Topic: piloting adapted WHO digital interventions for health system strengthening in primary care mental health in Nigeria: a mixed-methods RE-AIM evaluation

Abstract

Mental health treatment gaps persist across low- and middle-income countries despite task-shifting initiatives integrating mental healthcare into primary care. Digital health interventions were piloted within the Mental Health in Primary Care (MeHPriC) programme in Lagos, Nigeria, yet evidence on their real-world performance in routine workflows remains limited. This study conducted a pragmatic mixed-methods RE-AIM evaluation of five adapted WHO Guideline on Digital Interventions for Health System Strengthening recommendations. A pre–post evaluation was conducted across five primary health care centres over three months. Five digital interventions (drug stock notification, targeted client communication, digital supervision, client helpline, and e-mhGAP-IG clinical decision support) were assessed. Quantitative indicators were summarised descriptively at facility level without cluster-based inferential modelling. Qualitative interviews with health workers, managers, and policymakers, alongside satisfaction surveys, were analysed using framework and convergent mixed-methods approaches. Administrative interventions showed high reach and consistent improvements. Psychotropic medication stockout days fell from 8.2 to 2.5 per facility-month (− 69.5%; range − 4.8 to − 7.1 days), and appointment adherence rose from 67.0% to 89.0% (+ 22.0% points; range + 21 to + 24), with all five facilities improving on both indicators. Pharmacy staff and managers reported high satisfaction, perceiving these tools as low-cost solutions absorbable within existing budgets. Clinical interventions performed considerably worse. Helpline utilisation averaged 34.0% of eligible clients and was lower in peri-urban than urban facilities (27% vs. 44%), indicating an equity gradient. Fidelity to the e-mhGAP-IG tool declined from 75.0% to 58.0% between Month 1 and Month 3 at all sites. Health workers described both clinical tools as cumbersome and workflow-disruptive and expressed anxiety about medico-legal responsibility for remote care. Managers were reluctant to sustain clinical tools without additional governance and financial support. This pragmatic pilot suggests that adapted digital interventions may strengthen selected aspects of mental health service delivery in Nigerian primary care, but performance differed by intervention type. Administrative tools showed broad reach, consistent service improvements, and realistic maintenance prospects, whereas clinician-facing tools were difficult to embed and raised governance concerns. The urban–peri-urban gradient in helpline uptake signals a potential digital divide, consistent with a digital inverse care law. These findings support selective, phased scaling of tools with strong workflow fit while redesigning clinical tools through co-design, improved integration, and clarified liability arrangements.