomes of a programme integrating neuropsychiatric care into a public primary care system. Methods and analysis A mixed-methods evaluation will be conducted. First, we will conduct a quantitative outcomes evaluation using a pretest and post-test design at 4 purposively selected MESH MH participating health centres. At least 112 consecutive adults with schizophrenia, bipolar disorder, depression or epilepsy will be enrolled. Primary outcomes are symptoms and functioning measured at baseline, 8 weeks and 6 months using clinician-administered scales: the General Health Questionnaire and the brief WHO Disability Assessment Scale. We hypothesise that service users will experience at least a 25% improvement in symptoms and functioning from baseline after MESH MH programme participation. To understand any outcome improvements under the intervention, we will evaluate programme processes using (1) quantitative analyses of routine service utilisation data and supervision checklist data and (2) qualitative semistructured interviews with primary care nurses, service users and family members. Ethics and dissemination This evaluation was approved by the Rwanda National Ethics Committee (Protocol #736/RNEC/2016) and deemed exempt by the Harvard University Institutional Review Board. Results will be submitted for peer-reviewed journal publication, presented at conferences and disseminated to communities served by the programme

Organic residue, limestone, gypsum, and phosphorus adsorption by lowland soils Resíduo orgânico, calcário e gesso e a adsorção de fósforo por solos de várzea

Organic residue application is a low cost alternative to reduce the use of inorganic fertilizers and correctives. In order to study the effect of organic residues, limestone and gypsum application on phosphorus adsorption by lowland soils, four experiments were carried out. A Mesic Organosol (OY), a Melanic Gleysol (MG), a Haplic Gleysol (GX), and a Fluvic Neosol (RU) were used in a completely randomized design and factorial scheme (3 x 2), with five replicates: three soil amendment practices (limestone, gypsum and no corrective) and two levels of organic residue (with and without corral manure). Soil samples were incubated for 60 days, with and without organic residue incorporation. After this period, we applied the corrective and incubated the soil for 30 days, then P and basic fertilization (macro and micronutrients) were applied and the soil was incubated for additional 60 days. Equilibrium phosphorus, maximum phosphate adsorption capacity, pH, exchangeable Al and phosphorus-buffering index were measured. Organic residue and limestone application increased soil pH and reduced exchangeable Al, decreasing P adsorption. Gypsum application did not increase the pH but reduced exchangeable Al and P adsorption.<br>A aplicação de resíduo orgânico é uma alternativa de baixo custo para reduzir a aplicação de fertilizantes inorgânicos e corretivos. Com objetivo de estudar a relação da aplicação de resíduo orgânico, calcário e gesso com adsorção de fósforo em solos de várzea conduziram-se simultaneamente quatro experimentos com os solos Organossolo Mésico (OY), Gleissolo Melânico (GM), Gleissolo Háplico (GX) e Neossolo Flúvico (RU). O delineamento experimental utilizado foi o inteiramente casualizado, em esquema fatorial 3x2, com cinco repetições, sendo três práticas de correção do solo (calcário, gesso e sem corretivo) e dois níveis de resíduo orgânico com e sem esterco de curral curtido. Amostras dos solos foram incubadas por 60 dias com e sem incorporação do resíduo orgânico; após este período, por mais 30 dias com os corretivos e em seguida por 60 dias com o fósforo e uma adubação básica com macro e micronutrientes. Determinaram-se o fósforo remanescente, capacidade máxima de adsorção de fósforo, pH, Al trocável e índice tampão de fósforo. A aplicação de resíduo orgânico, calcário - pela elevação do pH e redução dos teores de Al trocável - e gesso - pela redução de Al trocável - reduzem a adsorção de fósforo nos solos de várzea estudados